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  • Washington Highlights

    CMS Issues Proposed Physician Fee Schedule (MPFS) and Quality Payment Program (QPP) Rule for 2019

    Gayle Lee, Director, Physician Payment & Quality
    Kate Ogden, Physician Payment & Quality Specialist

    The Centers for Medicare and Medicaid Services (CMS) proposed historic changes to the evaluation and management code documentation and payment in a proposed rule released July 12, 2018. This rule will update payment rates and policies for services provided by physicians and other clinicians to Medicare beneficiaries in 2019. The rule also proposes changes to the QPP, which consists of two participation pathways — merit-based incentive payment system (MIPS), which measures performance based on four categories, and advanced alternative payment models (APMs) in which clinicians may earn incentive payments based on sufficient participation in models. The AAMC will analyze the proposed rule in more detail in the coming weeks and will be submitting comments by the September 10, 2018, deadline.

    Key highlights in the MPFS include proposing:

    • A 2019 MPFS conversion factor of $36.05, a slight increase from the 2018 conversion factor of $35.99
    • Streamlining “evaluation and management” (E&M) documentation guidelines by allowing clinicians to choose to document E&M visits using medical decision-making or time, or alternatively continue to use the current framework
    • Single, blended payment rates for new and established office or outpatient visits level two to five and add-on codes to reflect additional resources
    • Allowing practitioners to focus their documentation on what has changed since the last visit, rather than redocumenting information in the history and exam
    • Allowing practitioners to review and verify certain information in the medical record that is entered by ancillary staff or the beneficiary rather than re-entering it
    • Paying separately for newly defined physician services furnished using communication technology, such as paying for virtual checkups by phone or video chats with physicians
    • Creation of a bundled episode of care for management and counseling treatment for substance use disorder
    • Maintaining the relativity adjuster of 40% for payments of items and services provided in certain off-campus hospital outpatient provider-based departments
    • Creation and payment for two new codes to describe physician consultative services:
      • CPT 994X0 interprofessional telephone/internet/electronic health record referral service(s) provided by a treating/requesting physician or qualified health care professional, 30 minutes
      • 994X6 interprofessional telephone/internet/electronic health record assessment and management service provided by a consultative physician including a written report to the patient’s treating/requesting physician or other qualified health care professional, 5 or more minutes of medical consultative time
    • Reducing drug payment add-on for wholesale acquisition cost-based payments for new Part B drugs from 6% to 3%
    • Reducing total number of measures in the Medicare Shared Savings Program quality measure set from 31 to 24 measures and focusing the measures on outcomes-based measures
    • Requiring hospitals to make public a list of their standard charges

    A CMS fact sheet on the MPFS proposed rule is available here.

    Key highlights in the QPP include proposing:

    • A 15% weight for the cost performance category, an increase from the 10% weight in 2018
    • Expanding the definition of MIPS-eligible clinicians to include new clinician types (physical therapists, occupational therapists, qualified speech-language pathologists, certified nurse-midwives, qualified audiologists, clinical social workers, clinical psychologists, registered dieticians or nutrition professionals)
    • Adding a third element, number of covered professional services, to the low-volume threshold determination, and providing an opt-in policy that offers eligible clinicians who meet or exceed at least one element of the low-volume threshold the ability to participate in MIPS
    • Providing the option to use facility-based scoring for facility-based clinicians
    • Modifying the MIPS Promoting Interoperability performance category to align with the proposed new Promoting Interoperability Program requirements for hospitals
    • Streamlining the definition of a MIPS-comparable measure in both the advanced APM criteria and Other Payer Advanced APM criteria
    • Updating the MIPS APM measure sets that apply for purposes of the APM scoring standard
    • Increasing flexibility for the All-Payer Combination Option and Other Payer Advanced APMs for non-Medicare payers to participate in QPP
    • Updating the Advanced APM certified EHR technology (CEHRT) threshold so that an advanced APM must require at least 75% of eligible clinicians in each APM entity use CEHRT
    • Extending the 8% revenue-based nominal standard for advanced APMs through performance year 2024