CMS Proposed Medicare Physician Fee Schedule Changes for Calendar Year 2019

On July 12, 2018, the Centers for Medicare & Medicaid Services (CMS) issued a proposed rule that includes proposals to update payment policies, payment rates, and quality provisions for services furnished under the Medicare Physician Fee Schedule (PFS) on or after January 1, 2019.

CMS will accept comments on the proposed rule until September 10, 2018, and will respond to comments in a final rule. The proposed rule can be downloaded from the Federal Register at:

Below is a summary of pertinent parts of the 1,400 plus page document that impacts radiology. ADVOCATE will complete a comprehensive review of the rule and provide a summary next week.

Conversion Factor

CMS estimates a CY 2019 conversion factor of $36.0463, which reflects the 0.25 percent update specified by the Medicare Access and CHIP Reauthorization Act and a budget neutrality adjustment of -0.12 percent. Overall, this is a slight increase from the current conversion factor of $35.9996.

There are approximately 60 new and revised radiology codes for CY 2019. CMS proposes to increase values for some radiology codes while decreasing values for others.

CMS estimates an overall impact of the MPFS proposed changes to radiology and interventional radiology to be a neutral 0 percent change, while nuclear medicine would see an aggregate decrease of 1 percent and radiation oncology and radiation therapy centers a 2 percent decrease if the provisions within the proposed rule are finalized.

Radiology Assistant Supervision

CMS is proposing to revise the physician supervision requirements so that any diagnostic test performed by a Radiologist Assistant (RA) may be furnished under, at most, a direct level of physician supervision, when performed by an RA in accordance with state law and state scope of practice rules. This is in response to stakeholder comments that the current requirement of personal supervision that applies to some diagnostic tests is overly restrictive when the test is performed by an RA, and does not allow for radiologists to make full use of RAs; and that reducing the required level of supervision will improve efficiency of care.

Payment Rates for Nonexcepted Off-campus Provider-Based Hospital Departments Paid Under the MPFS

Section 603 of the Bipartisan Budget Act of 2015 requires that certain items and services furnished by certain off-campus hospital outpatient provider-based departments are no longer paid under the Hospital Outpatient Prospective Payment System (OPPS) beginning January 1, 2017. For CY 2018, CMS pays for these items and services under the MPFS at a rate of 40 percent of the OPPS rate. For CY 2019, CMS is proposing to maintain the current MPFS payment rates for these items and services.

Appropriate Use Criteria/Clinical Decision Support

On the topic of AUC, after hearing concerns from various medical specialties societies on the readiness of the previously proposed July 1, 2019 implementation date, CMS finalized a January 1, 2020, implementation date in the 2018 final rule. This delay allows time to further develop claims processing instructions. Due to the complex nature of the AUC program, CMS finalized an “educational and operations testing period” of one year that would begin on January 1, 2020. During this period, ordering professionals will consult AUC and furnishing providers will report AUC consultation information on the claim, but CMS will continue to pay claims if the correct information is included. The agency notes that this educational period will allow professionals to actively participate in the program while avoiding claims denials during the learning curve.

In the 2019 proposed rule, CMS reaffirmed the January 1, 2020 mandatory consultation date, with a one-year education and operations testing period. In order to meet this deadline, CMS is again proposing use of a series of G-codes and modifier for claims processing. The agency notes that it will consider future opportunities to use a unique consultation identifier (UCI) for claims processing and will continue to engage with stakeholders on this topic.

In response to comments in the 2018 rulemaking cycle seeking clarification on who is required to perform the consultation of AUC through a qualified clinical decision support mechanism, CMS is proposing that the consultation may be performed by “clinical staff working under the direction of the ordering professional”. This allows flexibility, but still achieves the goal of the program to promote the use of AUC.

CMS is also proposing to add independent diagnostic testing facilities (IDTFs) to the definition of “applicable setting” for the AUC program. Other applicable settings include a physician’s office, a hospital outpatient department (including an emergency department) and an ambulatory surgical center. The agency believes adding IDTFs as an applicable setting “appropriately and consistently applies the AUC program across the range of outpatient settings where applicable imaging services are furnished.” CMS also invites comments on the addition of any other applicable settings for the AUC program.

Streamlining Evaluation and Management (E/M) Payment and Reducing Clinician Burden

CMS is proposing a number of coding and payment changes to reduce administrative burden and improve payment accuracy for E/M visits. CMS ha proposed:

  • to allow practitioners to choose to document office/outpatient E/M visits using medical decision-making or time instead of applying the current 1995 or 1997 E/M documentation guidelines, or alternatively practitioners could continue using the current framework;
  • to expand current options by allowing practitioners to use time as the governing factor in selecting visit level and documenting the E/M visit, regardless of whether counseling or care coordination dominate the visit;
  • to expand current options regarding the documentation of history and exam, to allow practitioners to focus their documentation on what has changed since the last visit or on pertinent items that have not changed, rather than re-documenting information, provided they review and update the previous information; and
  • to allow practitioners to simply review and verify certain information in the medical record that is entered by ancillary staff or the beneficiary, rather than re-entering it.

Proposed Rule for 2019 Medicare Quality Payment Program

CMS is proposing some new policies for Year 3 (2019) of the Quality Payment Program via the Medicare Physician Fee Schedule (PFS) Notice of Proposed Rulemaking (NPRM).  Below are some of the highlights for Year 3 of the Quality Payment Program:

  • Category weights of Total Composite Score:
    • Quality: 45%
    • Improvement Activities: 15%
    • Promoting Interoperability: 25% (Formerly called Advancing Care Information)
    • Cost: 15%
  • Performance Threshold is set at 30 points
  • Exceptional performance threshold set at 80 points
  • The maximum negative payment adjustment is -7 percent while positive payment adjustments can be up to 7% (but they are multiplied by a scaling factor to achieve budget neutrality)
  • Providing the option to use facility-based scoring for facility-based clinicians that doesn’t require data submission.
  • Modifying the MIPS Promoting Interoperability (formerly Advancing Care Information) performance category to support greater electronic health record (EHR) interoperability and patient access while aligning with the proposed new Promoting Interoperability Program requirements for hospitals.
  • Moving clinicians to a smaller set of Objectives and Measures with scoring based on performance for the Promoting Interoperability performance category.
  • 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 the Quality Payment Program.
  • Updating the Advanced APM Certified EHR Technology (CEHRT) threshold so that an Advanced APM must require that at least 75% of eligible clinicians in each APM Entity use CEHRT.
  • Extending the 8% revenue-based nominal amount standard for Advanced APMs through performance year 2024.

As always, ADVOCATE will keep you up to date on this and all issues impacting radiology as they become available.

Best regards,
Kirk Reinitz, CPA