The Centers for Medicare & Medicaid Services (CMS) proposed changes to both Medicare physician payment and quality reporting program policies that would generally take effect Jan. 1, 2019. The proposed rule would change the MIPS and alternative payment model (APM) participation options and requirements for 2019. MGMA Government Affairs staff summarized the changes that would affect medical group practices in a comprehensive analysis, excerpted below.

Physician payment update

CMS estimates the 2019 Medicare PFS conversion factor will be $36.0463, which includes a 0.25% update as required by the Bipartisan Budget Act of 2018. The conversion factor update is offset by a -0.12% budget-neutrality adjustment. The anesthesia conversion factor is estimated to be $22.2986.

Modernizing physician payment through communication technology-based services

CMS proposes to pay separately for the following newly defined physician services furnished using communication technology:

• Brief non-face-to-face appointments (virtual check-ins) using HCPCS code GVCI1
• Evaluation of patient submitted images or video (“store and forward” technology) using HCPCS code GRAS1

CMS would pay separately for new codes describing interprofessional internet consultation and expands on its policy to cover remote patient monitoring (RPM) services. CMS previously recognized RPM services as a new modality of technology-based services and began providing separate payment under CPT code 99091. CMS proposes to add new codes to describe when a qualified health professional remotely monitors physiological parameters such as weight, blood pressure, pulse oximetry and respiratory rate using CPT codes 990X0, 990X1 and 994X9.

Significantly, CMS believes RPM services and virtual check-ins fall outside the scope of “Medicare telehealth services” defined in Section 1834(m) of the Social Security Act. This change in interpretation is important because Section 1834(m) establishes coverage restrictions on telehealth services that require a beneficiary to be located at a specific type of originating site located in a remote or rural location, among other limitations (83 FR 35723).

E/M services

Proposed changes to E/M visit payment amounts: CMS believes the system of 10 codes for new and established office visits is “outdated” and proposes to retain but revise and simplify the codes and their reimbursement by applying a single, blended payment rate for level 2 through 5 office visits.


Other coding and payment proposals related to E/M visits: CMS proposes to:

• Reduce payment by 50% for the least expensive procedure or visit that the same physician (or a physician in the same group practice) furnishes on the same day as a separately identifiable E/M visit.
• Create an add-on payment of about $5 (0.15 RVUs) for primary care office visits via a new code — GPC1X, visit complexity inherent to evaluation and management associated with primary medical care services.
• Create an add-on payment of about $12 (0.33 RVUs) for office visits performed by certain specialties via a new code — GCG0X, visit complexity inherent to evaluation and management associated with: Allergy/Immunology, Cardiology, Endocrinology, Hematology/Oncology, Interventional Pain Management-Centered Care, Neurology, Obstetrics/Gynecology, Otolaryngology, Rheumatology, or Urology.

CMS would also create a new prolonged service code as an add-on to any office visit lasting more than 30 minutes beyond the office visit (i.e., hourlong visits in total). The code GPRO1, prolonged evaluation and management or psychotherapy services(s) (List separately in addition to code for office or other outpatient Evaluation and Management or psychotherapy service), would have a payment rate of approximately $67 (1.85 RVUs).

Proposed documentation changes for office and outpatient E/M visits: Physicians would be allowed to choose one of the following methods of documentation:

• 1995 or 1997 E/M guidelines for history, physical exam and medical decision-making (i.e., the current framework for documentation)
• Medical decision-making only
• Physician time spent face-to-face with patients

Because payment rates for levels 2 to 5 E/M visits would be collapsed, CMS proposes a minimum documentation standard, requiring documentation to support the medical necessity of a level 2 E/M visit code. CMS assumes that physicians may continue to document according to the five E/M levels of codes for clinical, legal, operational and other purposes.

In addition, physicians would no longer be required to re-record elements of history and physical exam when there is evidence that the information has been reviewed and updated. CMS would eliminate re-entry of information regarding chief complaint and history already recorded by ancillary staff or the beneficiary. The practitioner would only document that he or she reviewed and verified the information.

Proposed implementation date: The proposed implementation date for E/M changes is Jan. 1, 2019. CMS is seeking comment on whether the implementation should be delayed to Jan. 1, 2020.

Part B drugs

CMS proposes to reduce Medicare reimbursement rates for new drugs coming onto the market. Generally, Medicare payment is tied to the Average Sales Price (ASP) for drugs, which includes discounts and rebates. Because there is no ASP data for new drugs, reimbursement during the first available quarter is tied to the Wholesale Acquisition Cost (WAC), which is based on the manufacturer’s list price and does not include discounts and rebates. The ASP or WAC is then increased by 6% to reflect overhead costs (but after a 2% sequester cut is applied to Medicare’s share of the payment, the add-on is 4.3%). CMS proposes to reduce the new drug add-on to 3% (which would then be subject to the sequester cut) for a period of three months.

Appropriate use criteria (AUC) for advanced diagnostic imaging services

The AUC program requires ordering providers to consult with applicable AUC through a qualified clinical decision support mechanism for applicable imaging services. CMS previously delayed implementation of this program by including a voluntary reporting period, which started in July 2018 and runs through December 2019. In 2020, the AUC program period will begin with an educational and operations testing period, during which CMS will continue to pay claims whether they correctly include AUC information.

CMS proposes to:

• Create significant hardship exceptions from AUC requirements specific to the AUC program and independent of other Medicare programs
• Establish the coding methods, to include G-codes and modifiers, to report the required AUC information on Medicare claims
• Allow nonphysicians, under the direction of an ordering professional, to consult with AUC when the consultation is not performed personally by the ordering professional

2019 MIPS proposals

New eligible clinicians (ECs)

CMS would use its statutory authority to expand the EC definition to new clinician types including physical therapists, occupational therapists, clinical social workers and clinical psychologists. CMS estimates approximately 650,000 clinicians will be MIPS ECs in 2019.

Low-volume threshold and opt-in opportunity

CMS proposes to add a third criterion for the low-volume threshold that excludes certain ECs and groups. CMS proposes to exclude ECs and groups that bill $90,000 or less in Medicare Part B charges, see 200 or fewer Medicare beneficiaries or provide 200 or fewer covered professional services under the PFS. As Congress required in the MGMA-supported Bipartisan Budget Act of 2018, CMS proposes to remove Part B drugs from the low-volume threshold determinations.

CMS would allow ECs and group practices that exceed at least one of the three low-volume threshold criteria to opt in to MIPS and be eligible for a corresponding payment bonus or penalty. The agency estimates 42,000 ECs will opt in to MIPS in 2019.

MIPS score and payment adjustments

ECs and group practices would continue to be scored 0 to 100 points in MIPS based on data in four performance categories: quality (45 points), promoting interoperability (25 points), cost (15 points) and improvement activities (15 points). ECs and group practices would need to earn at least 30 out of a possible 100 points in 2019 to avoid a Medicare payment cut of up to 7% in 2021. This is an increase from the current threshold of 15 points. ECs and groups earning more than 30 points would be eligible for a positive payment adjustment in 2021.

As required by the Bipartisan Budget Act of 2018, MIPS payment adjustments would be applied only to the professional services payments of ECs and not to Part B drugs.

Certified EHR technology (CEHRT) requirements

CMS proposes requiring use of 2015 Edition CEHRT beginning in 2019. According to the Office of National Coordinator for Health Information Technology, only 66% of MIPS ECs have 2015 CEHRT as of the first quarter of 2018.

MIPS category: Quality (45% of MIPS score)

In response to MGMA advocacy, CMS proposes to allow ECs and groups to report quality data using multiple data collection types, such as two qualified registries, except for the CMS Web Interface. The agency proposes to allow third-party intermediaries to submit data to the CMS Web Interface in addition to groups and on behalf of groups. CMS seeks comment about expanding the CMS Web Interface reporting option to groups consisting of 16 or more ECs in future years. Currently, the CMS Web Interface is available only to groups of 25 or more ECs.

CMS proposes to limit the claims-based reporting option to small practices (15 or fewer ECs); however, the agency would allow small groups to report via claims at the group practice level.

MIPS category: Promoting interoperability (25% of MIPS score)

CMS renamed the “advancing care information” category and is now referring to it as “promoting interoperability.” Promoting interoperability would move away from base, performance and bonus scoring and instead use performance-based scoring for each measure, except for those that require a yes/no response. ECs and groups would be required to report certain measures from four objectives and the scores for each measure would be added together to calculate the overall category score of up to 100 possible points. As part of this scoring reconfiguration, CMS proposes to remove the bonus for reporting certain improvement activities using CEHRT.

MIPS category: Cost (15% of MIPS score)

CMS proposes to increase the weight of the cost category from 10% to 15% of an EC’s or group’s final MIPS score in 2019. CMS would continue to measure ECs and group practices on the total per capita cost and Medicare spending per beneficiary measures. The agency would add eight episode-based measures, which only include items and services related to the episode of care for a clinical condition or procedure, as opposed to including all services provided to a patient over a given period of time.

Facility-based measurement

CMS proposes a facility-based measurement option for ECs who perform at least 75% of their services in the hospital inpatient, on-campus outpatient or emergency department setting and groups with 75% or more such ECs. The agency would calculate the quality and cost scores for qualifying ECs and groups using a hospital’s performance in the Medicare Hospital Value-Based Purchasing program. To be measured as a group, a facility-based group must submit data in the improvement activities or promoting interoperability categories.

CMS proposes to automatically apply facility-based quality and cost scores to qualifying ECs and groups unless the agency receives another quality data submission for that EC or group and the combined quality and cost performances scores for the other submission results in a higher combined quality and cost score than the facility-based score.