2019 Medicare Physician Reimbursement and MIPS changes

MODERNIZING MEDICARE PHYSICIAN PAYMENT THROUGH COMMUNICATION TECHNOLOGY-BASED SERVICES 

CMS modernizes the Medicare program by expanding reimbursement opportunities for communications-based services, including telephone interactions, patient-submitted photos, and inter-professional consultations starting in 2019. These new services are not considered “Medicare telehealth services” and therefore are not subject to the same coverage limitations or coding policies.

Section 1834(m) of the Social Security Act defines “Medicare telehealth services” as including professional consultations, office visits, and office psychiatric visits that are furnished using two-way, real-time interactive communication between an eligible beneficiary and practitioner. To be eligible, a beneficiary must be located in a rural geographic setting at a clinical facility (an “originating site”), such as a physician office, hospital, or skilled nursing facility. Section 1834(m)’s restrictive requirements have significantly impeded the adoption of Medicare telehealth services, and despite broad congressional support to expand Medicare beneficiary access to these services, Congress has yet to remove statutory barriers and CMS lacks regulatory authority to make changes. 

In the 2019 PFS, CMS articulates a new interpretation of “Medicare telehealth services” by concluding this definition, and therefore associated statutory limitations, applies to a discrete set of services that are ordinarily defined, coded, and paid for as if they were furnished during an in-person encounter. CMS determined that communication technology-based services are inherently remote and rely on technology communications and are therefore outside the scope of Section 1834(m). This change in interpretation opens the door to new payment policies that recognize practitioners for the work they do outside of the traditional office visit and permits group practices to furnish communications technology-based services without meeting restrictive billing requirements that apply to “Medicare telehealth services.” PRACTICEFORCES is very supportive of this policy. 

Virtual care codes

Starting Jan. 1, 2019, CMS will pay separately for two newly-defined physician services:

Brief non-face-to-face appointment (e.g., a virtual check-in), using HCPCS code G2012. This code is intended to provide separate payment when a healthcare professional has a brief check-in with a beneficiary using communications technology like a telephone. To be separately reimbursable, the check-in cannot originate from a related E/M visit furnished within the previous seven days nor lead to an in-person visit within 24 hours or soonest available appointment. The work RVU for this service is 0.25.

Evaluation of patient-submitted images or video and subsequent follow-up, using HCPCS code G2010. The patient follow-up could take place via telephone, audio/video communication, secure text messaging, email or patient portal communication. Use of this code is subject to the same timeframe limitations as the virtual check-in code. The work RVU for this service is 0.18.

These codes are reportable by practitioners who independently bill Medicare for E/M visits and are limited to established patients. Beneficiaries must provide consent prior to each service and are responsible for any co-insurance amount owed.

Inter-professional consultations

CMS finalizes separate payment for two new codes that describe inter-professional internet/telephone consultations between a treating practitioner and a consulting practitioner (CPT codes 99451 and 99452) and unbundles existing CPT codes 99446, 99447, 99448, and 99449. Although these codes are intended to describe collaborative medical decision making among practitioners, beneficiaries are responsible for co-insurance amounts and practitioners must obtain and document prior consent.

Remote patient monitoring (RPM)

In the 2018 PFS, CMS finalized coverage for RPM services by unbundling and making separate payment for CPT code 99091. CMS expands on this policy through the 2019 PFS and will cover three new chronic care remote physiologic monitoring codes starting Jan. 1, 2019 (CPT codes 99453, 99454, and 99457). CMS declines to clarify the types of technology that will qualify for remote monitoring codes but intends to issue sub-regulatory guidance in the future.

MEDICARE TELEHEALTH SERVICES

CMS adds two new codes to the approved list of Medicare telehealth services starting in 2019 to describe prolonged preventive services (HCPCS codes G0513 and G0514). These services qualify as “Medicare telehealth services,” and therefore are subject to Section 1834(m)’s restrictions and administrative billing requirements, including use of the telehealth place of service (POS) code 02.

CMS finalizes modifications to existing Medicare telehealth regulations required or permitted by the Bipartisan Budget Act of 2018, including flexibilities for certain services related to end-stage renal disease home dialysis and acute stroke. Pursuant to the SUPPORT for Patients Act of 2018, CMS removes geographic requirements and adds a beneficiary’s home as a permissible originating site for telehealth services furnished for purposes of treatment of a substance use disorder or a co-occurring mental health disorder for services furnished on or after July 1, 2019. 

EVALUATION AND MANAGEMENT (E/M) SERVICES

In the 2019 PFS, CMS proposed revisions to E/M documentation requirements intended to reduce physician burden starting Jan. 1, 2019. Additionally, CMS proposed coding and payment revisions for new and established patient office visits by applying a single blended payment rate for level 2 through 5 visits. CMS included additional E/M payment proposals, including the creation of multiple add-on codes for use during certain visits and a multiple procedure payment reduction (MPPR) for certain same-day services. PRACTICEFORCES and other stakeholder groups overwhelmingly supported efforts to reduce documentation burden, but opposed collapsing payment rates, opposed applying the MPPR to same-day visits, and expressed concern that add-on code proposals lacked sufficient clarity. 

In general, the final rule reflects positive updates from the proposed rule.

contact author by clicking on contact us page.

PRACTICEFORCES comments to CMS. In the final rule, CMS aims to reduce documentation burden beginning Jan. 1,

Changes to E/M visit documentation requirements in CY 2019

Effective Jan. 1, 2019, CMS finalizes the following changes to E/M documentation guidelines that were supported by PRACTICEFORCES:

•             Practitioners are no longer required to re-record elements of history and physical exam when there is evidence that the information has been reviewed and updated;

•             Practitioners must only document that they reviewed and verified information regarding chief complaint and history that is already recorded by ancillary staff or the beneficiary; and

•             Practitioners no longer need to document medical necessity of furnishing visits in the home rather than office

Final 2019 MIPS Policies

NEW ELIGIBLE CLINICIANS (ECS)

CMS expands the EC definition to include new clinician types including physical therapists, occupational therapists, clinical social workers, qualified speech-language pathologists, audiologists, registered dietitians/nutritional professionals, and clinical psychologists. CMS estimates approximately 798,000 clinicians will be MIPS ECs in 2019.

LOW-VOLUME THRESHOLD AND OPT-IN OPPORTUNITY

CMS adds a third criterion for the low-volume threshold that excludes certain ECs and groups from MIPS. The current threshold is $90,000 or less in Medicare Part B charges or 200 or fewer Medicare beneficiaries. For the 2019 performance period, the final rule excludes ECs and groups that bill

$90,000 or less in Medicare Part B charges, see’s 200 or fewer Medicare beneficiaries, or provides 200 or fewer covered professional services under the PFS. As required by Congress in the MGMA-supported Bipartisan Budget Act of 2018, CMS removes Part B drugs from low-volume threshold determinations.

CMS now allows ECs and group practices who exceed one or two of the three low-volume threshold criteria to voluntarily opt-in to MIPS to become eligible for a corresponding payment bonus or penalty. ECs and groups wishing to opt-in should elect to do so using the QPP portal; CMS notes this decision is irrevocable. 

MIPS SCORE AND PAYMENT ADJUSTMENTS

ECs and group practices will continue to be scored 0-100 points in MIPS based on data in four performance categories: quality (45 points), Promoting Interoperability (25 points), cost (15 points),

MIPS CATEGORY: PROMOTING INTEROPERABILITY (25% OF MIPS SCORE)

The agency adds two new measures to the e-Prescribing objective: “Query of Prescription Drug Monitoring Program” and “Verify Opioid Treatment Agreement.” Both measures will be optional for 2019 and 2020, although ECs that choose to report them will earn up to 5 bonus points for each measure. CMS consolidated two former measures into one new measure, Receive and Incorporate Health Information, and there is a new exclusion from this measure when a physician’s EHR cannot receive or use electronic health information

MIPS CATEGORY: COST (15% OF MIPS SCORE)

CMS increases the weight of the cost category from 10% to 15% of an EC’s or group’s final MIPS score in 2019. The cost category was originally scheduled to increase to 30% in 2019. However, the Bipartisan Budget Act of 2018, which was supported by MGMA, authorized CMS to weight cost between 10% and 30% through the 2021 performance year.

CMS continues to measure ECs and group practices on the Total Per Capita Cost and Medicare Spending Per Beneficiary measures. The agency also adds eight episode-based measures listed below. The episode-based measures only include items and services related to the episode of care for a clinical condition or procedure, as opposed to including all services that are provided to a patient over a given period of time.