2019 MPFS and QPP Proposed Rule: Critique and Anticipated Impact

Major overhaul to physician reimbursement is proposed.

The Centers for Medicare & Medicaid Services (CMS) revealed the proposed rule for Medicare Physician Fee Schedule (MPFS), in conjunction with the 2019 Quality Payment Program (QPP) in the Federal Register on July 27. The deadline to comment on this proposal is Sept. 10, 2019.

First off, according to the proposed rule, the 2019 MPFS conversion factor is $36.05: a slight increase from the 2018 conversion factor of $35.99.

In my opinion, this is a most dramatic and major overhaul to the way physicians are reimbursed for their services, especially in the outpatient setting. The common theme in this proposal is lessening the burden of documentation on physicians, as well as simplifying the complicated payment formulas for different levels of services that have been in use for decades (1995). There is also a new recognition of importance of technology-based virtual care and inter-professional communication.

In this 2019 iteration, CMS is proposing to simplify evaluation and management (E&M) codes by making single blended payments for level 2-5 for both initial as well as follow-up visits. They propose $135 for initial visits and $93 for follow-up visits. They are removing the documentation requirements, as they have been in place for years. And this particularly is of much interest to physicians who have busy outpatient practices and are bogged down by requirements of extensive documentation, most of which is redundant and copied and pasted from previous notes. CMS also is proposing that physicians acknowledge findings of other office staff without having to re-document everything in their notes.

On the flip side, removing documentation requirements does create a perfect setup for scammers to game the system, and the possibility of a trend towards using shorter but more frequent visits to maximize reimbursement. For example, in our practice we have family practitioners, internal medicine generalists, and geriatric psychiatrists and geriatricians.

Our geriatricians and internists do tend to use higher levels of codes that under the new rule would cut their payments for each visit. But also, we have family practitioners who perform level 2 or 3 routine visits for common chronic conditions, and they might get a payment bump from these follow-ups. We definitely welcome reductions in documentation requirements, as well as increased payments for levels 2 and 3, but we are apprehensive about our geriatricians and geriatric psychiatrist, who will be getting lower payment for their usual level 5 visits. The proposed rule mentions additional payments for certain specialties due to the nature and complexity of their practice, but geriatrics and geriatric psychiatry are not included, so we are concerned about that.

I would recommend that this drastic change in payment structure for all outpatient visits first should be piloted in a demonstration project for a few years to see how it fares overall, and if it is successful and leads to better outcomes, better primary care, and better physician satisfaction, it could be rolled out to all physicians.

The question still remains how medical necessity for these visits will be determined, as well as how fraud-and-abuse audits targeting multiple unnecessary visits will be conducted.

Since this bombshell was dropped, the unsuspecting physician community is trying to make heads or tails of it. The Internet is abuzz with comments from various physician societies.

The next change that I would like to comment on is the payment reduction for multiple procedures per visit. For an E&M service as well as a procedure taking place on a single day, the proposal calls for reduction a payment by 50 percent to the lower-level code.

This is something that will negatively affect our practice and its revenue. A step closer to bringing telemedicine into the mainstream, the new rule proposes payments for non face-to-face visits that include virtual check-ins, “brief communication technology-based service,” asynchronous images and video, “remote evaluation of pre-recorded patient information,” and peer-to-peer Internet consults called “inter-professional Internet consultation.” These new codes will surely promote person-centered care and help achieve the triple aim.

Although our group reports into the Quality Payment Program (QPP) throughout track 1, plus the Medicare Shared Savings Program (MSSP) Accountable Care Organization (ACO), the major changes in QPP propose increased weightage of cost category to 15 percent, hence signaling CMS’s intentions to keep holding physicians accountable for total cost of care for their attributed Medicare patients.

Other important QPP changes include expanding the definition of Merit-based Incentive Payment System (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 dietitians, or nutrition professionals), implementing an option to use facility-based scoring for facility-based clinicians, and modifying the MIPS Promoting Interoperability (PI) performance category to align with the proposed new PI requirements for hospitals.

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