Highlights of the Medicare Physician Fee Schedule Final Rule

Highlights of the 2019 Medicare Physician Fee Schedule, released on Nov. 1, are provided by the author.

There will be no change in E&M payment levels for 2019, as was proposed in the Centers for Medicare & Medicaid Services (CMS) proposed, rule, news that comes as a relief to many that expected to lose valuable revenue as a result. Practitioners may still use the 1995 or 1997 Documentation Guidelines for Evaluation and Management Services.

In addition, beginning Jan. 1, 2019 and running through 2020, the other good news is that CMS has relaxed the rules for documentation requirements for E&M services for new and established patients’ office visits. The entire history can now be recorded by ancillary staff. The practitioner must review and validate the information from ancillary staff for the history portion of the service to be counted, and the service must still be medically necessary. The rule goes on to state that if relevant information is already contained in the medical record, the practitioner may focus documentation on what has changed since the last visit, or on pertinent items that have not changed. The practitioner does not need to re-record these elements if there is evidence that the previous information was reviewed and updated. I recommend that if the information is reviewed, the practitioner either indicate this with a brief statement, or, if using an intake or history form for this information, sign and date the form to validate that the information was reviewed or updated.

In addition, the physician will no longer be required to re-record elements of the physical exam when there is evidence the information has been reviewed and updated.

The final rule also removes duplicative requirements for services documented by residents or other members of the medical team for E&M services furnished by teaching physicians. CMS is also removing the requirement to document medical necessity when furnishing an E&M home visit, rather than an office visit.

In the final rule, CMS also notes it plans to go forward with implementing changes for E&M office outpatient visits in 2021. CMS is finalizing the following:

• Payment of a single rate for E&M office/outpatient visit levels 2 through 4 for new and established patients;
• Maintaining the payment for level 5 E&M office/outpatient visits for complex patients;
• Permitting practitioners to choose to document E&M office/outpatient level 2 through 5 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 guidelines;
• Flexibility will be allowed for how visits are documented. CMS will apply a minimum documentation standard for level 2 visits. Medicare will require information documented to support a level 2 E&M office outpatient visit for the three key components (history, examination, medical-decision making);
• Medical necessity must be documented for the visit when time is used for documentation requirements;
• Add-on codes will be created for additional resources in visits for primary and specialty care, to be reported with level 2-4 visits without specialty restrictions, as previously proposed; and
• Add-on codes will be created for extended visits for use with level 2-4 E&M office/outpatient visits when practitioners need to spend extended time with a patient.

It will be important to watch how the American Medical Association (AMA) and medical societies will react to CMS’s plan.

Telehealth Services

CMS also finalized its policy for telehealth services, adding separate Medicare payment for two types of service for brief non-face-to-face appointments via communications (virtual check-in) and remote evaluation of recorded video or images.

HCPCS code G2012 has been created for virtual check-in and will be used to determine whether an office visit or other type of service is necessary. Medicare will reimburse these services only when another related E&M service by the same practitioner does not lead to another related E&M service by the same practitioner within the previous seven days (or another E&M service within the next 24 hours, or the soonest available appointment).

HCPCS code G2010 will be used for remote evaluation of recorded video or images submitted by the patient. The same rule applies as with G2012, in relation to another E&M service. CMS also stated that a follow-up with the patient could take place via phone call, secure text messaging, email, audio/video communication, or patient portal. The beneficiary’s consent may be verbal or written, which includes electronic confirmation noted in the medical record.

Prolonged service codes G0513 and G0514 for prolonged preventive services was added to the list of Medicare telehealth services. These services include geographical requirements and originating site restrictions, as with other codes for telehealth.

Beginning July 1, 2019, CMS is removing the originating site and geographic requirements for opioid use disorders and will allow for reimbursement for origination in the patient’s home for treatment of a substance use disorder or a co-occurring mental health disorder.

In 2019 CMS will pay for chronic care remote physiologic monitoring and interprofessional internet consultation with the following CPT® codes:

• 99446: Interprofessional telephone/Internet/electronic health record assessment and management service provided by a consultative physician, including a verbal and written report to the patient’s treating/requesting physician or other qualified health care professional, with 5-10 minutes of medical consultative discussion and review
• 99447: 11-20 minutes of medical consultative discussion and review
• 99448: 21-30 minutes of medical consultative discussion and review
• 99449: 31 minutes or more of medical consultative discussion and review
• 99451: 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 healthcare professional, with five minutes or more of medical consultative time
• 99452: Interprofessional telephone/Internet/electronic health record referral service(s) provided by a treating/requesting physician or other qualified healthcare professional, 30 minutes
• 99453: Remote monitoring of physiologic parameters (e.g., weight, blood pressure, pulse oximetry, respiratory flow rate, etc.), with initial set-up and patient education on use of equipment
• 99454: Device(s) supply with daily recording(s) or programmed alert(s) transmission, each 30 days
• 99457: Remote physiologic monitoring treatment management services, with 20 minutes or more of clinical staff/physician/ other qualified healthcare professional time in a calendar month requiring interactive communication with the patient/caregiver during the month

Physical Therapy

The functional status HCPCS G codes, which indicate the patient’s functional limitations and severity provided during outpatient therapy services, will be discontinued effective Jan. 1, 2019.

New payment HCPCS modifiers for physical therapy assistants and occupational therapy assistants will be established for use in 2020.

Merit-Based Incentive Payment System (MIPS)

CMS is removing low-value and low-priority quality measures to focus on more meaningful measures that have a greater impact on health outcomes. In addition, MIPS-eligible practitioners must now use, at a minimum, 2015-certified electronic health record (EHR) technology beginning in 2019, ensuring that incentives are directly related to practitioners updating their systems so they are interoperable. CMS has introduced an opt-in policy for practitioners who see a low volume of Medicare patients, so they can still participate in MIPS if they choose.

The final rule increases the physician fee schedule conversion faction to $36.04, which is an increase from 2018.

The rule can be found in its entirety online at: https://www.cms.gov/MedicarE&Medicare-Fee-for-Service-Payment/PhysicianFeeSched/PFS-Federal-Regulation-Notices-Items/CMS-1693-F.html.

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