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HHS releases final Physician Fee Schedule and Quality Payment Program rules

11/09/2018 11:33 AM | Deleted user

November 9, 2018, WMS Medigram

The Centers for Medicare and Medicaid Services (CMS) released its final rule for 2019 for the Physician Fee Schedule (PFS) and the Quality Payment Program (QPP) last Thursday. Based on a preliminary review, the biggest provisions in the 2,400 page final rule relate to changes for Evaluation and Management (E/M) codes, expanding the use of telehealth services, reweighting the components of the Merit and Incentive-Based Payment System (MIPS), adding an opt-in option for MIPS, raising the scoring threshold for MIPS and creating a new category under MIPS called “Promoting Interoperability” (PI).

Under the 2019 PFS, CMS will begin a two-year transition process to a new documentation and reimbursement structure for E/M codes. Starting in calendar year (CY) 2021, clinicians will be able to document their E/M visits using any one of the following methods: 1995/1997 guidelines, medical decision making or time. In exchange for the flexibility and lowered administrative burden, CMS will reduce the number of reimbursement levels for E/M codes from to three. Level 1 and Level 5 will maintain their current reimbursement structure, while Levels 2 through 4 will be collapsed into a single rate. In the interim, the current reimbursement structure will remain in place, and clinicians should still use either 1995 or 1997 guidelines when billing E/M codes.

This change is intended to decrease administrative burden for clinicians by reducing documentation requirements. CMS originally proposed collapsing Levels 2 through 5 into a single rate effective January 1, 2019. However, there was significant pushback from all national, state, and specialty medical societies, including the Wisconsin Medical Society.

The PFS final rule also expands the use of telehealth services. New codes will now cover virtual check-ins, remote evaluation, substance use disorder and preventive services and will reimburse federally qualified health centers and rural health clinics for telehealth services when there is no billable visit.

In terms of MIPS, the minimum threshold score is being raised from 15 points to 30, and individual scoring components will be reweighted as follows:

  • Quality: 45 percent
  • Cost: 15 percent
  • Improvement Activities: 15 percent
  • Promoting Interoperability (NEW): 25 percent

The small practice bonus will be added to the Quality component score, rather than the overall MIPS score, as was the case previously. However, the complex patient bonus will remain as an addition to the final overall MIPS score.

CMS is also reconfiguring the Advancing Care Information (ACI) category under MIPS. Starting in 2019, ACI will be identified as the Promoting Interoperability (PI) category. Under PI, the base, performance and bonus scores that existed under ACI are being eliminated and replaced with a single set of objectives and measures. However, the reweighting and exemption provisions that applied to ACI will continue with under the new PI category.

Another change is that, for the first time, clinicians may opt-in to the MIPS provided they exceed one of the three low-volume thresholds:

  1. They have ≤$90,000 in Part B charges
  2. They provide services to ≤200 Part B beneficiaries
  3. They provide ≤200 Part B services.

This change is intended to add flexibility to the MIPS process.

There is little change to the Advanced Alternative Payment Models (APMs) for CY 2019. The nominal risk-based revenue thresholds will remain at 8 percent until 2024, although the certified electronic health record threshold will increase to 75 percent for all eligible APM clinicians. In addition, all measures used by APMs must be evidence-based, reliable and valid. Lastly, CMS will allow for a determination period for a new model of APM known as the “All-Payer Option” APM, which will be available in CY 2020 at the earliest.

Society staff continue to analyze the final rule and provide updates as appropriate.

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