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CMS Proposes Payment, Reporting Changes for 2019

July 18, 2018

Updates to the Quality Payment Program (QPP), significant revisions regarding documentation and payment for Evaluation & Management (E&M) services, a slight increase in the conversion factor from $35.99 to $36.05, and numerous proposals to streamline reporting and other requirements for eligible clinicians (ECs) are among the highlights of the proposed Medicare Physician Fee Schedule (PFS) for 2019.  The Centers for Medicare and Medicaid Services (CMS) requests comments on the proposed rule before September 10, 2018.

For Year 3 of the QPP, CMS proposes, among other things, to:

  • Expand the definition of eligible clinicians to include physical therapists, occupational therapists, clinical social workers and clinical psychologists.
  • Expand the low-volume threshold criteria and give clinicians who meet only one or two elements of the criteria the option not to participate in the QPP’s Merit-Based Incentive Payment System (MIPS).  Currently, clinicians who bill $90,000 or less in Medicare charges and who see 200 or fewer Medicare patients may opt out of MIPS.  In 2019, CMS proposes adding a third opt-out criterion: 200 or fewer covered professional services.
  • Revise the MIPS Promoting Interoperability (formerly known as Advancing Care Information) category to focus on enhancing interoperability among electronic health records, supporting patient access to their health information and aligning measures for this category with a proposed new Promoting Interoperability Program requirement for hospitals.

CMS also said it “will continue to identify low value or low priority process measures, which will be recommended for removal, and focus on meaningful quality outcomes for patients and streamlining reporting for clinicians.”

CMS proposes to restructure E&M requirements, coding and policies to:

  • Allow clinicians to choose to document office and outpatient E&M visits using medical decision-making or time instead of using current documentation guidelines, or to continue using the current framework.
  • Expand current options to allow clinicians to document and bill for E&M services based on time, regardless of whether the visit consists primarily of care coordination or counseling.
  • Allow clinicians to focus on documenting what has changed since the patient’s previous visit or what has not changed, rather than having to re-document the patient’s history, provided previous information is reviewed and updated as needed.
  • Allow practitioners to review and verify certain information in the medical record that has been entered by ancillary staff or the patient, rather than re-entering it.
  • Eliminate the requirement to justify the medical necessity of a home visit in lieu of an office visit, and eliminate a policy that prevents payment for same-day E&M visits by multiple practitioners in the same specialty within a group practice.
  • Eliminate payment differentials for Level 2 through Level 5 E&M visits in office and outpatient settings.  CMS would develop a single set of relative value units for these Level 2 through Level 5 visits for new patients (CPT codes 99202-99205) and a single set of RVUs for established patients (CPT codes 99212-99215).

The rationale of these and other proposals regarding E&M services is to “allow practitioners greater flexibility to exercise clinical judgment in documentation, so they can focus on what is clinically relevant and medically necessary for the beneficiary.”

In the proposed rule, CMS also requests comments from the public regarding barriers to price transparency for patients.  Specifically, CMS is interested in input regarding changes needed to support greater transparency around patient obligations for their out-of-pocket costs; how providers can better inform patients of these obligations; and what role providers and suppliers should play in this initiative.

The complete proposal is available here.


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