Summary
The proposed Medicare Physician Fee Schedule for 2019 includes a slight increase in the anesthesia conversion factor as well as some changes to the Quality Payment Program and a significant overhaul of documentation requirements for Evaluation & Management services. CMS is accepting comments on the proposal until September 10, 2018.

The Centers for Medicare and Medicaid Services (CMS) released the proposed Physician Fee Schedule (PFS) for 2019 on July 12, 2018. This eAlert highlights aspects of the proposed rule with the greatest importance for anesthesia practitioners.

According to the proposal, the national conversion factor (CF) for anesthesia services (unadjusted for geographic practice cost differences) would see a slight increase in the next calendar year to $22.2986 from $22.1887 in 2018. As with the non-anesthesia PFS CF, (see below), these increases include the 0.25 percent positive adjustment and budget neutrality adjustment mandated by the Bipartisan Budget Act of 2018. The anesthesia CF also reflects additional anesthesia-specific adjustments for increases in resource costs related to practice expenses and malpractice insurance.*

The proposed Resource-Based Relative Value Scale (RBRVS) CF (non-anesthesia) of $36.043 for 2019 also represents a slight increase from the 2018 CF of $35.996. The RBRVS, based on recommendations from the American Medical Association/Specialty Society Relative Value Scale Update Committee (RUC), is designed to vary payment for physician services to reflect changes in the resource costs of providing those services in three areas: physician work, practice expense and professional liability insurance. (Anesthesiologists would use this CF to bill for flat fee services, such as the use of ultrasound guidance in the placement of a nerve block.)

Significant changes to the Quality Payment Program (QPP) and a restructuring of coding and documentation requirements for Evaluation and Management (E&M) services to reduce administrative burden for clinicians are also among the proposal's highlights. In a statement, CMS Administrator Seema Verma hailed the 1,400-page document as the fulfillment of a promise by the agency "to put patients over paperwork by enabling doctors to spend more time with their patients." According to Ms. Verma, the proposals would streamline documentation requirements, enabling clinicians to be more productive and focus more on the delivery of care.

CPT code 95970 was identified as potentially misvalued. The chart below reflects CMS's proposed RVU for this code for 2019. CMS disagrees with the RUC's recommendation to keep the work RVU for the code at 0.45 and proposes a reduction to 0.35.


Source: CMS-1693-P, TABLE 13: CY 2019 Proposed Work RVUs for New, Revised, and Potentially Misvalued Codes

Evaluation & Management Restructuring

As part of its Patients Over Paperwork initiative to reduce the administrative burden for clinicians, CMS is proposing significant changes to the documentation and coding requirements for E&M services. These proposals are likely to have the greatest significance for chronic and interventional pain specialists.

"E&M visits make up 40 percent of all charges for Medicare physician payment, so changes to the documentation requirements for these codes would have wide-reaching impact," noted Ms. Verma in a July 17 letter to physicians.

The proposed overhaul would increase the options for documentation requirements from the 1995 and 1997 guidelines to also include the more liberal use of time and medical decision-making. The current payment differentials for levels 2-5 would be replaced with one payment level for office visits for new patients (CPT codes 99202-99205) and one payment level for established patients (CPT Codes 99212-99215).

"Most specialties would see changes in their overall Medicare payments in the range of 1-2 percent up or down from this policy, but we believe that any small negative payment adjustments would be outweighed by the significant reduction in the documentation burden," she said.

CMS also proposes restructuring E&M documentation and coding requirements to:

•​ 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 key aspects of 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.

•​ Eliminate a policy that prevents payment for same-day E&M visits by multiple practitioners in the same specialty within a group practice as long as medical necessity is justified.

•​ Create a separate G-Code for use by several specialties, including interventional pain management, that would add RVUs to the visit to account for the complexity of issues being treated.

•​ Create a new prolonged services G-Code for care 30 minutes beyond the typical time for the base code.

Quality Payment Program Changes

According to CMS, the proposed changes to the QPP also aim to reduce administrative burden, while focusing on outcomes and promoting the interoperability of electronic health records. For Year 3 of the QPP, CMS proposes, among other things, to:

•​ Expand the low-volume threshold criteria and give clinicians who meet only one of the three criteria the option not to participate in the QPP's Merit-Based Incentive Payment System (MIPS). Currently, eligible clinicians (ECs) who bill $90,000 or less in Medicare charges or 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.

•​ In addition, starting in Year 3, clinicians or groups would be able to opt-in to MIPS if they meet or exceed one or two, but not all, of the low-volume threshold criteria.

•​ 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.

•​ Allow facility-based clinicians to use the measure set for the Hospital Value-Based Purchasing Program (VBP) for their Quality and Cost scores.

•​ Remove MIPS 426 (Transfer of Care to PACU) and MIPS 427 (Transfer of Care to Intensive Care Unit) from the MIPS Quality category. (These measures have been topped out.)

•​ Require ECs or practices to achieve 30 MIPS total points in order to avoid a negative payment adjustment of up to 7 percent in payment year 2021.

​

For More Information

The complete 2019 proposed rule is available here.

A fact sheet on the proposed rule is available here.

A fact sheet on the proposed rule for Year 3 of the QPP is available here.

A press release on the proposed rule is available here.

CMS is accepting comments on the proposed rule until September 10, 2018. You can expect the final rule to be published in mid-November.

With best wishes,

Tony Mira
President and CEO