Some Relief in 2019 MPFS Proposed Rule

On July 12 the Centers for Medicare & Medicaid Services (CMS) released the Proposed Rule for the Medicare Physician Fee Schedule (MPFS) for CY 2019. The Proposed Rule was published in the Federal Register on July 27, and public comments are due by September 10. The Final Rule will be released by early November. See the MPFS Proposed Rule in its entirety at:

CMS estimates a 2019 conversion factor of $36.05, up from $35.99 in 2018. The estimated conversion factor reflects the 0.25% update specified by the Medicare Access and CHIP Reauthorization Act (MACRA) and a budget neutrality adjustment of -0.12%.

If the provisions in the Proposed Rule are finalized, CMS estimates a neutral (0%) impact for radiology and interventional radiology. However nuclear medicine would see an aggregate 1% decrease and radiation oncology would see a 2% decrease.

With approximately 60 new or revised radiology codes for 2019, CMS is proposing increased relative value units (RVUs) for some codes and decreased RVUs for others.

Appropriate Use Criteria/Clinical Decision Support

CMS has finalized a date of January 1, 2020 for implementation of appropriate use criteria (AUC)/clinical decision support (CDS) for all advanced diagnostic imaging services. This delay allows more time to develop instructions for claims processing. An “educational and operations testing period” will begin on January 1, 2020 for one year. During this period, ordering professionals will consult AUC, and imaging providers will report AUC information on their claims, but claims will be paid regardless of correct reporting.

CMS is still proposing the use of a series of G codes and modifier for claims processing.

CMS proposes that the consultation may be performed by “clinical staff working under the direction of the ordering professional,” allowing flexibility, yet achieves the goal of promoting the use of AUC.

CMS also proposes adding independent diagnostic testing facilities (IDTFs) to the definition of “applicable setting,” to apply the AUC program across a range of outpatient settings where the applicable imaging services are provided. CMS also invites comment on adding any other applicable settings for the program.

CMS proposes that when ordering advance diagnostic imaging services, physicians who are experiencing insufficient internet access, electronic health record (HER) or clinical decision support mechanism (CDSM) vendor issues, or extreme/uncontrollable circumstances (including natural and manmade disasters) are not required to consult AUC using a qualified CDSM.

Regarding outlier ordering professionals, CMS will not be using the data during the testing period to identify outliers. CMS is therefore inviting public suggestion for methodologies for identification of outliers.

Site Neutral Payment

The site-neutral payment policy, which was implemented in 2017, applies to non-excepted off-campus provider-based hospital departments (PBDs), such as a physician office that is owned by a hospital and maintained as a hospital outpatient department, is remote from the hospital campus, and did not begin providing services until November 2, 2015, or later.

Medicare currently pays for services provided in non-excepted PBDs under the MPFS at 40% of the Outpatient Prospective Payment System (OPPS) payment rate for the service. For 2019 CMS proposes to maintain this payment rate.

Proposed Valuation of Specific Codes for CY 2019

CMS proposes valuation changes to several established codes and several new CPT® codes yet to be fully released by the American Medical Association (AMA). Those codes relevant to radiology that are specifically addressed by CMS include:

  • Fine needle aspiration (FNA) - 10021, 10X11, 10X12, 10X13, 10X14, 10X15, 10X16, 10X17, 10X18, 10X19, 76942, 77002, and 77021
  • PICC line procedures – 36568, 36569, 36X72, 36X73, 36584
  • Radioactive tracer – 38792
  • Gastrostomy tube replacement – 43X63, 43X64
  • Urinary tract dilation – 50X39, 50X40, 52334, 74485
  • X-ray of spine – 72020, 72040, 72050, 72052, 72070, 72072, 72074, 72080, 72100, 72110, 72114, 72120
  • X-ray of sacrum – 72200, 72202, 72220
  • X-ray of elbow/forearm – 73070, 73080, 73090
  • X-ray of heel – 73650
  • X-ray of toe – 73660
  • X-ray of esophagus – 74210, 74220, 74230
  • X-ray of urinary tract – 74420
  • Fluoroscopy – 76000
  • Echo exam of eye thickness – 76514
  • Ultrasound elastography – 767X1, 767X2, 767X3
  • Ultrasound of scrotum – 76870
  • Contrast-enhanced ultrasound – 76X0X, 76X1X
  • Magnetic resonance imaging (MRI) – 76X01
  • Computed tomography (CT) scan for needle biopsy – 77012
  • Dual-energy x-ray absorptiometry – 77081
  • Breast MRI with computer aided detection (CAD) – 77X49, 77X50, 77X51, 77X52

This article will not discuss the specific proposals for the RVU adjustments. Refer to the Proposed Rule for more information.

Radiologist Assistant

Currently, some diagnostic tests require personal supervision when performed by a radiology assistant (RA). CMS proposes to revise the required physician supervision for those services to direct physician supervision when performed by an RA, when permitted by state lay and state scope of practice regulations. This addresses the stakeholder comments that the current level of supervision is restrictive and does not allow radiologists to fully utilize RAs.

Evaluation and Management Guidelines

In the 2018 Proposed Rule, CMS request public comment on how to bet update 1995 and 1997 Documentation Guidelines for Evaluation and Management (E/M) Services, which are “potentially outdated and need to be revised, especially the history and exam components.” In the 2019 Proposed Rule, CMS suggests a step-wise approach that would limit changes to only the office/outpatient E/M code set (99201-99205, 99211-99215). CMS is not ruling out changes or expansion into inpatient and emergency department care, but simply admits that these codes come with “unique clinical and legal issues and the potential intersection with hospital Conditions of Participation (CoPs).”

Specifically, CMS has proposed the following changes to office and outpatient E/M services.

CMS proposes public comments about eliminating or making adjustments or exceptions for the provision in which billing same-day visits by practitioners of the same group and same specialty are not separately billable. The original intent was that these services would not be medically necessary. However, it is becoming more likely that a patient may be seen for different reasons by the same physician or specialty group as physicians cross train into multiple specialties.

CMS proposes allowing physicians to choose a documentation that better serves to support the type of work and visits each physician provides. The choices would be continue utilizing the 1995 or 1997 guidelines, utilize a framework designed around medical decision making as the main component, or utilize a time based framework. CMS believes this change would lessen the burden to practitioners to no longer document irrelevant components or those that are burdensome to include. The same codes (99201-99215) would be used.

CMS is also proposing for only the key components of history or exam for established patients, and only those corresponding items that had changed or have not changed since the last visit would be documented.

Regardless of the selected framework, CMS proposing two different reimbursement values between the 5 levels of new patient visits and two different reimbursement values between the 5 levels of established patient visits.

CMS is also proposing new G codes to reflect the use or more or less resources used by certain specialties.

Finally, regarding teaching physicians, CMS is proposing to allow the presence of the teaching physician to be doumented with a note in the medical record by a physician, resident, or nurse. Additionally the extent of the participation and direction of services provided to the beneficiary may be demonstrated by notes in the medical record by a physician, resident, or nurse.

- Article by Coding Strategies® Staff