CMS Issues Guidance for 2019

There are important action items for radiology providers in the 2019 Final Rules for the Medicare Physician Fee Schedule (MPFS) and the Outpatient Prospective Payment System (OPPS). This article summarizes the most important changes. For information about the Appropriate Use Criteria Program in a separate article.

Site Neutral Payment

Medicare’s site-neutral payment policy, which was implemented in 2017, applies to non-excepted off-campus provider-based hospital departments (PBDs). For example, the policy applies to 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 OPPS payment rate for the service. For 2019, the payment rate will continue at 40% of the OPPS rate.

Hospitals must continue to apply modifier PN (Nonexcepted service provided at an off-campus, outpatient, provider-based department of a hospital) to unexcepted services provided in unexcepted PBDs so that the Medicare contractor can identify these services and pay them appropriately.

Alternatively, excepted services must be reported with modifier PO (Excepted service provided at an off-campus, outpatient, provider-based department of a hospital) and are paid in the normal manner under OPPS.

Radiologist Assistant

CMS finalized its proposal to allow radiologist assistants (RAs) and radiology practitioner assistants (RPAs) to perform diagnostic tests under direct supervision when permissible by respective state law and state scope of practice.

This does not change the level of physician supervision required for exams, nor will a new supervision indicator be created. Rather, this simply allows RAs and RPAs to perform diagnostic imaging tests under direct supervision that otherwise require personal supervision. This does not affect diagnostic imaging exams that require general supervision.

Evaluation and Management Services

Many changes were proposed in relation to evaluation and management (E/M) services this year. CMS will be implementing only some of these changes effective January 1, 2019. Requirements for teaching physician documentation will be revised to allow the presence and extent of participation of the teaching physician to be documented in the notes of a physician, resident, or nurse. The revisions are “intended to align and simplify teaching physician E/M service documentation requirements . . . [and] reduce burden and duplication of effort for teaching physicians.”

CMS also implemented changes to “simplify and reduce redundancy in documentation.” For new and established patients, documentation of history and exam obtained by ancillary staff or the patient does not need to be re-entered by the physician. The physician should, however, indicate in the medical record that the information has been reviewed and verified. Additionally, when the medical record of an established patient already contains the relevant information for the visit, the physician only has to document pertinent information on what has changed or not changed since the last visit. The physician should also indicate that the previous documentation was reviewed.

CMS has also committed to revamping and updating reporting and reimbursement of office/outpatient E/M services for new and established patients. They admit a stepwise approach is necessary, and therefore, are focusing only on changes to CPT® codes 99201-99205 and 9921199215 for now. These changes have not been finalized and have been delayed until 2021.

MIPS (Merit-Based Incentive Payment System)

CMS announced that 91% of MIPS eligible clinicians participated in the CY 2017 transition year. The data from CY 2017 was used to estimate eligibility and payment adjustments for CY 2019 MIPS performance period. CMS also noted that significantly more clinicians are expected to participate in MIPS using the group reporting option for CY 2019.

CMS is estimating there will be approximately 798,000 MIPS eligible clinicians for CY 2019 MIPS performance period. CMS is also estimating payment adjustments of approximately $390 million, including negative and positive adjustments.

For 2019, the following provider types are being added to the list of MIPS eligible clinicians:

  • Physical therapist
  • Occupational therapist
  • Qualified speech-language pathologist
  • Qualified audiologist
  • Clinical psychologist
  • Registered dietitians or nutrition professional
  • Group that includes such clinicians

MIPS has 4 performance categories. For CY 2019, the categories and contributions are as follows:

  • Quality – 45%
  • Cost – 15%
  • Improvement Activities (IA) – 15%
  • Promoting Interoperability (PI) – 25%

Note that the Promoting Interoperability category replaces the former category of Advancing Care Information (ACI).

- Article by Coding Strategies® Staff