The Centers for Medicare & Medicaid Services (CMS) has issued its final Medicare physician fee schedule (PFS) rule for calendar year (CY) 2019.  In addition to updating rates for physician services, the rule adopts changes to numerous other Medicare Part B policies.  Highlights of the final rule include the following:

  • The final 2019 conversion factor (CF) is $36.0391, up slightly from the 2018 CF of $35.9996.  This rate is based on a statutory update of 0.25%, offset by a -0.14% relative value unit (RVU) budget neutrality adjustment.
  • The rule reduces from 6% to 3% the “add-on” payment for new, separately-payable Part B drugs and biologicals that are paid based on wholesale acquisition cost when average sales price during first quarter of sales is unavailable.
  • The rule makes a number of changes to the Appropriate Use Criteria (AUC) program, which requires that physicians who order outpatient advanced diagnostic imaging (ADI) services (diagnostic magnetic resonance imaging, computed tomography, and positron emission tomography/nuclear medicine) for a Medicare beneficiary consult with AUC developed by provider-led organizations approved by CMS via a qualified clinical decision support mechanism (CDSM).  Specifically, the final rule:
    • Extends the requirements to independent diagnostic testing facilities (joining physician offices, hospital outpatient departments, and ambulatory surgical centers).
    • Clarifies that AUC consultation information must be reported on all applicable technical component and professional component claims (i.e., not just reported on claims by furnishing facilities).
    • Provides that when delegated by the ordering professional, clinical staff under the direction of the ordering professional may perform the AUC consultation with a qualified CDSM (a modification to the proposed rule, which would have specified that AUC consultations may be performed by auxiliary personnel under the direction of the ordering professional and incident to the ordering professional’s services).
    • Uses established coding methods (e.g., G-codes and modifiers) to report required information.
    • Revises the significant hardship exception criteria to include (1) insufficient internet access; (2) electronic health record or CDSM vendor issues; (3) extreme and uncontrollable circumstances; and (4) self-attestation of hardship status for ordering professionals.

For information regarding the AUC implementation schedule, see our previous post.

  • The final rule provides that those diagnostic tests paid via the Medicare Physician Fee Schedule that are performed by a registered radiologist assistant who is certified and registered by the American Registry of Radiologic Technologists, or a radiology practitioner assistant who is certified by the Certification Board for Radiology Practitioner Assistants, and that would otherwise require a personal level of supervision (Level 3, in the room throughout the procedure), may be furnished under a direct level of physician supervision to the extent permitted by state law and state scope of practice regulations. Until CMS issues additional guidance, this rule does not apply to the supervision of tests for Medicare hospital outpatients. 
  • CMS adopted changes to evaluation and management (E/M) payment and documentation policies that are intended to reduce administrative burdens and improve payment accuracy.  Notably, CMS is postponing adoption of the most significant policies until 2020, including elimination of the payment distinction and documentation requirements between E/M visit levels 2 through 4 (in a change, CMS is retaining the separate payment rate for level 5 codes).  In addition, based on comments, CMS is not adopting its proposed 50% multiple procedure payment adjustment when E/M visits and procedures with global periods are furnished together; as a result, CMS will apply a budget neutrality adjustment that is projected to reduce payment for specialties that do not furnish office/outpatient E/M visits.
  • The final rule makes numerous changes to the Quality Payment Program (QPP) designed to reduce burdens on clinicians, focus on outcomes, and promote interoperability of electronic health records. These proposals are discussed in a detailed CMS fact sheet.
  • The final rule includes numerous other policy provisions, including:  writing and signature requirements for certain compensation arrangement exceptions to the Stark Act; implementation of a statutory provision adding mobile stroke units, renal dialysis facilities, and the homes of ESRD beneficiaries as Medicare telehealth originating sites; payment for new communication technology-based service codes; discontinuation of certain functional reporting requirements for outpatient therapy services; and changes to the definition of “applicable laboratory” for clinical laboratory fee schedule purposes.