The RBMA Federal Affairs Committee (FAC)  has prepared a summary of the provisions of the 2019 (CMS) Medicare Physician Fee Schedule (MPFS) Final Rule


The MPFS Proposed Rule was issued July 10th and the RBMA FAC went to work quickly in reviewing and formulating RBMA comments which were submitted to CMS on 9/10/18.  
In general, CMS has listened to the “House of Radiology” in developing the Final Rule which will govern all Medicare physician reimbursement policy in calendar year 2019.  The current copy of the Final Rule is a “Display Copy” and the regulation will be issued on 11/23/18 in the Federal Register.  The Final Rule can be seen at CMS.gov.  Note Title:  CMS-1693-F
Questions regarding the MPFS Final Rule benefit all members and should be posted on RBMA Connect Practice Management site with members and staff responding.  

RBMA Federal Affairs Committee:  Linda Wilgus, Chair; Wendy Block, Linda Bredl, Keith Chew, Clark Davis, Matthew DesRosiers, Jamie Dyer, Mark Isenberg, Mark Kalmar, Julie Pekarek, Liz Quam, Don Rodden, Lauren Sloan, David Smith, Jennifer Studdard, Suzanne Taylor, Bob Still, Executive Director, Shea McCarthy; Thorn Run Partners. 

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2019 Conversion Factor = $36.0391 an increase of 0.0401.

Appropriate Use Criteria (AUC)/Clinical Decision Support (CDS).

  • CMS has reaffirmed the implementation date of January 1, 2020.
    • Year 2020 would be an educational and operations testing period, no impact on reimbursement.
    • Year 2021 penalties will apply to exams not consulted.
  • CMS is going forward with G Codes and modifiers vs. a unique identifier
    • The actual G Codes and modifiers will be specified at a future date.
  • CMS is encouraging the Clinical Decision Support Mechanisms (CDSMs) to return/supply the G Code and modifier to the entity consulting and will consider regulatory guidance if necessary.
  • In the proposed rule there was much confusion on who could consult CDSMs and if it could be delegated to an “auxiliary” staff member under the direction of the ordering provider.  CMS modified the proposal to state that, "when not personally performed by the ordering professional, the consultation with a qualified CDSM may be performed by clinical staff under the direction of the ordering professional." CMS used the word "clinical" rather than "auxiliary" and removed the link to incident to regulations. 
  • QQ still in effect for voluntary reporting.
  • Included in the definition of “applicable setting” are IDTFs.  
  • CMS has clarified that the consultation must be reported on the both the TC and PC.
  • Hardship exceptions (HCPCS designated code where providers self-attest)
    • Insufficient internet access.
    • Electronic medical records/CDSM vendor issues.
    • Extreme or uncontrollable circumstances.

     

Radiology Assistants

  • CMS finalized the rule allowing Radiology Assistants (RA) to perform certain diagnostic tests previously required under personal supervision to be furnished under direct supervision.  
  • Providers need to ensure state laws and scope of practice rules allows RAs to perform these tests.
  • Note: Limited to only diagnostic tests, not procedures.


Practice Expense Review – Equipment/Labor/Supplies

  • CMS hired a third-party contractor (StrategyGen) to conduct an in-depth market research/review of supply costs, equipment pricing and labor costs that make up the components of the practice expense RVUs.  Upon completion of this review, new direct practice expense (PE) values would be created and new values phased in over a 4-year period (2019-2021).  After reviewing the survey, RBMA expressed significant concern over the equipment values associated with two Ultrasound Rooms.  Fully implemented, the new values associated with these rooms would have cut the technical component of Ultrasound reimbursement by 40%, phased in over 2019-2021.  RBMA, in conjunction with the ACR, ACC and other stakeholders, combined efforts to form a coalition to educate CMS, the Office of Management and Budget (OMBP) and members of Congress of our concern with the inaccurate information and the lack of transparency over the process.  In the final rule, CMS updated 60 supply and equipment values, but did not go forward with the values associated with the Ultrasound rooms.  For now, the cuts have been temporarily averted. 
  • There continues work to be done in order to provide CMS with accurate cost information associated with Ultrasound Services.  RBMA will be looking for help from members who have purchased ultrasound equipment during the past 18 months.  


E & M Codes

In order to reduce administrative burden and improve payment accuracy, CMS proposed moving away from the current documentation guidelines to a more complex and time-based method.  In the proposed rule, current reimbursement for a Level 1 visit remains the same, but for levels 2 through 5, reimbursement was averaged and fixed at the same level.  Providers would then use add on codes to indicate time spent and/or complexity of the medical decision making.
Providers across all subspecialties expressed significant concern.  In the final rule, CMS made a slight modification to their proposal in that they kept current reporting and reimbursement for Levels 1 and 5, and averaged/fixed reimbursement for Levels 2 – 4.  The changes won’t take effect until 2021 and CMS is still open to review and feedback on this change. 

Quality Payment Program – Year 3

Notable changes are as follows:

  • Composite Scoring Weights for 2019 reporting year, 2021 payment year are as follows:
    • Cost – 15%.
    • Quality – 45%.
    • Promoting Interoperability – 25% (Formerly known as Advancing Care Information).
    • Clinical Improvement Activities – 15%.
  • Bonus/Penalty thresholds are set at +7%/-7%.
  • MIPS performance threshold has been increased from 15 points in 2018 to 30 points for 2019
  • Exceptional performer bonus threshold has been increased from 70 to 75 points for 2019
  • Low Volume Threshold now includes a 3rd criteria
    • Have < $90K in Part B allowed charges or
    • Provide care to < 200 beneficiaries or
    • Provide < 200 covered professional services
  • Data completeness is maintained at 60%, but eligible clinicians can use multiple types of data collection tools vs. a single submission mechanism.
  • CMS has finalized 8 episode-based measures that trigger patient attribution relevant to the Total per Capita Cost and MSPB measures:
    • Knee Arthroplasty.
    • Elective Outpatient Percutaneous Coronary Intervention.
    • Revascularization for Lower Extremity Chronic Limb Ischemia.
    • Routine Cataract Removal with Intraocular Lens Implantation.
    • Screening/Surveillance Colonoscopy.
    • Intracranial Hemorrhage or Cerebral Infarction.
    • Simple Pneumonia with Hospitalization.
    • ST-Elevation Myocardial Infarction with PCI.
  • Use of AUC still qualifies as a high-weighted clinical improvement activity.
  • Participation in R-Scan still qualifies as a median weighted clinical improvement activity.
  • Eligible clinicians may have the option to use facility-based scoring (VBP) for facility-based clinicians that would not require quality data submission.  To be eligible for this option, clinicians would need to furnish 75% or more of their covered professional services in an inpatient hospital, on campus outpatient hospital or emergency room.  Clinicians would still need to attest to Improvement Activities and Promoting Interoperability.
    • If more than 1 facility is used to calculate the 75%, the clinician is attributed to the hospital at which they provide the most services to Medicare patients.
  • No significant change to Improvement Activities.
    • CMS added 6 new activities, modified 5 activities and removed 1.
  • Promoting Operability 
    • Reweighting of this category remains the same (i.e. 50% or more of patient encounters occurs in a location where clinician has no control over the availability of CEHRT, non-patient facing, etc.).
    • Using 2015 CEHRT edition, scoring changes include eliminating base, performance and bonus scores.  New methodology is at the individual level attesting yes/no to 1 objective and 1 measure set.