Medicare Physician Fee Schedule Proposed Rule for CY 2019

The proposed rule that will affect some payments under the Medicare Physician Fee Schedule and/or payment methodologies was released by CMS on July 12, 2018. This is a high overview of some of the changes; all clients should review the proposed rule to identify any categories that may affect them. Once the proposed rule is published on July 27, 2018 the comment period will be open until September 10, 2018. All comments must be submitted to CMS for consideration by September 10, 2018. The Final Rule is expected to be published October – November 2018. Meridian Medical Management will distribute Part 2 of the Proposed Rule which will contain information on proposed changes for the Quality Payment Program.

Changing the way office and outpatient Evaluation and Management (EM) services are documented and reimbursed

CMS is proposing changes to the way office/outpatient EMs are documented and reimbursed. They propose four ways to document, allowing practitioners to choose the method that is best for them. These include:

  • Medical Decision making
  • Use time as the driving factor in selecting the visit level and documenting the EM visit, regardless of whether counseling or coordination of care dominates the visit
  • Continue documenting via the 1995 Documentation Guidelines (DGs)
  • Continue documenting via the 1997 Documentation Guidelines (DGs)

Reimbursement proposal for office/outpatient EM services:

  • 99201 and 99211 would be reimbursed at the following rates:
    • 99201 = $44.00
    • 99211 = $24.00
  • 99202 – 99205 would be reimbursed at a fixed rate of $135.00
  • 99212 – 99215 would be reimbursed at a fixed rate of $93.00

For both sets of codes starting at level 2, payment will be made at the same rate regardless of the code billed. Time based coding has not been decided.

CMS is soliciting comments on the best way to reimburse for face to face time with the patient. The benefit for this type of payment is a decreased risk of audit. Documentation must support at least a level 2 new/established patient visit regardless of whether you bill 99205 or 99215 as payment will be the same.

Other proposals affecting EM services

  • CMS is proposing a reduction for EM service by 50% for those visits billed with modifier 25 – procedure done on the same day.
  • CMS is aware that some specialties are more complex and is proposing that certain specialties be allowed to bill add on codes in addition to levels 2-5, to adequately reflect resources utilized by these specialties.
  • CMS is proposing eliminating the requirement to justify the medical necessity of a home visit in lieu of an office visit.
  • For E/M visits furnished by teaching physicians, they have proposed to eliminate potentially duplicative requirements for notations in medical records.

Communication Technology-Based Services

Proposal: Separate payment for Technology-Based services

  • Checking in with patients via phone or other devices to determine if a visit or other service is required.
  • Remote evaluation of recorded video and/or images submitted by the patient to determine if a visit or other service is needed.

Chronic Care/Inter-Professional Internet Consultations

Proposal: Separately paying for new coding described as Chronic Care Remote Physiologic Monitoring

  • CPT codes 990X0, 990X1 and 994X9

Proposal: Separately paying for Inter-Professional Internet Consultations

  • CPT codes 994X6, 994X0, 99446, 99447, 99448 and 99449

Radiology Assistants (RAs)

Proposal: Revise the requirement for the level of supervision required for RAs

  • This allows radiologists to make full use of RAs. Reducing the required level of supervision will improve efficiency of care.

Physical/Occupational Therapy

Since 2013 CMS has required functional status information on claims for outpatient therapy services. This was accomplished with the use of G codes and modifiers.

Proposal: Discontinue functional status reporting requirements for services furnished on or after 1/1/19

Proposal: Establish two new therapy modifiers, one for PT assistants and one for OT assistants

  • These modifiers are to be used when services are provided in whole or in part by these assistants and are to be used in conjunction with the existing three modifiers. This will fulfil the requirement that these services be reimbursed at 85% of the Part B payment amount effective 1/1/2022.

2019 Conversion Factor

The proposed 2019 PFS conversion factor is $36.05 which is an increase from the 2018 PFS conversion factor of $35.99.

Market-Based Supply and Equipment Pricing Update

Proposal: Update the direct Practice Expense (PE) input prices for approximately 1,300 supplies and 750 equipment items

  • CMS is proposing a four year “phase in” process which would begin in 2019 and continue through 2022.

Medicare Telehealth Services

Proposal: the addition of two codes to the list of telehealth services.

  • G0513 and G0514 – these two codes would report prolonged telehealth preventive services.

ESRD Patients and patients with acute stroke

Proposal: Add dialysis facilities and the homes of ESRD patients

  • Not apply originating site requirements for hospital-based or critical access hospital-based renal dialysis centers, dialysis facilities and beneficiary homes.
  • Add mobile stroke units as originating sites and not apply the requirements for telehealth services for the purpose of diagnosis, evaluation, or treatment of symptoms of acute stroke.

Clinical Laboratory Fee Schedule (CLFS)

Proposal: Change the way Medicare Advantage payments are treated in CMS definition of “applicable laboratory”

  • Lab fees are based on data from applicable laboratories that is collected in a specified period of time. By changing the definition of “applicable laboratory” this will allow CMS to increase the number of laboratories that they can collect data from.

Ambulance Fee Schedule Payments

Proposal: To revise the regulations to conform to the requirements set forth by the Bipartisan Budget Act of 2018 to extend the temporary add-on payments for ground ambulance services for 5 more years.

RHCs and FQHCs – Technology-Based Services

Proposal: Payment for RHCs and FQHCs for communication technology-based services and remote evaluation services that are furnished by an RHC or FQHC practitioner when there is no associated billable visit.

Wholesale Acquisition Cost (WAC)

Proposal: Effective 1/1/2019 WAC-based payments for new Part B drugs during the first quarter of sales when Average Sale Price (ASP) is unavailable

  • The drug payment add-on would be 3% replacing the 6% add-on that is currently in use.

Aligning the Medicare Shared Savings Program Accountable Care Organization (ACO) with the meaningful Measures Initiative

Proposal: Reduce the total number of measures in the Shared Savings Program quality measure set from 31 to 24 with a focus on more outcome-based measures.

Appropriate Use Criteria (AUC)

Proposal: Revise the significant hardship criteria in the AUC program to include three hardships:

  1. Insufficient internet access
  2. EHR or Clinical Decision Support Mechanism (CDSM) vendor issues
  3. Extreme and uncontrollable circumstances.

Proposal: Add independent diagnostic testing facilities (IDTFs) to the definition of applicable setting under this program

Proposal: Allow AUC Consultations to be performed by auxiliary personnel, allowing the ordering professional to delegate at their discretion the performance of this consultation.

For a fact sheet on the CY 2019 Physician Fee Schedule proposed rule, please visit:

To view the CY 2019 Physician Fee Schedule proposed rule, please visit: