Healthcare Revenue Cycle Management, ICD-10, Claims Reimbursement, Medicare, Medicaid

Policy & Regulation News

CMS Proposes 2019 Physician Payment, Quality Payment Program Changes

A recently proposed rule aims to reduce clinician burden with Medicare physician payments and the Quality Payment Program.

Medicare physician payments and Quality Payment Program

Source: Xtelligent Media

By Jacqueline LaPointe

- CMS recently proposed major changes to Medicare physician payments and the Quality Payment Program to reduce the administrative burden of medical billing.

The potential changes in the Medicare Physician Fee Schedule would save individual clinicians 51 hours per year if 40 percent of their patients are in Medicare, while proposed changes to the Quality Payment Program would collectively save clinicians about 29,305 hours and approximately $2.6 million in reduced administrative costs, the federal agency reported.

“Today’s proposals deliver on the pledge to put patients over paperwork by enabling doctors to spend more time with their patients,” stated CMS Administrator Seema Verma. “Physicians tell us they continue to struggle with excessive regulatory requirements and unnecessary paperwork that steal time from patient care.”

“This Administration has listened and is taking action,” she added. “The proposed changes to the Physician Fee Schedule and Quality Payment Program address those problems head-on, by streamlining documentation requirements to focus on patient care and by modernizing payment policies so seniors and others covered by Medicare can take advantage of the latest technologies to get the quality care they need.”

Proposed changes to the Physician Fee Schedule

Major changes to Evaluation & Management (E&M) payments would significantly reduce clinician burden, the proposed rule states.

READ MORE: How MACRA Implementation Rules Affect Provider Profitability

“CMS and the Office of the National Coordinator for Health Information Technology (ONC) have heard from stakeholders that CMS’s extensive documentation requirements for Evaluation and Management codes have resulted in unintended consequences,” CMS explained in a fact sheet.

“To meet these documentation requirements, providers have to create medical records that are a collection of predefined templates and boilerplate text for billing purposes, in many cases reflecting very little about the patients’ actual medical care or story.”

Responding to these concerns, CMS proposed CY 2019 Physician Fee Schedule changes that would “help to free EHRs to be powerful tools that would actually support efficient care while giving physicians more time to spend with their patients, especially those with complex needs, rather than on paperwork.”

The potential changes to E&M payments include:

  • Simplifying, streamlining, and allowing more flexibility in documentation requirements for E&M office visits
  • Decreasing unnecessary physician supervision of radiologist assistants for diagnostic tests
  • Eliminating burdensome and complex functional status reporting requirements for outpatient therapy

READ MORE: The Difference Between Medicare and Medicaid Reimbursement

Additionally, CMS may also start to reimburse clinicians for virtual care under the updated Medicare Physician Fee Schedule.

The recently proposed rule would establish reimbursement for virtual check-ins and evaluations of patient-submitted photos. CMS would also expand Medicare-covered telehealth services to include prolonged preventative services.

“CMS is committed to modernizing the Medicare program by leveraging technologies, such as audio/video applications or patient-facing health portals, that will help beneficiaries access high-quality services in a convenient manner,” Administrator Verma stated.

Other major proposed changes to the Medicare Physician Fee Schedule in 2019 included:

READ MORE: Exploring the Fundamentals of Medical Billing and Coding

  • Physician Fee Schedule conversion factor of $36,05, up from $35.99 in 2018
  • Creation of two new therapy modifiers for PT assistants and OT assistants when services are wholly or partly furnished by the providers
  • Phase-in of new direct practice expense input pricing starting in 2019
  • Average sales price plus six percent payments for Part B drugs with wholesale acquisition cost (WAC)-based payments
  • Reduction in the number of quality measures used in the Medicare Shared Savings Program

In the proposed rule, CMS also sought additional stakeholder feedback on a new hospital price transparency requirement. The federal agency is looking for more information on a rule that would require hospitals to make public a list of their standard charges.

Specifically, stakeholders should comment on the barriers preventing providers and suppliers from informing patient of their out-of-pocket costs, what changes are needed to bolster price transparency, what can be done to inform patients of their financial responsibility, and what role providers have in healthcare price transparency.

Possible Quality Payment Program changes in 2019

Proposed changes to the third year of MACRA implementation aim to decrease clinician burden, prioritize outcomes, and increase EHR interoperability, CMS reported.

The federal agency intends to meet its Quality Payment Program goals by removing process-based quality measures in the Merit-Based Incentive Payment System (MIPS). CMS will remove measures that clinicians have identified as low-value or low-priority.

The proposed rule also contained changes to the “Promoting Interoperability” performance category of MIPS, which recently replaced the Advancing Care Information component of the new value-based purchasing program.

CMS plans to “overhaul” the MIPS performance category “to support greater electronic health record interoperability and patient access while aligning with the proposed new Promoting Interoperability Program requirements for hospitals,” an accompanying fact sheet stated.

The proposed rule would reduce the set of Objectives and Measures in the performance category.

The federal agency also included the following Quality Payment Program modifications in the proposed rule:

  • Expanding the definition of MIPS eligible clinician to include physical therapists, occupational therapists, clinical social workers, and clinical psychologists
  • Adding a third component to the low-volume threshold determination (200 covered professional services or less)
  • Gradual implementation of the Quality Payment Program by only requiring a performance threshold of 30 points
  • Allowing eligible clinicians who meet one or two elements of the now three-pronged low-volume threshold to participate in MIPS by choice
  • Creating an option for facility-based scoring for the Quality and Cost performance measures for certain facility-based clinicians

Additionally, the proposed rule would implement changes required under the Bipartisan Budget Act of 2018. Key changes from the act included only applying MIPS payment adjustments to covered professional services under the Physician Fee Schedule and using the same services to determine low-volume threshold calculations.

The MIPS Cost performance category would also weigh “not less than and not more than 30 percent for the third, fourth and fifth years of the Quality Payment Program.”

In addition, small practices would see additional flexibilities in MIPS. On top of retaining the small practice bonus, CMS also proposed to award small practice three points for quality measures that do not meet data completeness requirements and consolidate the low-volume threshold determination periods with the determination period for identifying a small practice.

Stakeholders can comment on the proposed changes to both the Medicare Physician Fee Schedule and the Quality Payment Program until Sept. 10, 2018.


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