On November 1, the Centers for Medicare & Medicaid Services (CMS) released the Calendar Year (CY) 2019 Medicare Part B physician fee schedule (PFS) and Quality Payment Program (QPP) final rule. This rule includes numerous policies that impact physician payments under Medicare. Most notably, the final rule:
• Delays and modifies CMS’ proposal to streamline documentation requirements and create a new, single blended payment rate for new and established patients for office/outpatient Evaluation and Management (E/M) visits.
• Creates separate payments for two newly defined physicians’ services furnished using remote communication technology.
• Addresses ACEP’s concerns about the Appropriate Use Criteria (AUC) Program for advanced imaging by clarifying that an emergency medical condition includes instances where an emergency medical condition is suspected, but not yet confirmed. Therefore, if physicians think their patients are having a medical emergency (even if they wind up not having one), they are excluded from the AUC requirements.
• Finalizes a subset of changes to the Medicare Shared Savings Program for ACOs proposed in the August 2018 proposed rule “Medicare Program; Medicare Shared Savings Program; Accountable Care Organizations Pathways to Success.”
• Establishes set of policies related to the third year of the QPP– the performance program established by the Medicare Access and CHIP Reauthorization Act (MACRA).
ACEP’s summary of the rule can be found here.
Hospital Outpatient Rule
On November 2, CMS released the CY 2019 Medicare Hospital Outpatient Prospective Payment System (OPPS) and Ambulatory Surgical Center (ASC) Payment System final rule. In this nearly 1200-page rule, CMS is finalizing the following major policies:
• Paying for clinic visit services at 40 percent of the OPPS rate at all off-campus provider-based departments. The change will be phased in over two years, instead of one year as CMS originally proposed.
• Expanding Medicare reimbursement cuts for drugs purchased through the 340B discount program to certain hospital off-campus departments, focusing Medicare cuts on non-grandfathered hospital outpatient departments – equal to the 22.5% reductions imposed on all other settings in January 2018.
• Updating the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) patient experience of care survey measure by removing the three recently revised pain communication questions.
• Adding a new claim-line modifier, “ER,” that must be billed for outpatient hospital services furnished in an off-campus, provider-based emergency department.
• Paying separately for non-opioid pain management drugs that function as a supply when used in a covered surgical procedure performed in an ASC.
• Removing measures from the Hospital Outpatient Quality Reporting Program and from the Ambulatory Surgery Center Quality Reporting Program.
CMS is also not finalizing a major proposal to pay the site-neutral rate to an otherwise excepted off-campus hospital outpatient department for new clinical families of services not previously offered between November 1, 2014, and November 1, 2015.