CMS Releases Final Rule for 2019 Medicare Physician Fee Schedule

On November 1, the Centers for Medicare & Medicaid Services (CMS) finalized updates to payment policies and rates for services furnished under the Medicare Physician Fee Schedule (PFS) on or after January 1, 2019.
CMS also finalized on November 2 the 2019 Hospital Outpatient Prospective Payment System rule.  This communication offers a summary of two components of the PFS rule that have the potential to significantly impact nuclear cardiology.
Appropriate Use Criteria (AUC) for Advanced Diagnostic Imaging
CMS made clear in the final rule that it is moving forward with implementation in 2020 of the Medicare AUC Program for Advanced Diagnostic Imaging, which will begin with a testing phase. ASNC is deeply disappointed that CMS is proceeding toward implementation of the Program which is in clear conflict of its objective to put “Patients over Paperwork.”  CMS states in the rule that granting blanket provider exemptions from the AUC Program, such as waiving AUC requirements for participants in the Quality Payment Program, would require action by Congress.  In the weeks ahead during the Lame Duck session of Congress, ASNC will be calling upon each and every member to contact their members of Congress urging their action to stop implementation of the costly and burdensome Medicare AUC Program.
CMS finalized with little modification its proposals for continued implementation of the AUC Program. Most notably, CMS finalized that AUC data will be reported by furnishing professionals on the Medicare claim form using a series of G codes and modifiers — a proposal CMS previously abandoned. CMS acknowledged that the use of G-codes and modifiers may not be an ideal solution for reporting AUC data, but allows for program implementation to occur in 2020 as finalized.  CMS also noted there are still technical issues that will need to be worked out with regard to G-codes. CMS has yet to propose how the transfer of AUC information will occur between the ordering and furnishing professions, nor how it will identify outlier ordering professionals who will be subject to prior authorization.
In the final rule CMS finalized that:
  • Independent Diagnostic Testing Facilities are an applicable setting, meaning that providers furnish advanced diagnostic imaging in those settings will need to meet AUC Program requirements.
  • Consultation of AUC may be performed by clinical staff under the direction of the ordering professional.
  • Claims from both furnishing professionals and facilities must include AUC consultation information.
  • G-codes and modifiers will be used to report consultation information on claims.
Evaluation and Management (E/M) Documentation and Payment

The Final Rule reflects substantial positive changes from the proposed rule, changes that largely reflect ASNC comments to CMS.  CMS finalized changes to streamline E/M documentation for 2019, but E/M payment changes and corresponding documentation requirements will not take effect until 2021. CMS says that it intends to use this two-year window to continue to seek input from the physician community and an AMA-convened workgroup of coding and valuation experts as to the appropriate valuation of E/M services.
  • CMS has finalized documentation changes as part of its ongoing commitment to reduce regulatory burden.  These changes will take effect in 2019:
  1. The requirement to document medical necessity of furnishing visits in the home rather than office will be eliminated
  2. Physicians will no longer be required to re-record elements of history and physical exam when there is evidence that the information has been reviewed and                updated
  3. Physicians must only document that they reviewed and verified information regarding chief complaint and history that is already recorded by ancillary staff or the patient
  • CMS did not finalize application of a multiple-procedure payment reduction to separate E/M services furnished on the same day as a global procedure.
  • CMS has modified and delayed implementation of a new E/M payment policy.
CMS proposed to collapse into a single, blended payment rate E/M levels 2-5. CMS has instead finalized a single payment rate for office and outpatient E/M levels 2-4 that will take effect in 2021. These payment changes will be accompanied by corresponding documentation changes. Collapsing levels 2-4 will have a redistributive effect on the specialties that bill E/M codes. For 2019, providers should continue to use either the 1995 or 1997 E/M documentation guidelines to document E/M office and outpatient visits billed to Medicare.