CMS Proposed 2019 Medicare Physician Fee Schedule and QPP Proposed Rules for Pathologists

CMS Proposed 2019 Medicare Physician Fee Schedule and Quality Payment Program Proposed Rules – impact on Pathology Practices

Each June CMS publishes its proposed rule for the following year.  On Thursday, July 12th, CMS released the proposed rules for calendar year 2019.  I’m sure you will be receiving numerous updates from a variety of sources, but here are a few quick highlights and their potential impact to your practice in 2019.

The proposed conversion factor, which is the amount to be multiplied by each procedure’s RVU value, will increase slightly from $35.99 to $36.05.

The total net impact of RVU adjustments to pathology is a reduction of 1% per the table listed on page 1025 of the proposed rule.   (See table below for impact to all individual specialties)

Evaluation and Management Code Changes (“E&M Codes)

Although your practice may be minimally impacted by changes in E&M Codes, the changes for 2019 are significant.  The major changes are:

  1. Allowing providers to base E&M coding determinations on medical decision-making time in addition to the current guidelines which originated in 1995 and 1997.
  2. Proposing to pay a single rate for E&M levels 2 through 5, to reduce burden and inconsistent application of E&M coding levels between providers.
    1. Although the rule has not been finalized, modeled on 2018 reimbursement, this would yield $135.00 for new patients and $93.00 for established patients.

Telehealth Services

CMS is proposing to pay for the following new applications of technology:

  1. Brief communication between provider and patient.
  2. Remote Evaluation of Recorded Video and or Images Submitted by the Patient.
  3. Chronic Are Remote Physiologic Monitoring.
  4. Prolonged Preventive Service.

Price Transparency

CMS is seeking information from the public to increase price transparency for patients with regard to their out of pocket costs and information as to what can be done by providers to better inform patients of these obligations.

Appropriate Use Criteria for Advanced Imaging

The 2018 rule delayed the requirement for using a qualified Clinical Decision Support Mechanism (“CDSM”) until January 1, 2020, with voluntary reporting beginning July of 2018.  The 2019 rule reaffirms this timely, but CMS will not begin to deny claims until January 1, 2021 to allow providers time to test and implement the reporting requirements.

Merit Based Payment System  (“MIPS”)

A number of proposed changes will impact the calculations and we will continue to provide ongoing support to help you achieve the maximum thresholds and reimbursement levels.  Proposed changes include the following:

  1. Increase the performance threshold from 15 to 30 points.
    • This can have an impact as high as 7% upward or as low as 7% downward for 2021, based on 2019 activity.
  2. Expansion of Eligible Clinician provider types.
  3. Proposed changing Advancing Care Information category to Promoting Interoperability category.
  4. Reducing the Quality category from 50% to 45%.
  5. Increase the Resource Use from 10% to 15%.

As with any proposal, some of these proposed changes will be impacted by comments which stakeholders must submit by September 10, 2018.  Based on prior year precedence and the amount of stakeholder engagement CMS used in arriving at these proposals, it is likely that many of these proposed changes will be finalized at or near their present form in late November when the final rule is published in the Federal Register.

Here is the link to the entire 1473 page proposed rule:

Should you have questions about any of the specific provisions or their potential impact to your practice, please let us know.  Watch for an update from HealthPro once the proposed changes are finalized and published in the Federal Register in late November.

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