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Medicare Physician Fee Schedule Rule

Update

On September 10, AAPM&R submitted comments for the Medicare Physician Fee Schedule 2019 Proposed Rule. Hundreds of members voiced their opinions regarding the rule. Click here to read physiatry's comments, submitted by your primary medical society.

Overview: 2019 MPFS Proposed Changes to Office and Outpatient E/M

On July 12, 2018 the Centers for Medicare & Medicaid Services published the CY 2019 Medicare Physician Fee Schedule proposed rule. The rule includes several provisions related to office and outpatient evaluation and management (E/M) services, which will impact the entire house of medicine, including physiatry. The below information summarizes some of the key issues the Academy is collecting member input on for a comment letter which will be submitted to CMS by the September 10, 2018 deadline.

Documentation

In place of current documentation requirements for office and outpatient E/M, CMS proposes that providers will be allowed to choose from the following:

  • Existing 1995/1997 guidelines
  • Medical Decision Making
  • Time

Furthermore, when meeting documentation guidelines, a minimum documentation standard is proposed whereby practitioners would only need to meet documentation requirements associated with a level 2 visit unless the practitioner is using time to document. 

Payment

CMS proposes to pay a single payment rate for visit levels 2 through 5 by developing a single set of RVUs for new patient levels 2 through 5 and established patients levels 2 through 5.

 

New Patient

Code

Current wRVU

Current Payment

Proposed wRVU

Estimated Proposed Payment

99201

0.48

$45

0.48

$44

99202

0.93

$76

1.90

$135

99203

1.42

$110

99204

2.43

$167

99205

3.17

$211

Established Patient

Code

Current wRVU

Current Payment

Proposed wRVU

Estimated Proposed Payment

99211

0.18

$22

0.18

$24

99212

0.48

$45

1.22

$93

99213

0.97

$74

99214

1.50

$109

99215

2.11

$148

 

Payment Reduction when Procedures are Billed with E/M

CMS proposes to resolve perceived duplicative payment when E/M visits and procedures are billed together.  In such instances when the same patient has an E/M visit and a procedure on the same day by the same provider, payment for the least expensive service will be reduced by 50 percent.  This proposed policy is similar to modifier 25 reduction policies proposed by private payers this year. 

Add-on G Codes

CMS proposes to create new add-on codes to be billed with office and outpatient E/M to recognize additional resources for certain services:

  • GPCIX – visit complexity inherent to evaluation and management associated with primary medical care services that serve as the continuing focal point for all needed health care services (add-on code, list separately in addition to an established patient evaluation and management visit)
  • GCG0X – visit complexity inherent to evaluation and management associated with endocrinology, rheumatology, hematology/oncology, urology, neurology, obstetrics/gynecology, allergy/immunology, otolaryngology, cardiology, or interventional pain management-centered care (add-on code, list separately in addition to an evaluation and management visit

ALERT: Ultrasound of Extremity Practice Expense Reimbursement Change 

We announced earlier this year that practice expense reimbursement for ultrasound of extremity codes 76881 and 76882 has changed for 2018. Practice expense for the complete code (76881) has decreased to account for a change in the typical specialty performing the procedure. CMS determined the service is no longer expected to be typically performed using a dedicated ultrasound room or PACS workstation. The decrease in 2018 was the first step in a multi-year decrease in practice expense for this code, which was approved in full by CMS in 2017.

In 2019, practices are expected to see another incremental decrease in reimbursement for this code, and should be prepared for this decrease to gradually expand over the next several years. Your Academy continues to advocate for the specialty and works to prevent additional changes like this in the future. 

About MPFS

Medicare payment for physicians, and some non-physician practitioners (NPPs), is based on set rates under Medicare Part B. The system for payment, known as the Medicare Physician Fee Schedule (MPFS), is used when paying for: professional services of physicians and some NPPs; covered services incident to physicians’ services (other than certain drugs covered as incident to services); diagnostic tests (other than clinical laboratory tests); and radiology services. The MPFS also addresses various quality issues, fraud and abuse issues, and other issues that impact physicians. CMS updates the MPFS regulations annually, with comment periods open prior to implementation of the final rule.