CMS Posts 2019 Physician Fee Schedule includes changes to Medicare Part B Drug Payments and Telehealth Reimbursement

On November 1, 2018, the Centers for Medicare & Medicaid Services (CMS) finalized its 2019 Medicare Physician Fee Schedule. We previously covered the proposed rule and the concerns it raised to the physician and healthcare community. In the final rule, physician groups secured a victory as CMS revised its policy. The agency also moved forward with telemedicine codes. However, CMS did finalize a change to Part B drug payments that many physician groups opposed.

Evaluation and Management (E/M) Codes

CMS largely backed off from its major proposal to collapse E/M codes 2-5 into one single rate. CMS finalized keeping level 5 codes and finalized collapsing levels 2-4 into one rate, starting in 2021.

As FierceHealthcare noted, CMS will immediately finalize several burden-reduction proposals that doctors supported, effective January 1, 2019. But in response to concerns, the final rule includes revisions that preserve access to care for complex patients, equalize certain payments for primary and specialty care and allow the delay in implementation of E/M coding reforms until 2021.

CMS backed off on immediate implementation after it received over 15,000 comments on a proposed rule released in July—many of them in opposition to the change, which would have collapsed payment rates for eight office visit services for new and established patients down to two each.  Saying it could underpay doctors who treat the sickest patients, more than 150 medical groups also sent a letter opposing the plan to consolidate E/M codes.

The American Medical Association, said it applauded the government for revising its original proposed E/M policies.

“The AMA also is grateful that the administration is not moving forward in 2019 with the payment collapse of E/M codes,” said AMA President Barbara L. McAneny, M.D. The two-year window for implementation of the proposal will allow time for an AMA-convened workgroup to make recommendations on the complicated topic, she said.

Part B Drug Costs

CMS finalized its proposed to change how the agency pays for new drugs on the market. Specifically, during this time period, the standard pricing tool, average sales price (ASP) is not available and Medicare instead reimburses based on wholesale acquisition cost (WAC). Starting January 1, 2019, during the phase in which Medicare Part B drugs are reimbursed based on WAC, drugs will be reimbursed at WAC plus 3 percent of the ASP, as compared to the current methodology of WAC plus 6 percent of ASP. CMS states that it believes this change in policy is likely to decrease copayments for individual beneficiaries who are prescribed new drugs.

Telehealth

In the final rule, CMS pushed forward with proposals to pay for two newly defined physicians’ services furnished using communication technology. The HCPCS codes G2012 and G2010, related to virtual check-ins and remote evaluation of recorded video and/or images submitted by an established patient.

Physicians could be separately paid for the brief communication technology-based service when the patient checks in with the practitioner via telephone or other telecommunications device to decide whether an office visit or other service is needed. Similarly, the service of remote evaluation of recorded video and/or images submitted by an established patient would allow physicians to be separately paid for reviewing patient-transmitted photo or video information conducted via pre-recorded “store and forward” video or image technology to assess whether a visit is needed. CMS is also finalizing policies to pay separately for new coding describing chronic care remote physiologic monitoring and interprofessional internet consultation.

Quality Payment Program (QPP)

The rule advances CMS’ plan to update the quality measures included in Year 3 of QPP to only include those most crucial for enabling improvements in patient health outcomes in accordance with the CMS Meaningful Measures initiative. CMS also increases the small practice bonus to 6 points and includes this bonus in the Quality performance category score of clinicians in small practices instead of as a standalone bonus. Under QPP Year 3, CMS will continue to award small practices 3 points for submitted quality measures that do not meet the data completeness requirements.