Provisions in 2019 Updates to Medicare Physician Payments

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Provisions in 2019 Updates to Medicare Physician Payments

Their likely effects on ASCs

ASCA regulatory coverage primarily focuses on Medicare payments to ASCs—called the technical component or technical payment—which are outlined and updated each year by a proposed rule in the summer and a final rule in the fall. The technical payment is the amount the Centers for Medicare & Medicaid Services (CMS) has determined will be paid to facilities for administrative, personnel or capital costs related to providing a certain procedure. This payment will differ by procedure and by facility type (i.e., ASCs receive different reimbursement for the same procedure performed in a hospital or physician office).

The other part of Medicare reimbursement, the professional payment, reimburses the physician for their work in completing the procedure. Like the technical payment, CMS also updates these payment rates annually with a proposed update released in the summer and a final update released in the fall. Taken as a whole, these set of rates are called the Medicare Physician Fee Schedule (MPFS).

Although changes to MPFS rates and guidelines do not affect ASC payments, they do affect physician behavior. This year the MPFS created a significant amount of controversy in the health care world, as the new administration attempted to put its stamp on Medicare with a bold new proposal for Evaluation and Management (E/M) services. More than 15,000 comments were submitted in response to the CY 2019 MPFS Proposed Rule, up from 2,500 the year before. Although CMS would ultimately back down from the most controversial parts of the proposal, for context, it is worthwhile to examine what was finalized for the coming year. However, any downstream effects on day-to-day ASC administration would result from changes in physician behavior/patient selection and are as yet undetermined.

Evaluation and Management Changes

The controversial proposal mentioned above surrounded E/M services, specifically, how physicians document and are paid for such services. E/M codes are straightforward. As their name suggests they “classify services provided by physicians in evaluating patients and managing their medical care.” Although routine, these services provide an important baseline in the care process, determining the complexity of any subsequent care needed. The current guidelines for documenting such visits, created in 1995 and 1997, have long been considered outdated for modern practice. After asking for feedback on overhauling the guidelines in last year’s MPFS Proposed Rule, CMS delivered a number of proposed changes in this year’s rule.

Many of these changes centered around reducing time and redundancy, such as allowing practitioners to review and sign-off on, rather than re-enter, information added to the medical record by ancillary staff. CMS also proposed that, for established patients, practitioners focus on documenting information that has changed rather than re-recording a defined list of elements. The health care community applauded both proposals and others like them and CMS finalized them.

Proposed changes to payments, however, were not so well-received. Currently, E/M visits are paid according to complexity, with the most complex, Level 5, visits receiving the highest reimbursement and the least complex, Level 1, visits receiving the lowest reimbursement. In this year’s MPFS, CMS proposed a drastic new structure, in which the five levels of complexity would be collapsed into just two levels, with one lower Level 1 payment and one higher payment for Levels 2 through 5. The proposal outraged the health care industry and medical professionals posted comments on the Federal Register, made their voice heard in op-eds in the Hill, Health Affairs and the New England Journal of Medicine, and in an AMA letter in which 170 medical groups signed on to oppose the changes. Consequently, the MPFS Final Rule put forward a much reduced proposal, collapsing payments into three rates—rather than the proposed two—and, more importantly, pushed any changes off until 2021. Substantial advocacy in the intervening years could pull back the policy even further.

Other Final Provisions

The rest of the CY 2019 Final Rule proved much less controversial. Many cheered the addition of a number of new codes for telehealth, as CMS worked around strict statutory requirements that has limited telehealth reimbursement to rural/under-served locations. CMS elected for no change to payment rates for off-campus hospital outpatient departments (HOPD), now covered in the MPFS after their payments were split off from the Outpatient Prospective Payment System (OPPS) rates beginning in 2017. This policy is an effort by CMS to prevent hospitals from acquiring freestanding physician offices or ASCs and realizing higher reimbursement rates for the same procedures. These facilities will continue to be paid at 40 percent of the OPPS rate.

Finally, this year CMS folded the Quality Payment Program (QPP)—the Medicare Access and CHIP Reauthorization Act (MACRA) mandated value-based purchasing program for Medicare physician payments—into the MPFS. The QPP includes the Merit-based Incentive Payment System (MIPS), which ASC clinicians might be participating in. CMS made only minor updates to the MIPS program for 2019, most notably renaming the Advancing Care Information (ACI) performance category to Promoting Interoperability and thus aligning it with the Inpatient Prospective Payment System rule earlier in the year. ASC-based clinicians, however, continue to be exempt from reporting in this category due to lack of access to certified EHR technology.

For more information, write Alex Taira.