On November 2, 2018, CMS published its CY 2019 physician fee schedule final rule.  The final rule implements a number of significant changes to the way practitioners receive reimbursement for items and services provided to Medicare beneficiaries, including:

  • Eliminating the requirement for a practitioner to document the medical necessity of a home visit in lieu of an office visit beginning with CY 2019.
  • Reducing the documentation for established patient office and outpatient visits so that practitioners do not need to re-record information previously put in the medical record and instead focus on updates to the record.  For evaluation and management (“E/M”) office and outpatient visits practitioners will not need to re-enter relevant patient information and instead may indicate that the information has been reviewed and verified.
  • Changes to the E/M office and outpatient visit codes.  In response to comments, the changes will not take effect until calendar year (CY) 2021.  Beginning in CY 2021, CMS will begin paying a single rate for levels 2 through 4  E/M office and outpatient visits.  This will apply to both established and new patients.  In a change from the proposed rule, CMS will maintain the payment rate for E/M office and outpatient visit level 5 to account for the additional needs of complex patients.
  • Modifies documentation requirements for E/M visits beginning in CY 2021.  More specifically, for E/M office and outpatient level 2 through 5 visits, practitioners may document visit levels using the current framework, medical decision-making or time instead of the 1995 or 1997 E/M documentation guidelines.  For visits meeting levels 2 through 4, minimum supporting documentation standard currently associated with level 2 visits will apply.  If a practitioner chooses to use time to document the medical necessity of the visit, documentation for the face-to-face time spent with a beneficiary by the billing practitioner will need to be provided.
  • CMS will also implement an “extended visit” add-on code for level 2 through 4 visits.
  • Finalizing CY 2019 payment rates for non-excepted off-campus provider-based hospital departments. CMS will make payment for items and services furnished in non-excepted off-campus provider-based departments using a PFS Relativity Adjuster of 40%.  In CY 2019, CMS will make payments for non-excepted items and services at 40% of the amount that would have been paid under the Outpatient Prospective Payment System.
  • Beginning January 1, 2019, wholesale acquisition cost (WAC)-based payments for Part B drugs will be reduced.  Presently, during the first quarter of sales when average sales price is unavailable, Part B drugs are reimbursed at average sales price plus 6%.  The final rule reduces the add-on to 3%.  CMS believes this will reduce excessive spending on new drugs and decrease beneficiary cost sharing.
  • The final rule also adds two additional HCPS codes related to telehealth services.   Medicare will provide reimbursement for virtual check-ins and evaluation of remote recorded video and/or images of an established patient.
  • The final 2019 PFS conversion factor is $36.04, which is a slight adjustment from the 2019 PFS conversion factor of $35.99.

A fact sheet summarizing the final rule is available here.

The final rule is available here (it will be published in the Federal Register on November 23, 2018).

A fact sheet regarding Evaluation & Management payment amounts is available here.