Blog Post

Physician payment 2019: Your 4 biggest takeaways

November 14, 2018

    CMS recently released 4,242 pages of final rules affecting payment for physician services in 2019. With several significant updates to both the Medicare Physician Fee Schedule (MPFS) and the Hospital Outpatient Prospective Payment System (HOPPS), here are the four biggest things you need to know.

    Download the slides: Decode Medicare's 2019 outpatient final rule

    1. Both simpler documentation and consolidated payment for E&M levels 2-4 on the horizon

    Starting in calendar year (CY) 2019, providers will only need to highlight changes since they last saw the patient. CMS advanced its "Patients Over Paperwork" initiative by eliminating two documentation requirements:

    1. That providers justify the medical necessity of a home visit over an office visit; and

    2. For physicians to re-document information added to a patient's records either by practice staff or the patient or during a previous visit.

    Beginning in CY 2021, CMS will also collapse evaluation and management (E&M) code levels 2 through 4 into one and pay providers a single rate (one each for established and new patients). CMS initially proposed to fold the level-5 E&M code into that single rate but instead will leave it separate. Retaining the standalone level-5 code and the two-year delay before payment changes go into effect are likely in response to the significant pushback CMS received, including more than 15,000 comments on the Proposed Rule.

    2. Clinicians to receive expanded reimbursement for certain virtual interactions

    For years, patients have been able to consult their clinician virtually—through the phone or patient portal—about whether their condition warrants a visit. CMS will now reimburse providers for this "desktop medicine." In a landmark move, CMS created two new codes eligible providers can bill for virtual communication with established patients only: both virtual check-ins and reviewing patient-sent photos/videos.

    • G2012—for brief, live, non-face-to-face interactions. This code cannot originate from related services within previous seven days, nor leading to procedure within 24 hrs.

    • G2010—store and forward images. This code is not for wearables/other patient generated information that could be considered remote patient monitoring. It can only be used to see if an office visit or other service is warranted.

    3. MIPS continues a slow roll out

    CMS finalized the weighting of the Merit-based Incentive Payment System (MIPS) payment track for CY 2019, affecting provider payment in 2021. The weighting of MIPS' cost category will increase for performance year 2019 (payment year 2021) by five percentage points to 15%. The agency will offset that change by reducing the weight of the quality category from 50% in the 2018 performance year to 45% in 2019. Weights for the remaining two categories—promoting interoperability and improvement activities—will remain at their 2018 levels of 25% and 15%, respectively. With 93% of participants earning a MIPS bonus payment in 2019 based on their 2017 performance, MIPS hasn’t been a huge challenge for most eligible providers so far. But, the steady increase of the cost category weight could change that in future years. 

    4. Phased site-neutral payments for all off-campus hospital outpatient departments (HOPDs)

    Starting in 2019, all off-campus HOPDs will be impacted by lower reimbursement rates for a specific routine clinic visit, code G0463. Over the next two years, CMS will phase in a "site-neutral" payment rate for E&M code G0463 when this code is performed in an off-campus HOPD: In 2019, off-campus HOPDs will see a 30% payment reduction for clinic visit G0463, with an additional 30% reduction set to kick in for 2020.

    CMS believes the routine clinic visit described by G0463 can be suitably performed in a physician office setting, where (in 2018) the average reimbursed rate was 75% lower than the HOPPS rate. G0463 is an exceptionally high-volume service, accounting for a third of all codes billed at off-campus HOPDs in 2017.  CMS expects to save around $300M (with $80M in beneficiary savings on coinsurance) on routine clinic visits across 2019 alone. For medical groups billing clinic visits under HOPD, this reduced reimbursement is a source of potential financial concern. 

    Download the slides: Decode Medicare's 2019 outpatient final rule

    Access the slides and recording from our recent webconference to learn about CMS' changes to hospital outpatient and ASC payment in CY 2019.

    Get the Slides

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