The Centers for Medicare & Medicaid Services (CMS) released its 2019 proposed rule for both the Quality Payment Program (QPP) and the Medicare Physician Fee Schedule (MPFS) (pdf). The QPP section of the rule affects the 2019 performance period/2021 payment year related to your participation in the Merit-based Incentive Payment System (MIPS) and the Alternative Payment Models (APMs) as established within the Medicare Access and CHIP Reauthorization Act (MACRA).
Elements of the MPFS sections will impact practices for services provided on or after January 1, 2019.
According to the CMS press release on the QPP section, CMS has proposed several important changes to MIPS in 2019.
- CMS has added another threshold criteria – this time related to covered professional services. To be excluded from MIPS, eligible clinicians (ECs) or groups would need to meet one of the following three criterion: have ≤ $90K in Part B allowed charges for covered professional services OR provide care to ≤ 200 beneficiaries, OR provide ≤ 200 covered professional services under the MPFS.
- In addition, ECs or groups would be able to opt-in to MIPS if they meet or exceed one or two, but not all, of the low-volume threshold criterion.
- CMS has detailed a proposal on how facility-based clinicians may use the measure set for the fiscal year Hospital Value-Based Purchasing (VBP) program for their quality and cost component scores.
- CMS has proposed that out of 100 points available, 45% will be allocated to Quality, 15% to Cost, 25% to Promoting Interoperability (formerly Advancing Care Information) and 15% to Improvement Activities.
- CMS has proposed to remove MIPS 426 (Transfer of Care to PACU) and MIPS 427 (Transfer of Care to Intensive Care Unit) from the MIPS Quality component.
- The proposed performance threshold for 2019 is 30 MIPS Total Points. ECs or practices who fail to participate, when required, or to meet the 30 point threshold may incur up to a negative 7% payment adjustment in 2021.
In the MPFS section of the proposed rule, the estimated conversion factors are:
These figures are subject to change pending CMS decisions in the final rule to be posted this fall. The adjustments include the positive 0.25% adjustment under MACRA as well as other required adjustments. The anesthesia conversion factor also includes an additional positive adjustment for practice expense and malpractice updates.
If CMS finalizes its rule as proposed, the estimated impact on allowed charges for anesthesia and pain medicine physicians will be as follows:
||Allowed Charges (mil)
||Impact of Work RVU Changes
||Impact of Practice Expense RVU Changes
||Impact of Malpractice RVU changes
| Interventional Pain Mgmt
|Nurse Anes/Anes Asst
Source: CMS-1693-P, Table 94: CY 2019 PFS Estimated Impact on Total Allowed Charges by Specialty
Update on the Global Surgery Data Collection
CMS noted that the results of reporting on services performed within the global period of certain procedures (a data collection requirement established within MACRA) in 2017 failed to meet expectations. CMS is soliciting comments on what the agency may need to do to make practitioners aware of their obligation to report data and whether an enforcement mechanism is necessary.
CY 2019 Proposed Work Relative Value Unit Assignments (RVUs)
CMS is proposing the following work RVU assignments for new, revised, and potentially misvalued codes that are of note for anesthesiologists and pain medicine physicians:
||2018 Work RVU
||Proposed 2019 Work RVU
||Injection, anesthetic agent; greater occipital nerve
||Ultrasonic guidance for needle placement (eg, biopsy, fine needle aspiration biopsy, injection, localization device), imaging supervision and interpretation
||Electronic analysis of implanted neurostimulator pulse generator/transmitter (eg, contact group(s), interleaving, amplitude, pulse width, frequency (Hz), on/off cycling, burst, magnet mode, dose lockout, patient selectable parameters, responsive neurostimulation, detection algorithms, closed loop parameters, and passive parameters) by physician or other qualified health care professional; with brain, cranial nerve, spinal cord, peripheral nerve, or sacral nerve neurostimulator pulse generator/transmitter, without programming
Source: CMS-1693-P, TABLE 13: CY 2019 Proposed Work RVUs for New, Revised, and Potentially Misvalued Codes
In addition, CMS is proposing significant and substantial policy and payment changes to Evaluation and Management Services (E/MASA will post more information on E/M Services as we review the proposed rule.
Request for Information on Price Transparency: Improving Beneficiary Access to Provider and Supplier Charge Information
In this proposed rule, CMS notes its concerns about price transparency which includes patients receiving surprise bills for out-of-network services specifically mentioning anesthesiologists and radiologists. In an effort to determine how to promote greater transparency, CMS seeks comments on several questions which it included in the proposed rule. ASA will carefully review this section and provide thorough feedback to CMS on this issue which is so important to our members and their patients.
ASA members are encouraged to review CMS press releases, fact sheets and other opportunities to learn more about this significant rule.
- Press release - provides more detail about today's announcement
- Fact sheet - offers an overview of the proposed policies for 2019 (Year 3) and compares these policies to the current 2018 (Year 2) requirements
- Webinar - overview of the proposed rule for the 2019 performance period with the opportunity to ask questions
ASA will post additional information and details as staff and physicians continue to analyze the 1,473 page rule.