CMS Issues 2019 Final Rule: Conversion Factors, MIPS Updates and More
On November 1, 2018, CMS released the 2019 Medicare Physician Fee Schedule (MPFS) and 2019 Quality Payment Program (QPP) Final Rule. The rule will affect how physician anesthesiologists will be paid via Medicare in 2019 and how their QPP performance will affect their future 2021 payments.
As part of its comments on the proposed rule, ASA advocated for appropriate payment levels for anesthesia and pain medicine services, appropriate changes to the Quality Payment Program. ASA also supported the administration’s desire to reduce regulatory burden and to update rules and regulations that are dated and fail to reflect current practice. ASA was pleased that the final rule was consistent with many of ASA views.
Medicare Physician Fee Schedule (MPFS)
2019 Medicare Conversion Factors
Source: CMS-1693-F, CMS-1693-IFC, CMS-5522-F3, and CMS-1701-F. Table 92: Calculation of the Final CY 2019 PFS Conversion Factor. Table 93: Calculation of the Final CY 2019 Anesthesia Conversion Factor. November 1, 2018.
The final rule includes increases in both the anesthesia and RBRVS conversion factors. The calculations include a positive 0.25% adjustment per MACRA which is offset by a negative 0.14% adjustment due to budget neutrality adjustments. The anesthesia conversion factor includes a positive 0.27% adjustment for practice expense and malpractice changes – this is expressed in the relative value units (RVUs) assigned at the code level for RBRVS services.
2019 Overall Impact on Allowed Charges:
CMS estimated impacts on allowed charges for all specialties and specifically for anesthesiology and interventional pain management are as follows:
||Allowed Charges (mil)
||Impact of Work RVU Changes
||Impact of Practice Expense RVU Changes
||Impact of Malpractice RVU Changes
|Interventional Pain Management
|Nurse Anes / Anes Asst
Source: CMS-1693-F, CMS-1693-IFC, CMS-5522-F3, and CMS-1701-F. Table 94: CY 2019 PFS Estimated Impact on Total Allowed Charges by Specialty. November 1, 2018.
CY 2019 Proposed Work Relative Value Unit Assignments (RVUs)
CMS finalized the following work RVU assignments for new, revised, and potentially misvalued codes that are of note for anesthesiologists and pain medicine physicians. ASA was pleased that CMS supported the ASA and RUC recommendations for CPT® Code 64405 and 76942. ASA had urged CMS to accept the recommendations of 0.45 for CPT Code 95970 but agency declined to do so.
|2018 Work RVU
|Proposed 2019 Work RVU
|Final 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-F, CMS-1693-IFC, CMS-5522-F3, and CMS-1701-F. Table 13: CY 2019 Work RVUs for New, Revised, and Potentially Misvalued Codes. November 1, 2018.
Evaluation & Management (E/M) Services
The proposed rule included a number of far-reaching proposals, including revisions to how evaluation and management services (E/M) are documented and paid. ASA disagreed with the urgency that CMS had regarding the revised categorization and payment of office/outpatient E/M services from five distinct levels to just two payment levels. ASA urged CMS to work with specialty societies and other stakeholders to ensure revisions to E/M payments are thorough and well-thought out before making any changes to the current fee schedule structure.
Changes to E/M documentation requirements and payment are scheduled to be implemented in 2021. These changes will include:
- Establishing a single payment for office/outpatient E/M services at levels 2 through 4. There will be a single rate for new patients (99202-99204) and another single rate for established patients (99212-99214)
- Creating add-on codes for primary care-related services, for more complex patients and for instances in which the practitioner needs to spend an extended period of time with the patient. CMS clarifies that use of these codes will not be restricted to specific specialties and that they are reportable only in conjunction with office/outpatient E/M visits at levels 2, 3 or 4.
- Allowing use of current documentation guidelines, time or Medical Decision Making (MDM) when documenting care and selecting a level of service.
CMS intends to continue discussions over the next few years with stakeholders to potentially further refine these new policies in future rulemaking. ASA will likewise continue to engage CMS and others in these discussions as well.
Multiple Procedure Reductions
As part of the comment period, ASA had expressed strong opposition to CMS’s proposal to
impose a payment reduction when a procedure and an E/M service are reported during the same encounter. ASA is very pleased that CMS heeded those concerns and will not implement those reductions.
Global Surgery Data Collection
CMS is deferring further action on next steps to address concerns about how to collect information on services provided within the global period assigned to a procedure. The agency will evaluate the comments it received and consider whether to propose any action at a future date.
Quality Payment Program (QPP)
ASA advocated for a number of issues within the proposed 2019 Quality Payment Program rule that will enhance the role physician anesthesiologists play in delivering care and protecting patient safety. Foremost, ASA supported the opt-in for practices to report MIPS and earn a payment bonus. CMS finalized that proposal today.
As expected, CMS finalized the MIPS performance threshold at 30 points with an additional performance threshold of 75 points for exceptional performance. Those eligible clinicians scoring 30 points will receive a neutral adjustment; those scoring less than 30 points will incur a negative adjustment (up to 7% on Medicare Part B Fee for Service payments) and those above 30 points will receive a positive payment adjustment. The 2019 MIPS scores impact EC and group payments in FY 2021.
CMS removed 21 MIPS Clinical Quality measures (MIPS CQMs) from the program, including MIPS 426 and MIPS 427 – two transfer of care measures from the anesthesiology quality measure set. Despite ASA’s efforts, CMS finalized their proposal and stated that by “removing these extremely topped out measures, [CMS is] attempting to reduce reporting burden where there is little room for improvement.” (p. 2313).
CMS also finalized facility-based scoring where the measure set for the fiscal year of the Hospital Value-Based Purchasing (VBP) program that begins during the applicable MIPS performance period will be used for facility-based clinicians – those furnishing 75% or more of their covered professional services in inpatient hospital, on-campus outpatient hospital or an emergency room based on claims for a period prior to the performance period. ASA supported this proposal.
Request for Information on Price Transparency: Improving Beneficiary Access to Provider and Supplier Charge Information
In its proposed rule for CY 2019, CMS included an RFI pertaining to price transparency and concerns about “surprise bills” for out of network care In the RFI, anesthesiology was specifically cited as a specialty for which this is a concern. . ASA provided extensive comments and background on solutions to the out of network issue. CMS reports that it received about 90 responses to this RFI and that it appreciates the feedback. ASA urges CMS to consider ASA’s feedback if they further consider the issue in rulemaking or any other venue.
ASA physicians and staff continue to review the rule and will be releasing additional information as it becomes available. For more information, contact ASA Advocacy at firstname.lastname@example.org.
As the medical specialty representing the recognized leaders in patient safety and quality, ASA is committed to working with CMS to promote policies that support high quality care in a fiscally sustainable manner.
To read the final rule, click here: https://s3.amazonaws.com/public-inspection.federalregister.gov/2018-24170.pdf.
A CMS Fact Sheet on the MPFS can be viewed at: https://www.cms.gov/newsroom/fact-sheets/final-policy-payment-and-quality-provisions-changes-medicare-physician-fee-schedule-calendar-year.
A CMS Fact Sheet on the Quality Payment Program can be viewed here:
For a chart on E&M payment amounts, please visit: https://www.cms.gov/sites/drupal/files/2018-11/11-1-2018%20EM%20Payment%20Chart-Updated.pdf
To review ASA’s comments on the proposed rule, click here: https://www.asahq.org/advocacy-and-asapac/fda-and-washington-alerts/washington-alerts/2018/09/asa-pushes-for-reduced-regulatory-burden