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CMS Modifies and Delays Flawed E/M Proposal in 2019 Medicare Physician Fee Schedule Final Rule Following ASCRS and Medical Community Advocacy; Finalizes Policies for Quality Payment Program

As we alerted you yesterday, CMS released the 2019 Medicare Physician Fee Schedule (MPFS) final rule, which also includes policies for the 2019 performance year of the Quality Payment Program (QPP). In a major win for ASCRS and the entire medical community, CMS backed off its controversial proposals related to E/M services, and will modify, abandon, or delay several provisions. CMS notes that this change will allow time for the AMA’s CPT and RUC workgroup to develop updated recommendations for E/M codes. ASCRS supported this process in our comments on the proposed rule and is currently providing input.

E/M Documentation and Payment

CMS agreed with ASCRS and medical community comments on the proposed rule that immediate steps could be taken to reduce the burden of E/M documentation, but that proposals related to payment should be rethought because they would reduce physician reimbursement and were arbitrary and not resource-based. For CY 2019, CMS is finalizing several changes to documentation requirements:

  • The requirement to document medical necessity of furnishing visits in the home rather than office will be eliminated;
  • Physicians will no longer be required to re-record elements of history and physical exam when there is evidence that the information has been reviewed and updated; and
  • Physicians must only document that they reviewed and verified information regarding chief complaint and history that is already recorded by ancillary staff or the patient.

CMS is delaying implementation of several other provisions until CY 2021 and will consider input from the CPT/RUC workgroup and the medical community before that time. For CY 2021, CMS finalized:

  • ASCRS- and medical community-opposed collapse of E/M levels 2 through 4 for established and new patients, while maintaining the payment rate for E/M office/outpatient visit level 5;
  • Permitting documentation of E/M levels 2 through 5 using medical decision-making (MDM) or time instead of applying the current 1995 or 1997 E/M documentation guidelines, or continue using the current framework;
  • Implementation of add-on codes that describe the additional resources inherent in visits for primary care and particular kinds of non-procedural specialized medical care, but not including ophthalmology; and
  • Adoption of a new “extended visit” add-on code for use only with E/M office/outpatient level 2 through 4 visits to account for the additional resources required when practitioners need to spend extended time with the patient.

Quality Payment Program: MIPS and Advanced APMs

CMS is continuing its transition flexibility, as provided by the ASCRS-supported MACRA technical corrections enacted earlier this year, by not setting the performance threshold at the mean or median of the previous year’s score. For 2019 performance, which impacts 2021 payment, CMS is setting the performance threshold at 30 points, and the exceptional performance threshold is increased to 75 points, as opposed to the proposed 80-point level.

Low-Volume Threshold: In 2019, the low-volume threshold remains at $90,000 in allowed Part B charges or 200 patients, but CMS is adding a criterion of 200 or fewer covered professional services. CMS will allow clinicians who exceed one or two, but not all three, low-volume criteria to opt-in to MIPS.

Bonus Points: In the proposed rule, CMS proposed to modify the small practice bonus by lowering it to 3 points, removing it from the MIPS final score, and adding it to the Quality category score. However, following ASCRS and medical community advocacy, CMS is keeping the small practice bonus in the Quality category, but raising it to 6 points. In addition, CMS will maintain the complex patient bonus and electronic end-to-end reporting bonuses. Clinicians can still earn bonus points in the Quality category for reporting additional outcome or high-priority measures but will not earn them if they report through the CMS Web Interface.

Quality Category (45% of MIPS score): CMS will keep the reporting requirements of 6 measures with at least one being an outcome measure, or high-priority if no outcome is available, for 2019. In addition, CMS is maintaining the 60% data completeness threshold and will continue to score measures on a 10-point scale, relative to a pre-set benchmark. CMS finalized a proposal to allow for multiple submission mechanisms to be used in the category, but also removed the claims reporting option for large practices. CMS will remove the following measures citing they are duplicative of other measures in concept and patient population:

  • #18, Diabetic Retinopathy: Documentation of Presence or Absence of Macular Edema and Level of Severity of Retinopathy;
  • #140, Age-Related Macular Degeneration (AMD): Counseling on Antioxidant Supplement.

However, CMS agreed with our comments on the proposed rule did not finalize the proposal to remove #12, Primary Open-Angle Glaucoma (POAG): Optic Nerve Evaluation.

Promoting Interoperability (25% of MIPS score): Prompted by ASCRS advocacy as part of the AMA MIPS Workgroup, CMS made major changes to the reporting requirements and scoring of this category. CMS eliminated the confusing base and performance score structure of the current program and finalized four objectives: e-Prescribing, Health Information Exchange, Provider to Patient Exchange, and Public Health and Clinical Data Exchange. CMS eliminated ASCRS-opposed measures that rely on patient action, however, measures that rely on the action of other physicians remain. Similar to the current performance score, measures will be scored based on the performance percentage—dividing the numerator by the denominator—achieved by the clinician or group. Clinicians and groups can score up to 100 available points in the category. CMS will maintain exclusions for the e-Prescribe and Health Information Exchange measures.

Cost Category (15% of MIPS score): CMS increased the weight of this category slightly to 15%, but kept it under the originally mandated 30% weight following passage of the MACRA technical corrections. CMS maintains the problematic cost measures—Medicare Spending per Beneficiary and Total Per Capita Cost—and is adding eight episode-based cost measures, including cataract surgery. ASCRS participated in efforts to develop the cataract cost measure, which compares the total cost of uncomplicated cataract surgery (66984) and removes all ocular comorbidities that are currently exclusions in the cataract quality measures. Practices can access draft feedback reports based on performance from June 2016 to July 2017 on these measures through the CMS QualityNet portal.

Improvement Activities (15% of MIPS score): CMS did not make any significant changes to this category for 2019. Small practices may still earn full credit by submitting one high-weighted or two medium-weighted activities. CMS added several new improvement activities, modified five, and removed one. One of the new ones, Comprehensive Eye Exams, involves participation in programs that promote the importance of the comprehensive eye exam.

In the coming weeks, ASCRS will continue to analyze the rule and will update its in-depth MACRA guides for 2019 performance. If you have additional questions, please contact Allison Madson, manager of regulatory affairs, at or 703-591-2220.

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