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  • Ashley Geary, Esq.

Upcoming Comment Deadline on the 2019 Medicare Physician Fee Schedule Proposed Rule

On July 27, 2018, Medicare released its proposed rule for the 2019 Medicare Physician Fee Schedule (full text available here) (the “Proposed Rule”). Whereas Medicare makes revisions to the physician fee schedule every year, there are two (2) changes proposed this year which are likely to have a significant impact on practice revenue: (1) changes to billing and reimbursement for Evaluation and Management (“E/M”) codes and (2) changes to the Quality Performance Program (“QPP”) under MACRA.


E/M Coding

Medicare proposes to simplify E/M coding and documentation requirements. Under the current billing methodology, physicians have the option of coding office visits between a Level 1 and a Level 5, depending on the complexity of the patient’s visit. The reimbursement for the office visit increases as the level of complexity increases. However, under the Proposed Rule, all Level 2 through Level 5 physician office visits would be coded at the same level and paid at a single reimbursement rate (between the current Level 3 and Level 4 rate). Given the decrease in reimbursement that will occur for the higher level visits, Medicare also proposes limiting the documentation standards to those currently set for a Level 2 visit.


While this proposal may seek to streamline documentation requirements and E/M coding, it will significantly impact those specialists who often bill for office visits at the higher Level 4 and Level 5 reimbursement levels. In support of this proposal, CMS Administrator Seema Verma stated that “most specialties would see changes in their overall Medicare payments in the range of 1-2 percent up or down from this policy, but we believe that any small negative payment adjustments would be outweighed by the significant reduction in documentation burden.” The estimated impacts cited by CMS apply to Medicare payments within specialties; they do not assess the impact on individual physicians or group practices (e.g., those sub-specialty practices that bill Level 4 and 5 E/M codes on a regular basis). Further, based on the estimated impacts table published with the Proposed Rule, CMS expects some specialties (i.e., OB/GYN) to see a 4% increase while others (i.e., podiatry and dermatology) would face a 4% cut.


QPP Revisions

In addition to losing reimbursement on E/M codes, providers also face reimbursement cuts as a result of proposed revisions to the QPP. The QPP is the new value-based incentive program established under MACRA, which imposes positive and negative payment adjustments on providers based on their participation in the Merit-based Incentive Payment System (“MIPS”) or an Alternative Payment Model (“APM”). As the QPP is rolled out, new parameters are proposed every year. There are several proposed changes in the Proposed Rule that could significantly impact providers. These changes include:

  • Cutting the bonus points that small practices can earn;

  • Revising the Promoting Interoperability (“PI”) category to be more consistent with the all-or-nothing (as opposed to sliding scale) methodology under its former Meaningful Use counterpart, making it harder for providers to achieve participation points;

  • Requiring practices to use the latest version of Certified EHR Technology (“CEHRT”) to meet the PI requirements, which a number of EHR vendors do not yet support;

  • Increasing the requirements to earn credits for participation in qualified registries; and

  • Eliminating credits (at a future date) earned for participation in certain registries (e.g., the IRIS Registry).

Whereas CMS is keeping other QPP provisions that assist practices in meeting the thresholds for positive payment adjustments, the changes in the Proposed Rule will make it more difficult to achieve those thresholds.


Comments to the Proposed Rule are due by September 10, 2018. Understandably, a number of societies have or will be submitting comments in opposition to the Proposed Rule. However, if you would like to submit your own comment, you can do so here.

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