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Tuesday Jul 31, 2018

Early Thoughts on the 2019 Fee Schedule

"A nickel ain't worth a dime anymore."
-- Yogi Berra

On July 12, CMS released the 2019 Revisions to Payment Policies Under the Physician Fee Schedule and Other Revisions to Medicare Part B(s3.amazonaws.com) proposed rule. The proposal also includes several changes to the Quality Payment Program (QPP) -- revisions that CMS used to publish separately from the fee schedule.

[under review in red with exclamation point]

This post focuses on the Medicare physician fee schedule portions of the proposed rule. In my Aug. 14 post, I will cover the proposed changes to QPP and provide additional perspective on changes to the Medicare fee schedule.

Building on its Patients Over Paperwork(www.cms.gov) initiative, CMS has proposed several changes in policy and practice aimed at reducing the administrative burden of physicians participating in the Medicare program. The most notable is a dramatic reduction in documentation requirements for evaluation and management services. CMS has proposed that documentation for history and exam should focus on interval history since the patient's previous visit. In addition, the agency has proposed that physicians be allowed to document based on the 1995 or 1997 documentation guidelines, their level of medical decision-making, or time spent.

CMS also has proposed that physicians be allowed to review and verify certain information in the medical record that has been entered by ancillary staff or the beneficiary, rather than requiring them to re-enter the information themselves. The AAFP suggested this change to CMS, and we are pleased to see the agency embrace it.

The most intriguing -- and controversial -- portion of the proposed rule would collapse the number of codes for office visits by new patients (99201-99205) and existing patients (99211-99215) from five levels in each category to just two per category. In addition, CMS proposed adding a new code that would provide a $5 bump-up to the revised existing patient code for primary care, bringing the total for that code to $98. Figure 1 below shows the current value of each code and the proposed value of the collapsed codes. I provide some analysis and perspective in the Wonk Hard section below.

[in the trenches figure 1]

CMS estimates that the 2019 physician fee schedule conversion factor will be $36.0463, a slight increase from the 2018 conversion factor of $35.9996.

In addition to the changes outlined above, CMS proposes

  • a 50 percent multiple procedure payment reduction to the lower paid of two services when a physician provides an evaluation and management service and a procedure on the same date;
  • new CPT codes and payment for remote monitoring and interprofessional consultations;
  • establishing care management and communication technology services for rural health clinics and federally qualified health centers;
  • paying physicians for their time when they communicate with Medicare patients remotely, such as by phone;
  • paying physicians for the time it takes to review digital or video images submitted by a patient; and
  • further developing appropriate use criteria for advanced diagnostic imaging.

The AAFP has produced a high-level summary(2 page PDF) of the proposed rule, and we will make a more comprehensive summary available in the coming days. Check the Fighting for Family Medicine hub for updates.

In addition, CMS has created individual fact sheets on both the fee schedule(www.cms.gov) and the QPP.(www.cms.gov)  

Wonk Hard

The release of the 2019 Medicare physician fee schedule and QPP proposed rule has caused quite a stir in the physician community during the past few days. As is the case with all major policy proposals, there is much information to unpack and evaluate. The AAFP avoids snap judgments based on cursory reads of summaries and instead focuses on digging into the proposal and evaluating its positive and negative impacts on family medicine.

Although AAFP staff members are still evaluating the impact of the proposed rule on family physicians and the Medicare beneficiaries they care for, I want to provide some initial high-level takeaways:

  • The proposal is directionally appropriate but technically flawed in several key ways. Reducing the complexity of coding, eliminating onerous documentation requirements, adding additional spending for primary care and creating neutrality between sites of care are all positive steps that the AAFP supports. However, the construct and methodologies of the proposed rule are concerning -- some extremely so.
  • Increasing the overall spend on primary care is positive, and we applaud CMS' efforts to provide additional funding to family physicians. However, based on our initial analysis, the proposed $5 bump-up likely will not produce the desired results. It needs to be greater than $10 to have a measurable impact on primary care.
  • CMS' effort to reduce documentation requirements is a positive step, and we applaud the agency for its continued efforts to decrease administrative burden. The current complexity of documentation contributes nothing to patient care and is a major source of frustration for physicians -- not to mention a major source of "work after clinic," which drives physician burnout. Reducing the complexity of documentation is an extremely positive recommendation, and we all should give CMS officials credit for their continued efforts to accomplish this goal.
  • Reducing the complexity of coding is long overdue. However, there may be a need for three evaluation and management codes rather than the two that CMS proposed. A 99212 visit is much different from a 99214 or 99215 visit, and combining these into the same coding category doesn't seem like the appropriate policy choice. Additionally, it is our determination that the values CMS has assigned to the new existing patient code are too low. The distribution of codes in family medicine has shifted dramatically from 99213 to 99214. Figure 2 below shows that 99214 has grown from 43.73 percent in 2012 to 50.8 percent in 2016. If growth has continued at this pace in the past two years, it is safe to predict that 99214 is used in nearly 55 percent of all Medicare visits to family physicians. This trend suggest that the valuation of the new existing patient code is dramatically low and would impact family physicians negatively.
  • The proposal seems to move away from longitudinal care models toward episodes of care and patient churn, which is deeply concerning. The new payment levels likely de-incentivize longitudinal or comprehensive care in a single visit and incentivize multiple patient visits. This is not patient-centered and is inconsistent with high-quality primary care.
[in the trenches figure 2]

Posted at 09:00AM Jul 31, 2018 by Shawn Martin

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Shawn Martin, AAFP Senior Vice President of Advocacy, Practice Advancement and Policy.

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