CMS Releases 2019 PFS and QPP Final Rule

On November 1, the Centers for Medicare & Medicaid Services (CMS) issued the calendar year (CY) 2019 Physician Fee Schedule (PFS) and Quality Payment Program (QPP) final rule.

The summary below is based on the CMS fact sheet on the 2019 PFS final rule.

For CY 2019 and CY 2020, the agency is implementing several documentation policies "to provide immediate burden reduction" and would implement additional changes to documentation, coding, and payment in CY 2021. 

Coding for E/M Office/Outpatient Visits
The CMS fact sheet states:
"For CY 2019 and CY 2020, CMS will continue the current coding and payment structure for E/M office/outpatient visits and practitioners should continue to use either the 1995 or 1997 E/M documentation guidelines to document E/M office/outpatient visits billed to Medicare."

For CY 2021, CMS would move forward to reduce payment variation for E/M office/outpatient visit levels by paying a single rate for visit levels 2 through 4 for established and new patients, "while maintaining the payment rate for E/M office/outpatient visit level 5 to better account for the care and needs of complex patients."

For 2019, CMS finalized its proposal to pay separately for two newly defined physicians’ services furnished using communication technology:

• Brief communication technology-based service, e.g. virtual check-in (HCPCS code G2012) and
• Remote evaluation of recorded video and/or images submitted by an established patient (HCPCS code G2010)

And for 2019, CMS also finalizes policies to pay separately for new coding describing chronic care remote physiologic monitoring (CPT codes 99453, 99454, and 99457) and interprofessional internet consultation (CPT codes 99451, 99452, 99446, 99447, 99448, and 99449). 

Payment Rates for Non-excepted Off-campus Provider-Based Hospital Departments Paid Under the PFS
Since CY 2017, payment for certain items and services furnished in non-excepted off-campus provider-based departments has been made under the PFS using a PFS Relativity Adjuster based on a percentage of the OPPS payment rate. The PFS Relativity Adjuster in CY 2018 is 40 percent, i.e., non-excepted items and services are paid 40 percent of the amount that would have been paid for those services under the OPPS.

For CY 2019 CMS is finalizing that the PFS Relativity Adjuster remain at 40 percent.

Wholesale Acquisition Cost (WAC)-Based Payment for Part B Drugs: CMS Finalizes Reduction of Add-on Amount
Effective Jan. 1, 2019, WAC-based payments for Part B drugs determined under section1847A of the Social Security Act, during the first quarter of sales when average sales price (ASP) is unavailable, will be subject to a 3 percent add-on in place of the current 6 percent add-on. The agency reiterated that these changes only apply to WAC-based payment for new Part B drugs.

ACCC is analyzing the final rule and will provide in-depth analysis to the membership soon.

View the CY 2019 Physician Fee Schedule and Quality Payment Program final rule here.

Access the CMS fact sheet on the CY 2019 Physician Fee Schedule final rule.

Access the CMS fact sheet on the CY 2019 Quality Payment Program final rule.
Posted 11/1/18