On Nov. 1, the Centers for Medicare and Medicaid Services (CMS) released the final 2019 Medicare Physician Fee Schedule (PFS) rule, addressing Medicare payment rates and policy provisions for physicians in 2019. Physicians will see a 0.1 percent conversion factor payment increase on Jan. 1, 2019. CMS estimates that the final rule will neither increase nor decrease cardiology payments from 2018 to 2019. Estimates are based on cardiovascular practice in its entirety and can vary widely depending on the mix of services provided in a practice.

In a significant positive shift reflecting ACC comments and advocacy efforts, proposed changes to evaluation and management (E/M) payment were both altered and/or delayed until 2021 in the final ruling. CMS finalized changes to streamline E/M documentation for 2019, but the agency is not finalizing its proposal to apply a multiple-procedure payment reduction to separate E/M services furnished on the same day as a global procedure. CMS indicates an intent "to engage in further discussions with the public over the next several years to potentially further refine our policies for 2021."

The rule also includes updates to the Quality Payment Program (QPP) for the 2019 performance period. Clinicians and groups participating in the Merit-Based Incentive Payment System (MIPS) are subject to payment adjustments of up to +/- 7 percent in 2021. Advanced Alternative Payment Model (APM) participants remain eligible for a +5 percent lump sum bonus.

Additional highlights within the final rule include:

2019 Medicare PFS:

• To address potential misvaluation, CMS finalized a single, blended payment rate for E/M levels 2 through 4 visits for 2021. Deviating from the proposed rule, payment for level 5 visits will be maintained. CMS projects a 2 percent reduction to cardiology reimbursement from these changes in 2021 if no other changes are made.
• Streamlining E/M documentation to reduce clinician burden through upcoming changes allowing:

• Clinicians to focus on documentation changes since the prior visit or relevant items that are unchanged rather than re-documenting redundant information. – Effective in 2019
• Clinicians to review and verify some medical record information entered by staff or the beneficiary instead of re-entering it themselves. – Effective in 2019
• Teaching clinicians to review and verify notations in medical records by residents of other members of the care team. – Effective in 2019
• The use of time as the governing factor for selective the level of an E/M visit. – Effective in 2021
• The documentation of medical decision-making or time instead of the continued use of the 1995 or 1997 E/M guidelines. – Effective in 2021
• Minimum supporting documentation associated with level 2 visits for levels 2 through 4 visits. – Effective in 2021

• While finalizing a four-year phase-in of updated direct practice expense inputs based on a contracted analysis, CMS is overriding several specific inputs in response to stakeholder feedback. Of acute interest to echocardiographers, the pricing for the equipment in an ultrasound room will be maintained in 2019 rather than reduced by 60 – 65 percent.

• Continuing implementation of the mandate requiring that clinicians consult appropriate use criteria (AUC) through a qualified clinical decision support mechanism (CDSM) starting Jan. 1, 2020, when ordering advanced imaging services (i.e., SPECT/PET MPI, CT and MR). Finalized policies include:

• The use of HCPCS G-codes and modifiers to report the required AUC information on Medicare claims for both the technical and professional components.
• Allowing delegation of AUC consultation with a qualified CDSM to clinical staff working under the direction of the ordering professional.
• Adding Independent Diagnostic Testing Facilities to the list of applicable settings under the mandate.
• Revising the significant hardship criteria to include insufficient internet access, electronic health record (EHR) or CDSM vendor issues, or extreme and uncontrollable circumstances.

• Implementing final values for new codes describing leadless pacemaker services, subcutaneous quantitative cardiac rhythm monitor services (loop recorder), pulmonary wireless pressure sensor services and chronic care remote physiologic monitoring services. Updated values are finalized for external counterpulsation, coronary fractional flow reserve measurement, supervised exercise therapy for peripheral artery disease and cardiac output dilution studies.

• Maintaining the PFS Relativity Adjuster for items and services provided by non-excepted off campus provider-based departments (Section 603) at 40 percent of the Hospital Outpatient Prospective Payment System rate.

2019 QPP Performance Period:

• Increasing the MIPS Cost category weight to 15 percent, decreasing Quality to 45 percent and maintaining Promoting Interoperability and Improvement Activities at 15 percent and 25 percent, respectively.
• Increasing the MIPS performance threshold for avoiding a penalty to 30 points and the exceptional performance threshold to 75 points.
• Incorporating episode groups into the MIPS Cost score, including STEMI with PCI, elective outpatient PCI, and revascularization for lower extremity chronic critical limb ischemia.
• Eliminating the base, performance and bonus score structure of the Promoting Interoperability category and replacing it with performance-based scoring on individual measures.
• Updating the low-volume threshold for MIPS exemption ($90,000 or less in part B allowed charges or 200 or fewer Medicare beneficiaries) by adding in a third exclusion for clinicians providing 200 or fewer covered professional services under the PFS. Clinicians who meet or exceed at least one, but not all three, of the criteria may voluntarily opt into MIPS.
• Maintaining MIPS bonus points and flexibility for small practices.
• Eligible clinicians and groups who furnish 75 percent or more of their covered professional services in an inpatient hospital, on-campus outpatient hospital or emergency room will have their Quality and Cost scores automatically based on their facility's Hospital Value-Based Purchasing score if this results in a higher score than submitted MIPS data.
• Maintaining the revenue-based nominal amount threshold for Advanced APMs at 8 percent through performance year 2024.
• Requiring that at least 75 percent of the eligible clinicians in an Advanced APM use Certified Electronic Health Record Technology.
• Allowing eligible clinicians participating in Other Payer Advanced APMs to re-submit all payment arrangement information only if the arrangement undergoes any changes throughout its duration, rather than requiring annual attestation and resubmission.
• Allowing Advanced APM Qualifying Participant (QP) determinations for the All-Payer Option to be made at the TIN level in addition to the APM Entity and individual levels.

ACC staff will further review the final rule to identify additional topics of interest to ACC members in the coming days. More information on notable topics will be forthcoming in the Advocate newsletter and on ACC.org. Additionally, these adjustments will be thoroughly discussed during ACC's Cardiovascular Summit, taking place Feb. 14 – 16 in Orlando, FL.

Keywords: ACC Advocacy, Healthcare Common Procedure Coding System, Centers for Medicare and Medicaid Services, U.S., Decision Support Systems, Clinical, Medicare, Fee Schedules, Medicaid, Electronic Health Records, Emergency Service, Hospital, Prospective Payment System

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