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On November 1, 2018, the Centers for Medicare & Medicaid Services (CMS) issued their final rule that includes updates to payment policies, payment rates, and quality provisions for services furnished under the Medicare Physician Fee Schedule (MPFS) beginning on January 1, 2019.  Below are the highlights and analysis.

Fee Schedule

  • Conversion Factor

CMS finalized a CY 2019 conversion factor of $36.0391 which is up slightly from the current conversion factor of $35.9996

  • Based on our weighted average analysis, radiology groups will see a Medicare fee schedule increase of about 0.1%. This includes a 0.1 to 0.2% increase for diagnostic studies and a 1.0% decrease for interventional radiology.
  • Diagnostic Imaging centers that bill globally will see a decrease of approximately 1.0% to 2.0%.
  • Outpatient interventional radiology centers that bill globally will see a decrease of approximately 1.0% to 5.0% depending on procedures performed.
  • E&M Changes

CMS initially proposed significant changes to the current burdensome documentation and payment methodologies for E&M services. However, in the final rule CMS decided to push most of the E&M changes off until 2021. Accordingly, the documentation and reimbursement rules for E&M office/outpatient visits will continue to follow the 1995 or 1997 E&M documentation guidelines until CMS provides further guidance.

  • Appropriate Use Criteria (AUC)

The previously finalized implementation date of January 1, 2020 still stands.  2020 will be an educational and operations testing period and no penalties for non-compliance will be applied. 2021 will see the full implementation of the Appropriate Use Criteria(AUC)/Clinical Decision Support(CDS) program with penalties for non-compliance.

Effective January 1, 2020, ordering professionals must consult a qualified Clinical Decision Support Mechanism (CDSM) and obtain an applicable AUC before ordering advanced diagnostic imaging services.  The ordering professional must then report that AUC consultation information to the rendering provider to be included on the Medicare claim.  CMS has indicated that, if necessary, they will mandate CDSM’s establish the capability to supply such information (the G Code and modifiers) to rendering providers. CMS has clarified that independent diagnostic testing facilities (IDTFs) are covered under these regulations as an applicable setting.

CMS finalized allowing AUC consultations, when not personally performed by the ordering professional, to be performed by auxiliary personnel which they clarified to mean “clinical staff under the direction of the ordering professional.”  This will allow the ordering professional to exercise their discretion to delegate the performance of this consultation with the understanding that their staff member must have sufficient clinical knowledge and the ability to interact with the qualified CDSM.

CMS finalized moving forward with G-Codes and modifiers as the mechanism to notify rendering physicians that a CDSM was consulted, as opposed to a unique consultation identifier (UCI). CMS has indicated that a detailed list of codes would be made available in the coming months.  Each qualified CDSM will be assigned a G-code with a description that contains the name of the CDSM. The QQ modifier will remain in effect for voluntary reporting.

  • Radiology Assistants

In response to stakeholder comment, CMS finalized its proposal to revise the physician supervision requirements for certain diagnostic tests (not procedures) performed by a Radiologist Assistant (RA) so that they may now be furnished under direct supervision versus personal supervision.  The new requirements do not change existing requirements for procedures/interventional radiology. An in-depth analysis of this component of the 2019 fee schedule rule is currently in preparation.

  • Practice Expense Review

CMS did not finalize its proposed cuts to practice expense reimbursement.  CMS used an “independent” third party to conduct much of the analysis they relied on in the proposed analysis which could have resulted in as much as a, fully phased in, 38% decrease in the reimbursement for the technical component of ultrasound procedures. Many ultrasound industry advocates are providing more accurate information to CMS to combat these future proposed decreases.

Quality Payment Program

  • Performance category weights were finalized as follows: Quality – 45%, Promoting Interoperability – 25% (previously called the Advancing Care Information category), Improvement Activities – 15% and Cost – 15%
  • 2015 Edition CEHRT is now required for participation in the Promoting Interoperability performance category. However, as in past years, nearly all radiologists will be exempt from this category due to being either non-patient facing, or hospital based.
  • Data completeness remains at 60% for the Quality performance category.
  • The minimum composite score to avoid a penalty in 2019 is 30 points; a composite score of 75 points is now required be considered an exceptional performer.
  • Groups with over 15 providers will no longer be able to report quality measures via the claims-based submission option. As ADVOCATE is now a qualified registry, any ADVOCATE group impacted by this change will automatically be able to participate in our qualified registry.  Functionally, this will not change the reporting for physicians in these impacted groups at all.
  • CMS finalized its proposal for the small practice bonus points. Any practice with 15 or fewer eligible clinicians will receive 6 bonus points in the Quality performance category.
  • Providers will now be exempt from MIPS if they meet one or more of the following low-volume threshold criteria:
    • Have < $90,000 in Medicare Part B allowable charges
    • Provide care to < 200 Part B beneficiaries
    • Provide < 200 covered professional services under the Physician Fee Schedule
  • Providers who qualify for the low-volume exemption are now able to “opt-in” to the MIPS program.

As always, ADVOCATE will keep you up to date on this and all issues impacting radiology as they become available.