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Complete analysis of the 2019 Medicare Physician Fee Schedule final rule

The AASM provides this analysis to help members understand the changes to the 2019 Medicare Physician Fee Schedule (PFS) and the final policies for year three of the Quality Payment Program (QPP), which were published on Nov. 1 by the Centers for Medicare & Medicaid Services (CMS) in its final rule.

Sleep medicine professionals can download two payment and RVU comparison documents, which include a summary of reimbursement for sleep medicine and E/M codes for 2018 and 2019:

Reduced work RVUs for three Home Sleep Apnea Test (HSAT) codes

In response to CMS proposing to reduce the work RVUs for the three HSAT codes (95800, 95801, 95806), the AASM sent a letter to CMS expressing strong opposition to this proposal. The AASM also collaborated with the American Academy of Neurology (AAN), American College of Chest Physicians (CHEST), and the American Thoracic Society (ATS) to provide comments to the American Medical Association (AMA) expressing our strong disagreement with the decreased work RVUs. Overall, CMS rejected 29 percent of the recommendations made by the AMA/Specialty Society Relative Value Scale Update Committee (RUC). The AASM comments were included in a RUC comment letter to CMS, which urged CMS to accept the RUC-recommended values. A separate letter from the AMA also urged CMS to adopt all the recommendations made by the RUC. Despite these efforts, CMS has finalized the reduced work RVUs for the three HSAT codes shown below:

95800:  Sleep study, unattended, simultaneous recording; heart rate, oxygen saturation, respiratory analysis (e.g., by airflow or peripheral arterial tone), and sleep time
2018 Work RVU:  1.05
2019 Work RVU:  0.85

95801:  Sleep study, unattended, simultaneous recording; minimum heart rate, oxygen saturation, and respiratory analysis (e.g., by airflow or peripheral arterial tone)
2018 Work RVU: 1.00
2019 Work RVU: 0.85

95806:  Sleep study, unattended, simultaneous recording of heart rate, oxygen saturation, respiratory airflow, and respiratory effort (e.g., thoracoabdominal movement)
2018 Work RVU: 1.25
2019 Work RVU: 0.93

2019 Physician Fee Schedule Conversion Factor

The 2019 conversion factor was increased to 36.0391. This is approximately a $0.04 increase from the 2018 conversion factor of 35.9996, which results in a slight increase in payment for most sleep procedures and evaluation and management codes. Some sleep study codes will be reimbursed at lower rates due to slightly reduced RVUs. 

Potential changes to Evaluation and Management documentation guidelines and codes

The AASM comment letter to CMS also expressed disagreement with the CMS proposal to collapse payment rates for new and established patients. Instead the AASM encouraged CMS to support the newly created AMA E/M Workgroup focused on developing an alternative to the current E/M codes and payment rates. AASM also signed onto a letter submitted to CMS by the AMA on behalf of 170 organizations, requesting time for the AMA Workgroup to identify solutions to the current issues with E/M coding and payment, for potential implementation in 2020. Within the final rule, CMS delayed implementation of changes to the E/M documentation guidelines, coding and reimbursement until 2021. This gives the E/M Workgroup time to solidify proposed solutions to submit to CMS for consideration.

CMS finalized the following changes for Office/Outpatient Visits beginning in 2019:

Note: These documentation changes are OPTIONAL and do not require changes in coding or payment.

  1. It is no longer a requirement to document the medical necessity of a home visit in lieu of an office visit.
  2. When relevant information is already in the medical record for established patients, eligible clinicians can focus documentation on what has changed since the last visit OR pertinent items that have not changed. If there is evidence that the clinician reviewed the previously documented information, there is no need to document it again.
  3. There is also no need to document the chief complaint and history for new and established patients if it has already been entered by ancillary staff or the beneficiary, as long as the clinician indicates that he or she reviewed and verified the information.

Telemedicine: Modernizing Medicare Physician Payment by Recognizing Communication Technology-based Services

Brief Communication Technology-based Service (HCPCS code G2012)

CMS finalized its proposal to make separate payment for brief communication technology-based services with the addition of HCPCS code G2012.

G2012 – Brief communication technology-based service, e.g. virtual check-in, by a physician or other qualified health care professional who can report evaluation and management services, provided to an established patient, not originating from a related E/M service provided within the previous 7 days nor leading to an E/M service or procedure within the next 24 hours or soonest available appointment; 5-10 minutes of medical discussion

Remote Evaluation of Pre-Recorded Patient Information (HCPCS code G2010)

CMS finalized its proposal to make separate payment for remote evaluation of recorded video and/or images submitted by the patient with the addition of HCPCS code G2010.

G2010 (Remote evaluation of recorded video and/or images submitted by an established patient [e.g., store and forward], including interpretation with follow-up with the patient within 24 business hours, not originating from a related E/M service provided within the previous 7 days nor leading to an E/M service or procedure within the next 24 hours or soonest available appointment)

Interprofessional Internet Consultation (CPT codes 99451, 99452, 99446, 99447, 99448, 99449)

CMS finalized its proposal to make separate payment for CPT codes 99451, 99452, 99446, 99447, 99448, and 99449, describing interprofessional consultations. However, 99451 and 99452 have not been proposed to be added to the list of Medicare Telehealth services for 2019, since they describe services that are non-face-to-face and are not considered Medicare telehealth services.

Chronic Care Remote Physiologic Monitoring (CPT codes 99453, 99454, and 99457)

CMS finalized not adding these codes to the list of Medicare Telehealth services for 2019, as they are inherently non-face-to-face and therefore are not considered Medicare Telehealth services. These codes have instead been proposed for adoption under the PFS.

Sleep Apnea Measures Removed from the MIPS program for 2019

CMS finalized the removal of two sleep apnea measures for the 2019 reporting year and 2021 payment year. The following sleep apnea measures will be removed from the program:

  • QPP #276 – Sleep Apnea: Assessment of Sleep Symptoms
  • QPP #278 – Sleep Apnea: Positive Airway Pressure Therapy Prescribed

Although this decision further limits the number of sleep medicine-specific measures that are available for reporting, AASM urges eligible sleep medicine professionals to review the measure list on the Quality Payment Program website, once updated to include 2019 measures, to identify additional measures to report. Other measures that may be reportable by sleep medicine professionals include:

Preventive Care and Screening measures

#128 – Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up Plan

#134 – Preventive Care and Screening: Screening for Depression and Follow-Up Plan #226 – Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention

#317 – Preventive Care and Screening: Screening for High Blood Pressure and Follow-Up Documented

#431 – Preventive Care and Screening: Unhealthy Alcohol Use: Screening & Brief Counseling

Additional Process measures

#130 – Documentation of Current Medications in the Medical Record

Outcome measures

#236 – Controlling High Blood Pressure (Intermediate outcome measure)

#321 – CAHPS for MIPS Clinician/Group Survey (Patient-reported outcome measure)

Please send any questions about the Medicare Physician Fee Schedule final rule to coding@aasm.org.

2018-11-16T23:22:29+00:00 November 16th, 2018|Clinical Resources, Featured|