[Federal Register Volume 83, Number 145 (Friday, July 27, 2018)]
[Proposed Rules]
[Pages 35704-36368]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 2018-14985]
[[Page 35703]]
Vol. 83
Friday,
No. 145
July 27, 2018
Part II
Book 2 of 2 Books
Pages 35703-36398
Department of Health and Human Services
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Centers for Medicare & Medicaid Services
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42 CFR Parts 405, 410, 411, et al.
Medicare Program; Revisions to Payment Policies Under the Physician Fee
Schedule and Other Revisions to Part B for CY 2019; Medicare Shared
Savings Program Requirements; Quality Payment Program; and Medicaid
Promoting Interoperability Program; Proposed Rules
Federal Register / Vol. 83 , No. 145 / Friday, July 27, 2018 /
Proposed Rules
[[Page 35704]]
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DEPARTMENT OF HEALTH AND HUMAN SERVICES
Centers for Medicare & Medicaid Services
42 CFR Parts 405, 410, 411, 414, 415, and 495
[CMS-1693-P]
RIN 0938-AT31
Medicare Program; Revisions to Payment Policies Under the
Physician Fee Schedule and Other Revisions to Part B for CY 2019;
Medicare Shared Savings Program Requirements; Quality Payment Program;
and Medicaid Promoting Interoperability Program
AGENCY: Centers for Medicare & Medicaid Services (CMS), HHS.
ACTION: Proposed rule.
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SUMMARY: This major proposed rule addresses changes to the Medicare
physician fee schedule (PFS) and other Medicare Part B payment policies
to ensure that our payment systems are updated to reflect changes in
medical practice and the relative value of services, as well as changes
in the statute.
DATES: Comment date: To be assured consideration, comments must be
received at one of the addresses provided below, no later than 5 p.m.
on September 10, 2018.
ADDRESSES: In commenting, please refer to file code CMS-1693-P. Because
of staff and resource limitations, we cannot accept comments by
facsimile (FAX) transmission.
Comments, including mass comment submissions, must be submitted in
one of the following three ways (please choose only one of the ways
listed):
1. Electronically. You may submit electronic comments on this
regulation to http://www.regulations.gov. Follow the ``Submit a
comment'' instructions.
2. By regular mail. You may mail written comments to the following
address ONLY: Centers for Medicare & Medicaid Services, Department of
Health and Human Services, Attention: CMS-1693-P, P.O. Box 8016,
Baltimore, MD 21244-8016.
Please allow sufficient time for mailed comments to be received
before the close of the comment period.
3. By express or overnight mail. You may send written comments to
the following address ONLY: Centers for Medicare & Medicaid Services,
Department of Health and Human Services, Attention: CMS-1693-P, Mail
Stop C4-26-05, 7500 Security Boulevard, Baltimore, MD 21244-1850.
FOR FURTHER INFORMATION CONTACT:
Jamie Hermansen, (410) 786-2064, for any physician payment issues
not identified below.
Lindsey Baldwin, (410) 786-1694, and Emily Yoder, (410) 786-
1804, for issues related to evaluation and management (E/M) payment,
communication technology-based services and telehealth services.
Isadora Gil, (410) 786-4532, for issues related to payment rates
for nonexcepted items and services furnished by nonexcepted off-
campus provider-based departments of a hospital, and work relative
value units (RVUs).
Ann Marshall, (410) 786-3059, for issues related to E/M
documentation guidelines.
Geri Mondowney, (410) 786-1172, or Donta Henson, (410) 786-1947,
for issues related to geographic price cost indices (GPCIs).
Geri Mondowney, (410) 786-1172, or Tourette Jackson, (410) 786-
4735, for issues related to malpractice RVUs.
Patrick Sartini, (410) 786-9252, for issues related to
radiologist assistants.
Michael Soracoe, (410) 786-6312, for issues related to practice
expense, work RVUs, impacts, and conversion factor.
Pamela West, (410) 786-2302, for issues related to therapy
services.
Edmund Kasaitis, (410) 786-0477, for issues related to reduction
of wholesale acquisition cost (WAC)-based payment.
Sarah Harding, (410) 786-4001, or Craig Dobyski, (410) 786-4584,
for issues related to aggregate reporting of applicable information
for clinical laboratory fee schedule.
Amy Gruber, (410) 786-1542, or Glenn McGuirk, (410) 786-5723,
for issues related to the ambulance fee schedule.
Corinne Axelrod, (410) 786-5620, for issues related to care
management services and communication technology-based services in
Rural Health Clinics (RHCs) and Federally Qualified Health Centers
(FQHCs).
JoAnna Baldwin, (410) 786-7205, or Sarah Fulton, (410) 786-2749,
for issues related to appropriate use criteria for advanced
diagnostic imaging services.
David Koppel, (214) 767-4403, for issues related to Medicaid
Promoting Interoperability Program.
Fiona Larbi, (410) 786-7224, for issues related to the Medicare
Shared Savings Program Quality Measures.
Matthew Edgar, (410) 786-0698, for issues related to the
physician self-referral law.
Molly MacHarris, (410) 786-4461, for inquiries related to Merit-
based Incentive Payment System (MIPS).
Benjamin Chin, (410) 786-0679, for inquiries related to
Alternative Payment Models (APMs).
SUPPLEMENTARY INFORMATION:
Table of Contents
I. Executive Summary
II. Provisions of the Proposed Rule for PFS
A. Background
B. Determination of Practice Expense (PE) Relative Value Units
(RVUs)
C. Determination of Malpractice Relative Value Units (RVUs)
D. Modernizing Medicare Physician Payment by Recognizing
Communication Technology-Based Services
E. Potentially Misvalued Services Under the PFS
F. Radiologist Assistants
G. Payment Rates Under the Medicare PFS for Nonexcepted Items
and Services Furnished by Nonexcepted Off-Campus Provider-Based
Departments of a Hospital
H. Valuation of Specific Codes
I. Evaluation & Management (E/M) Visits
J. Teaching Physician Documentation Requirements for Evaluation
and Management Services
K. Solicitation of Public Comments on the Low Expenditure
Threshold Component of the Applicable Laboratory Definition Under
the Medicare Clinical Laboratory Fee Schedule (CLFS)
L. GPCI Comment Solicitation
M. Therapy Services
N. Part B Drugs: Application of an Add-On Percentage for Certain
Wholesale Acquisition Cost (WAC)-Based Payments
III. Other Provisions of the Proposed Rule
A. Clinical Laboratory Fee Schedule
B. Proposed Changes to the Regulations Associated With the
Ambulance Fee Schedule
C. Payment for Care Management Services and Communication
Technology-Based Services in Rural Health Clinics (RHCs) and
Federally Qualified Health Centers (FQHCs)
D. Appropriate Use Criteria for Advanced Diagnostic Imaging
Services
E. Medicaid Promoting Interoperability Program Requirements for
Eligible Professionals (EPs)
F. Medicare Shared Savings Program Quality Measures
G. Physician Self-Referral Law
H. CY 2019 Updates to the Quality Payment Program
IV. Requests for Information
A. Request for Information on Promoting Interoperability and
Electronic Healthcare Information Exchange Through Possible
Revisions to the CMS Patient Health and Safety Requirements for
Hospitals and Other Medicare- and Medicaid-Participating Providers
and Suppliers
B. Request for Information on Price Transparency: Improving
Beneficiary Access to Provider and Supplier Charge Information
V. Collection of Information Requirements
VI. Response to Comments
VII. Regulatory Impact Analysis
Regulations Text
Appendix 1: Proposed MIPS Quality Measures
Appendix 2: Improvement Activities
Addenda Available Only Through the Internet on the CMS Website
The PFS Addenda along with other supporting documents and tables
referenced in this proposed rule are available on the CMS website at
http://www.cms.gov/Medicare/Medicare-Fee-
[[Page 35705]]
for-Service-Payment/PhysicianFeeSched/PFS-Federal-Regulation-
Notices.html. Click on the link on the left side of the screen titled,
``PFS Federal Regulations Notices'' for a chronological list of PFS
Federal Register and other related documents. For the CY 2019 PFS
Proposed Rule, refer to item CMS-1693-P. Readers with questions related
to accessing any of the Addenda or other supporting documents
referenced in this proposed rule and posted on the CMS website
identified above should contact Jamie Hermansen at (410) 786-2064.
CPT (Current Procedural Terminology) Copyright Notice
Throughout this proposed rule, we use CPT codes and descriptions to
refer to a variety of services. We note that CPT codes and descriptions
are copyright 2017 American Medical Association. All Rights Reserved.
CPT is a registered trademark of the American Medical Association
(AMA). Applicable Federal Acquisition Regulations (FAR) and Defense
Federal Acquisition Regulations (DFAR) apply.
I. Executive Summary
A. Purpose
This major proposed rule proposes to revise payment polices under
the Medicare PFS and make other policy changes, including proposals to
implement certain provisions of the Bipartisan Budget Act of 2018 (Pub.
L. 115-123, enacted on February 9, 2018), related to Medicare Part B
payment, applicable to services furnished in CY 2019. In addition, this
proposed rule includes proposals related to payment policy changes that
are addressed in section III. of this proposed rule. We are requesting
public comments on all of the proposals being made in this proposed
rule.
1. Summary of the Major Provisions
The statute requires us to establish payments under the PFS based
on national uniform relative value units (RVUs) that account for the
relative resources used in furnishing a service. The statute requires
that RVUs be established for three categories of resources: Work;
practice expense (PE); and malpractice (MP) expense. In addition, the
statute requires that we establish by regulation each year's payment
amounts for all physicians' services paid under the PFS, incorporating
geographic adjustments to reflect the variations in the costs of
furnishing services in different geographic areas. In this major
proposed rule, we are proposing to establish RVUs for CY 2019 for the
PFS, and other Medicare Part B payment policies, to ensure that our
payment systems are updated to reflect changes in medical practice and
the relative value of services, as well as changes in the statute. This
proposed rule includes discussions and proposals regarding:
Potentially Misvalued Codes.
Communication Technology-Based Services.
Valuation of New, Revised, and Misvalued Codes.
Payment Rates under the PFS for Nonexcepted Items and
Services Furnished by Nonexcepted Off-Campus Provider-Based Departments
of a Hospital.
E/M Visits.
Therapy Services.
Clinical Laboratory Fee Schedule.
Ambulance Fee Schedule--Provisions in the Bipartisan
Budget Act of 2018.
Appropriate Use Criteria for Advanced Diagnostic Imaging
Services.
Medicaid Promoting Interoperability Program Requirements
for Eligible Professionals (EPs).
Medicare Shared Savings Program Quality Measures.
Physician Self-Referral Law.
CY 2019 Updates to the Quality Payment Program.
Request for Information on Promoting Interoperability and
Electronic Healthcare Information Exchange through Possible Revisions
to the CMS Patient Health and Safety Requirements for Hospitals and
Other Medicare- and Medicaid-Participating Providers and Suppliers.
Request for Information on Price Transparency: Improving
Beneficiary Access to Provider and Supplier Charge Information.
2. Summary of Costs and Benefits
We have determined that this major proposed rule is economically
significant. For a detailed discussion of the economic impacts, see
section VII. of this proposed rule.
II. Provisions of the Proposed Rule for the PFS
A. Background
Since January 1, 1992, Medicare has paid for physicians' services
under section 1848 of the Act, ``Payment for Physicians' Services.''
The PFS relies on national relative values that are established for
work, practice expense (PE), and malpractice (MP), which are adjusted
for geographic cost variations. These values are multiplied by a
conversion factor (CF) to convert the relative value units (RVUs) into
payment rates. The concepts and methodology underlying the PFS were
enacted as part of the Omnibus Budget Reconciliation Act of 1989 (Pub.
L. 101-239, enacted on December 19, 1989) (OBRA '89), and the Omnibus
Budget Reconciliation Act of 1990 (Pub. L. 101-508, enacted on November
5, 1990) (OBRA '90). The final rule published on November 25, 1991 (56
FR 59502) set forth the first fee schedule used for payment for
physicians' services.
We note that throughout this major proposed rule, unless otherwise
noted, the term ``practitioner'' is used to describe both physicians
and nonphysician practitioners (NPPs) who are permitted to bill
Medicare under the PFS for the services they furnish to Medicare
beneficiaries.
1. Development of the Relative Values
a. Work RVUs
The work RVUs established for the initial fee schedule, which was
implemented on January 1, 1992, were developed with extensive input
from the physician community. A research team at the Harvard School of
Public Health developed the original work RVUs for most codes under a
cooperative agreement with the Department of Health and Human Services
(HHS). In constructing the code-specific vignettes used in determining
the original physician work RVUs, Harvard worked with panels of
experts, both inside and outside the federal government, and obtained
input from numerous physician specialty groups.
As specified in section 1848(c)(1)(A) of the Act, the work
component of physicians' services means the portion of the resources
used in furnishing the service that reflects physician time and
intensity. We establish work RVUs for new, revised and potentially
misvalued codes based on our review of information that generally
includes, but is not limited to, recommendations received from the
American Medical Association/Specialty Society Relative Value Scale
Update Committee (RUC), the Health Care Professionals Advisory
Committee (HCPAC), the Medicare Payment Advisory Commission (MedPAC),
and other public commenters; medical literature and comparative
databases; as well as a comparison of the work for other codes within
the Medicare PFS, and consultation with other physicians and health
care professionals within CMS and the federal government. We also
assess the methodology and data used to develop the recommendations
submitted to us by the RUC and other
[[Page 35706]]
public commenters, and the rationale for their recommendations. In the
CY 2011 PFS final rule with comment period (75 FR 73328 through 73329),
we discussed a variety of methodologies and approaches used to develop
work RVUs, including survey data, building blocks, crosswalk to key
reference or similar codes, and magnitude estimation. More information
on these issues is available in that rule.
b. Practice Expense RVUs
Initially, only the work RVUs were resource-based, and the PE and
MP RVUs were based on average allowable charges. Section 121 of the
Social Security Act Amendments of 1994 (Pub. L. 103-432, enacted on
October 31, 1994), amended section 1848(c)(2)(C)(ii) of the Act and
required us to develop resource-based PE RVUs for each physicians'
service beginning in 1998. We were required to consider general
categories of expenses (such as office rent and wages of personnel, but
excluding MP expenses) comprising PEs. The PE RVUs continue to
represent the portion of these resources involved in furnishing PFS
services.
Originally, the resource-based method was to be used beginning in
1998, but section 4505(a) of the Balanced Budget Act of 1997 (Pub. L.
105-33, enacted on August 5, 1997) (BBA) delayed implementation of the
resource-based PE RVU system until January 1, 1999. In addition,
section 4505(b) of the BBA provided for a 4-year transition period from
the charge-based PE RVUs to the resource-based PE RVUs.
We established the resource-based PE RVUs for each physicians'
service in the November 2, 1998 final rule (63 FR 58814), effective for
services furnished in CY 1999. Based on the requirement to transition
to a resource-based system for PE over a 4-year period, payment rates
were not fully based upon resource-based PE RVUs until CY 2002. This
resource-based system was based on two significant sources of actual PE
data: The Clinical Practice Expert Panel (CPEP) data; and the AMA's
Socioeconomic Monitoring System (SMS) data. These data sources are
described in greater detail in the CY 2012 PFS final rule with comment
period (76 FR 73033).
Separate PE RVUs are established for services furnished in facility
settings, such as a hospital outpatient department (HOPD) or an
ambulatory surgical center (ASC), and in nonfacility settings, such as
a physician's office. The nonfacility RVUs reflect all of the direct
and indirect PEs involved in furnishing a service described by a
particular HCPCS code. The difference, if any, in these PE RVUs
generally results in a higher payment in the nonfacility setting
because in the facility settings some costs are borne by the facility.
Medicare's payment to the facility (such as the outpatient prospective
payment system (OPPS) payment to the HOPD) would reflect costs
typically incurred by the facility. Thus, payment associated with those
facility resources is not made under the PFS.
Section 212 of the Balanced Budget Refinement Act of 1999 (Pub. L.
106-113, enacted on November 29, 1999) (BBRA) directed the Secretary of
Health and Human Services (the Secretary) to establish a process under
which we accept and use, to the maximum extent practicable and
consistent with sound data practices, data collected or developed by
entities and organizations to supplement the data we normally collect
in determining the PE component. On May 3, 2000, we published the
interim final rule (65 FR 25664) that set forth the criteria for the
submission of these supplemental PE survey data. The criteria were
modified in response to comments received, and published in the Federal
Register (65 FR 65376) as part of a November 1, 2000 final rule. The
PFS final rules published in 2001 and 2003, respectively, (66 FR 55246
and 68 FR 63196) extended the period during which we would accept these
supplemental data through March 1, 2005.
In the CY 2007 PFS final rule with comment period (71 FR 69624), we
revised the methodology for calculating direct PE RVUs from the top-
down to the bottom-up methodology beginning in CY 2007. We adopted a 4-
year transition to the new PE RVUs. This transition was completed for
CY 2010. In the CY 2010 PFS final rule with comment period, we updated
the practice expense per hour (PE/HR) data that are used in the
calculation of PE RVUs for most specialties (74 FR 61749). In CY 2010,
we began a 4-year transition to the new PE RVUs using the updated PE/HR
data, which was completed for CY 2013.
c. Malpractice RVUs
Section 4505(f) of the BBA amended section 1848(c) of the Act to
require that we implement resource-based MP RVUs for services furnished
on or after CY 2000. The resource-based MP RVUs were implemented in the
PFS final rule with comment period published November 2, 1999 (64 FR
59380). The MP RVUs are based on commercial and physician-owned
insurers' MP insurance premium data from all the states, the District
of Columbia, and Puerto Rico. For more information on MP RVUs, see
section II.C. of this proposed rule.
d. Refinements to the RVUs
Section 1848(c)(2)(B)(i) of the Act requires that we review RVUs no
less often than every 5 years. Prior to CY 2013, we conducted periodic
reviews of work RVUs and PE RVUs independently. We completed 5-year
reviews of work RVUs that were effective for calendar years 1997, 2002,
2007, and 2012.
Although refinements to the direct PE inputs initially relied
heavily on input from the RUC Practice Expense Advisory Committee
(PEAC), the shifts to the bottom-up PE methodology in CY 2007 and to
the use of the updated PE/HR data in CY 2010 have resulted in
significant refinements to the PE RVUs in recent years.
In the CY 2012 PFS final rule with comment period (76 FR 73057), we
finalized a proposal to consolidate reviews of work and PE RVUs under
section 1848(c)(2)(B) of the Act and reviews of potentially misvalued
codes under section 1848(c)(2)(K) of the Act into one annual process.
In addition to the 5-year reviews, beginning for CY 2009, CMS and
the RUC identified and reviewed a number of potentially misvalued codes
on an annual basis based on various identification screens. This annual
review of work and PE RVUs for potentially misvalued codes was
supplemented by the amendments to section 1848 of the Act, as enacted
by section 3134 of the Affordable Care Act, that require the agency to
periodically identify, review and adjust values for potentially
misvalued codes.
e. Application of Budget Neutrality to Adjustments of RVUs
As described in section VII. of this proposed rule, in accordance
with section 1848(c)(2)(B)(ii)(II) of the Act, if revisions to the RVUs
cause expenditures for the year to change by more than $20 million, we
make adjustments to ensure that expenditures do not increase or
decrease by more than $20 million.
2. Calculation of Payments Based on RVUs
To calculate the payment for each service, the components of the
fee schedule (work, PE, and MP RVUs) are adjusted by geographic
practice cost indices (GPCIs) to reflect the variations in the costs of
furnishing the services. The GPCIs reflect the relative costs of work,
PE, and MP in an area compared to the national average costs for each
[[Page 35707]]
component. Please refer to the CY 2017 PFS final rule with comment
period for a discussion of the last GPCI update (81 FR 80261 through
80270).
RVUs are converted to dollar amounts through the application of a
CF, which is calculated based on a statutory formula by CMS's Office of
the Actuary (OACT). The formula for calculating the Medicare PFS
payment amount for a given service and fee schedule area can be
expressed as:
Payment = [(RVU work x GPCI work) + (RVU PE x GPCI PE) + (RVU MP x GPCI
MP)] x CF
3. Separate Fee Schedule Methodology for Anesthesia Services
Section 1848(b)(2)(B) of the Act specifies that the fee schedule
amounts for anesthesia services are to be based on a uniform relative
value guide, with appropriate adjustment of an anesthesia CF, in a
manner to ensure that fee schedule amounts for anesthesia services are
consistent with those for other services of comparable value.
Therefore, there is a separate fee schedule methodology for anesthesia
services. Specifically, we establish a separate CF for anesthesia
services and we utilize the uniform relative value guide, or base
units, as well as time units, to calculate the fee schedule amounts for
anesthesia services. Since anesthesia services are not valued using
RVUs, a separate methodology for locality adjustments is also
necessary. This involves an adjustment to the national anesthesia CF
for each payment locality.
B. Determination of Practice Expense (PE) Relative Value Units (RVUs)
1. Overview
Practice expense (PE) is the portion of the resources used in
furnishing a service that reflects the general categories of physician
and practitioner expenses, such as office rent and personnel wages, but
excluding MP expenses, as specified in section 1848(c)(1)(B) of the
Act. As required by section 1848(c)(2)(C)(ii) of the Act, we use a
resource-based system for determining PE RVUs for each physicians'
service. We develop PE RVUs by considering the direct and indirect
practice resources involved in furnishing each service. Direct expense
categories include clinical labor, medical supplies, and medical
equipment. Indirect expenses include administrative labor, office
expense, and all other expenses. The sections that follow provide more
detailed information about the methodology for translating the
resources involved in furnishing each service into service-specific PE
RVUs. We refer readers to the CY 2010 PFS final rule with comment
period (74 FR 61743 through 61748) for a more detailed explanation of
the PE methodology.
2. Practice Expense Methodology
a. Direct Practice Expense
We determine the direct PE for a specific service by adding the
costs of the direct resources (that is, the clinical staff, medical
supplies, and medical equipment) typically involved with furnishing
that service. The costs of the resources are calculated using the
refined direct PE inputs assigned to each CPT code in our PE database,
which are generally based on our review of recommendations received
from the RUC and those provided in response to public comment periods.
For a detailed explanation of the direct PE methodology, including
examples, we refer readers to the Five-Year Review of Work Relative
Value Units under the PFS and Proposed Changes to the Practice Expense
Methodology CY 2007 PFS proposed notice (71 FR 37242) and the CY 2007
PFS final rule with comment period (71 FR 69629).
b. Indirect Practice Expense per Hour Data
We use survey data on indirect PEs incurred per hour worked in
developing the indirect portion of the PE RVUs. Prior to CY 2010, we
primarily used the PE/HR by specialty that was obtained from the AMA's
SMS. The AMA administered a new survey in CY 2007 and CY 2008, the
Physician Practice Expense Information Survey (PPIS). The PPIS is a
multispecialty, nationally representative, PE survey of both physicians
and NPPs paid under the PFS using a survey instrument and methods
highly consistent with those used for the SMS and the supplemental
surveys. The PPIS gathered information from 3,656 respondents across 51
physician specialty and health care professional groups. We believe the
PPIS is the most comprehensive source of PE survey information
available. We used the PPIS data to update the PE/HR data for the CY
2010 PFS for almost all of the Medicare-recognized specialties that
participated in the survey.
When we began using the PPIS data in CY 2010, we did not change the
PE RVU methodology itself or the manner in which the PE/HR data are
used in that methodology. We only updated the PE/HR data based on the
new survey. Furthermore, as we explained in the CY 2010 PFS final rule
with comment period (74 FR 61751), because of the magnitude of payment
reductions for some specialties resulting from the use of the PPIS
data, we transitioned its use over a 4-year period from the previous PE
RVUs to the PE RVUs developed using the new PPIS data. As provided in
the CY 2010 PFS final rule with comment period (74 FR 61751), the
transition to the PPIS data was complete for CY 2013. Therefore, PE
RVUs from CY 2013 forward are developed based entirely on the PPIS
data, except as noted in this section.
Section 1848(c)(2)(H)(i) of the Act requires us to use the medical
oncology supplemental survey data submitted in 2003 for oncology drug
administration services. Therefore, the PE/HR for medical oncology,
hematology, and hematology/oncology reflects the continued use of these
supplemental survey data.
Supplemental survey data on independent labs from the College of
American Pathologists were implemented for payments beginning in CY
2005. Supplemental survey data from the National Coalition of Quality
Diagnostic Imaging Services (NCQDIS), representing independent
diagnostic testing facilities (IDTFs), were blended with supplementary
survey data from the American College of Radiology (ACR) and
implemented for payments beginning in CY 2007. Neither IDTFs, nor
independent labs, participated in the PPIS. Therefore, we continue to
use the PE/HR that was developed from their supplemental survey data.
Consistent with our past practice, the previous indirect PE/HR
values from the supplemental surveys for these specialties were updated
to CY 2006 using the Medicare Economic Index (MEI) to put them on a
comparable basis with the PPIS data.
We also do not use the PPIS data for reproductive endocrinology and
spine surgery since these specialties currently are not separately
recognized by Medicare, nor do we have a method to blend the PPIS data
with Medicare-recognized specialty data.
Previously, we established PE/HR values for various specialties
without SMS or supplemental survey data by crosswalking them to other
similar specialties to estimate a proxy PE/HR. For specialties that
were part of the PPIS for which we previously used a crosswalked PE/HR,
we instead used the PPIS-based PE/HR. We use crosswalks for specialties
that did not participate in the PPIS. These crosswalks have been
generally established through notice and comment rulemaking and are
available in the file called ``CY 2019 PFS Proposed Rule PE/HR'' on the
CMS website under downloads for the CY
[[Page 35708]]
2019 PFS proposed rule at http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched/PFS-Federal-Regulation-Notices.html.
For CY 2019, we have incorporated the available utilization data
for two new specialties, each of which became a recognized Medicare
specialty during 2017. These specialties are Hospitalists and Advanced
Heart Failure and Transplant Cardiology. We are proposing to use proxy
PE/HR values for these new specialties, as there are no PPIS data for
these specialties, by crosswalking the PE/HR as follows from
specialties that furnish similar services in the Medicare claims data:
Hospitalists from Emergency Medicine.
Advanced Heart Failure and Transplant Cardiology from
Cardiology.
The proposal is reflected in the ``CY 2019 PFS Proposed Rule PE/
HR'' file available on the CMS website under the supporting data files
for the CY 2019 PFS proposed rule at http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched/PFS-Federal-Regulation-Notices.html.
c. Allocation of PE to Services
To establish PE RVUs for specific services, it is necessary to
establish the direct and indirect PE associated with each service.
(1) Direct Costs
The relative relationship between the direct cost portions of the
PE RVUs for any two services is determined by the relative relationship
between the sum of the direct cost resources (that is, the clinical
staff, medical supplies, and medical equipment) typically involved with
furnishing each of the services. The costs of these resources are
calculated from the refined direct PE inputs in our PE database. For
example, if one service has a direct cost sum of $400 from our PE
database and another service has a direct cost sum of $200, the direct
portion of the PE RVUs of the first service would be twice as much as
the direct portion of the PE RVUs for the second service.
(2) Indirect Costs
We allocate the indirect costs to the code level on the basis of
the direct costs specifically associated with a code and the greater of
either the clinical labor costs or the work RVUs. We also incorporate
the survey data described earlier in the PE/HR discussion (see section
II.B.2.b of this proposed rule). The general approach to developing the
indirect portion of the PE RVUs is as follows:
For a given service, we use the direct portion of the PE
RVUs calculated as previously described and the average percentage that
direct costs represent of total costs (based on survey data) across the
specialties that furnish the service to determine an initial indirect
allocator. That is, the initial indirect allocator is calculated so
that the direct costs equal the average percentage of direct costs of
those specialties furnishing the service. For example, if the direct
portion of the PE RVUs for a given service is 2.00 and direct costs, on
average, represent 25 percent of total costs for the specialties that
furnish the service, the initial indirect allocator would be calculated
so that it equals 75 percent of the total PE RVUs. Thus, in this
example, the initial indirect allocator would equal 6.00, resulting in
a total PE RVU of 8.00 (2.00 is 25 percent of 8.00 and 6.00 is 75
percent of 8.00).
Next, we add the greater of the work RVUs or clinical
labor portion of the direct portion of the PE RVUs to this initial
indirect allocator. In our example, if this service had a work RVU of
4.00 and the clinical labor portion of the direct PE RVU was 1.50, we
would add 4.00 (since the 4.00 work RVUs are greater than the 1.50
clinical labor portion) to the initial indirect allocator of 6.00 to
get an indirect allocator of 10.00. In the absence of any further use
of the survey data, the relative relationship between the indirect cost
portions of the PE RVUs for any two services would be determined by the
relative relationship between these indirect cost allocators. For
example, if one service had an indirect cost allocator of 10.00 and
another service had an indirect cost allocator of 5.00, the indirect
portion of the PE RVUs of the first service would be twice as great as
the indirect portion of the PE RVUs for the second service.
Next, we incorporated the specialty-specific indirect PE/
HR data into the calculation. In our example, if, based on the survey
data, the average indirect cost of the specialties furnishing the first
service with an allocator of 10.00 was half of the average indirect
cost of the specialties furnishing the second service with an indirect
allocator of 5.00, the indirect portion of the PE RVUs of the first
service would be equal to that of the second service.
(3) Facility and Nonfacility Costs
For procedures that can be furnished in a physician's office, as
well as in a facility setting, where Medicare makes a separate payment
to the facility for its costs in furnishing a service, we establish two
PE RVUs: facility and nonfacility. The methodology for calculating PE
RVUs is the same for both the facility and nonfacility RVUs, but is
applied independently to yield two separate PE RVUs. In calculating the
PE RVUs for services furnished in a facility, we do not include
resources that would generally not be provided by physicians when
furnishing the service. For this reason, the facility PE RVUs are
generally lower than the nonfacility PE RVUs.
(4) Services With Technical Components and Professional Components
Diagnostic services are generally comprised of two components: A
professional component (PC); and a technical component (TC). The PC and
TC may be furnished independently or by different providers, or they
may be furnished together as a global service. When services have
separately billable PC and TC components, the payment for the global
service equals the sum of the payment for the TC and PC. To achieve
this, we use a weighted average of the ratio of indirect to direct
costs across all the specialties that furnish the global service, TCs,
and PCs; that is, we apply the same weighted average indirect
percentage factor to allocate indirect expenses to the global service,
PCs, and TCs for a service. (The direct PE RVUs for the TC and PC sum
to the global.)
(5) PE RVU Methodology
For a more detailed description of the PE RVU methodology, we refer
readers to the CY 2010 PFS final rule with comment period (74 FR 61745
through 61746). We also direct readers to the file called ``Calculation
of PE RVUs under Methodology for Selected Codes'' which is available on
our website under downloads for the CY 2019 PFS proposed rule at http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched/PFS-Federal-Regulation-Notices.html. This file
contains a table that illustrates the calculation of PE RVUs as
described in this proposed rule for individual codes.
(a) Setup File
First, we create a setup file for the PE methodology. The setup
file contains the direct cost inputs, the utilization for each
procedure code at the specialty and facility/nonfacility place of
service level, and the specialty-specific PE/HR data calculated from
the surveys.
(b) Calculate the Direct Cost PE RVUs
Sum the costs of each direct input.
Step 1: Sum the direct costs of the inputs for each service.
[[Page 35709]]
Step 2: Calculate the aggregate pool of direct PE costs for the
current year. We set the aggregate pool of PE costs equal to the
product of the ratio of the current aggregate PE RVUs to current
aggregate work RVUs and the proposed aggregate work RVUs.
Step 3: Calculate the aggregate pool of direct PE costs for use in
ratesetting. This is the product of the aggregate direct costs for all
services from Step 1 and the utilization data for that service.
Step 4: Using the results of Step 2 and Step 3, use the CF to
calculate a direct PE scaling adjustment to ensure that the aggregate
pool of direct PE costs calculated in Step 3 does not vary from the
aggregate pool of direct PE costs for the current year. Apply the
scaling adjustment to the direct costs for each service (as calculated
in Step 1).
Step 5: Convert the results of Step 4 to a RVU scale for each
service. To do this, divide the results of Step 4 by the CF. Note that
the actual value of the CF used in this calculation does not influence
the final direct cost PE RVUs as long as the same CF is used in Step 4
and Step 5. Different CFs would result in different direct PE scaling
adjustments, but this has no effect on the final direct cost PE RVUs
since changes in the CFs and changes in the associated direct scaling
adjustments offset one another.
(c) Create the Indirect Cost PE RVUs
Create indirect allocators.
Step 6: Based on the survey data, calculate direct and indirect PE
percentages for each physician specialty.
Step 7: Calculate direct and indirect PE percentages at the service
level by taking a weighted average of the results of Step 6 for the
specialties that furnish the service. Note that for services with TCs
and PCs, the direct and indirect percentages for a given service do not
vary by the PC, TC, and global service.
We generally use an average of the 3 most recent years of available
Medicare claims data to determine the specialty mix assigned to each
code. Codes with low Medicare service volume require special attention
since billing or enrollment irregularities for a given year can result
in significant changes in specialty mix assignment. We finalized a
proposal in the CY 2018 PFS final rule (82 FR 52982 through 59283) to
use the most recent year of claims data to determine which codes are
low volume for the coming year (those that have fewer than 100 allowed
services in the Medicare claims data). For codes that fall into this
category, instead of assigning specialty mix based on the specialties
of the practitioners reporting the services in the claims data, we
instead use the expected specialty that we identify on a list developed
based on medical review and input from expert stakeholders. We display
this list of expected specialty assignments as part of the annual set
of data files we make available as part of notice and comment
rulemaking and consider recommendations from the RUC and other
stakeholders on changes to this list on an annual basis. Services for
which the specialty is automatically assigned based on previously
finalized policies under our established methodology (for example,
``always therapy'' services) are unaffected by the list of expected
specialty assignments. We also finalized in the CY 2018 PFS final rule
(82 FR 52982 through 59283) a proposal to apply these service-level
overrides for both PE and MP, rather than one or the other category.
For CY 2019, we are proposing to add 28 additional codes that we
have identified as low volume services to the list of codes for which
we assign the expected specialty. Based on our own medical review and
input from the RUC and from specialty societies, we are proposing to
assign the expected specialty for each code as indicated in Table 1.
For each of these codes, only the professional component (reported with
the -26 modifier) is nationally priced. The global and technical
components are priced by the Medicare Administrative Contractors (MACs)
which establish RVUs and payment amounts for these services. The list
of codes that we are proposing to add is displayed in Table 1.
Table 1--New Additions to Expected Specialty List for Low Volume Services
----------------------------------------------------------------------------------------------------------------
2017
CPT code Mod Short descriptor Expected specialty Utilization
----------------------------------------------------------------------------------------------------------------
70557........................ 26 Mri brain w/o dye........... Diagnostic Radiology... 126
70558........................ 26 Mri brain w/dye............. Diagnostic Radiology... 32
74235........................ 26 Remove esophagus obstruction Gastroenterology....... 10
74301........................ 26 X-rays at surgery add-on.... Diagnostic Radiology... 73
74355........................ 26 X-ray guide intestinal tube. Diagnostic Radiology... 11
74445........................ 26 X-ray exam of penis......... Urology................ 26
74742........................ 26 X-ray fallopian tube........ Diagnostic Radiology... 5
74775........................ 26 X-ray exam of perineum...... Diagnostic Radiology... 80
75801........................ 26 Lymph vessel x-ray arm/leg.. Diagnostic Radiology... 114
75803........................ 26 Lymph vessel x-ray arms/leg. Diagnostic Radiology... 41
75805........................ 26 Lymph vessel x-ray trunk.... Diagnostic Radiology... 50
75810........................ 26 Vein x-ray spleen/liver..... Diagnostic Radiology... 46
76941........................ 26 Echo guide for transfusion.. Obstetrics/Gynecology.. 15
76945........................ 26 Echo guide villus sampling.. Obstetrics/Gynecology.. 31
76975........................ 26 Gi endoscopic ultrasound.... Gastroenterology....... 49
78282........................ 26 Gi protein loss exam........ Diagnostic Radiology... 8
79300........................ 26 Nuclr rx interstit colloid.. Diagnostic Radiology... 2
86327........................ 26 Immunoelectrophoresis assay. Pathology.............. 24
87164........................ 26 Dark field examination...... Pathology.............. 30
88371........................ 26 Protein western blot tissue. Pathology.............. 2
93532........................ 26 R & l heart cath congenital. Cardiology............. 28
93533........................ 26 R & l heart cath congenital. Cardiology............. 36
93561........................ 26 Cardiac output measurement.. Cardiology............. 28
93562........................ 26 Card output measure subsq... Cardiology............. 38
93616........................ 26 Esophageal recording........ Cardiology............. 38
93624........................ 26 Electrophysiologic study.... Cardiology............. 51
95966........................ 26 Meg evoked single........... Neurology.............. 72
95967........................ 26 Meg evoked each addl........ Neurology.............. 61
----------------------------------------------------------------------------------------------------------------
[[Page 35710]]
The complete list of expected specialty assignments for individual
low volume services, including the proposed assignments for the codes
identified in Table 1, is available on our website under downloads for
the CY 2019 PFS proposed rule at http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched/PFS-Federal-Regulation-Notices.html.
Step 8: Calculate the service level allocators for the indirect PEs
based on the percentages calculated in Step 7. The indirect PEs are
allocated based on the three components: The direct PE RVUs; the
clinical labor PE RVUs; and the work RVUs.
For most services the indirect allocator is: indirect PE percentage
* (direct PE RVUs/direct percentage) + work RVUs.
There are two situations where this formula is modified:
If the service is a global service (that is, a service
with global, professional, and technical components), then the indirect
PE allocator is: indirect percentage (direct PE RVUs/direct percentage)
+ clinical labor PE RVUs + work RVUs.
If the clinical labor PE RVUs exceed the work RVUs (and
the service is not a global service), then the indirect allocator is:
indirect PE percentage (direct PE RVUs/direct percentage) + clinical
labor PE RVUs.
(Note: For global services, the indirect PE allocator is based on
both the work RVUs and the clinical labor PE RVUs. We do this to
recognize that, for the PC service, indirect PEs would be allocated
using the work RVUs, and for the TC service, indirect PEs would be
allocated using the direct PE RVUs and the clinical labor PE RVUs. This
also allows the global component RVUs to equal the sum of the PC and TC
RVUs.)
For presentation purposes, in the examples in the download file
called ``Calculation of PE RVUs under Methodology for Selected Codes'',
the formulas were divided into two parts for each service.
The first part does not vary by service and is the
indirect percentage (direct PE RVUs/direct percentage).
The second part is either the work RVU, clinical labor PE
RVU, or both depending on whether the service is a global service and
whether the clinical PE RVUs exceed the work RVUs (as described earlier
in this step).
Apply a scaling adjustment to the indirect allocators.
Step 9: Calculate the current aggregate pool of indirect PE RVUs by
multiplying the result of step 8 by the average indirect PE percentage
from the survey data.
Step 10: Calculate an aggregate pool of indirect PE RVUs for all
PFS services by adding the product of the indirect PE allocators for a
service from Step 8 and the utilization data for that service.
Step 11: Using the results of Step 9 and Step 10, calculate an
indirect PE adjustment so that the aggregate indirect allocation does
not exceed the available aggregate indirect PE RVUs and apply it to
indirect allocators calculated in Step 8.
Calculate the indirect practice cost index.
Step 12: Using the results of Step 11, calculate aggregate pools of
specialty-specific adjusted indirect PE allocators for all PFS services
for a specialty by adding the product of the adjusted indirect PE
allocator for each service and the utilization data for that service.
Step 13: Using the specialty-specific indirect PE/HR data,
calculate specialty-specific aggregate pools of indirect PE for all PFS
services for that specialty by adding the product of the indirect PE/HR
for the specialty, the work time for the service, and the specialty's
utilization for the service across all services furnished by the
specialty.
Step 14: Using the results of Step 12 and Step 13, calculate the
specialty-specific indirect PE scaling factors.
Step 15: Using the results of Step 14, calculate an indirect
practice cost index at the specialty level by dividing each specialty-
specific indirect scaling factor by the average indirect scaling factor
for the entire PFS.
Step 16: Calculate the indirect practice cost index at the service
level to ensure the capture of all indirect costs. Calculate a weighted
average of the practice cost index values for the specialties that
furnish the service. (Note: For services with TCs and PCs, we calculate
the indirect practice cost index across the global service, PCs, and
TCs. Under this method, the indirect practice cost index for a given
service (for example, echocardiogram) does not vary by the PC, TC, and
global service.)
Step 17: Apply the service level indirect practice cost index
calculated in Step 16 to the service level adjusted indirect allocators
calculated in Step 11 to get the indirect PE RVUs.
(d) Calculate the Final PE RVUs
Step 18: Add the direct PE RVUs from Step 5 to the indirect PE RVUs
from Step 17 and apply the final PE budget neutrality (BN) adjustment.
The final PE BN adjustment is calculated by comparing the sum of steps
5 and 17 to the proposed aggregate work RVUs scaled by the ratio of
current aggregate PE and work RVUs. This adjustment ensures that all PE
RVUs in the PFS account for the fact that certain specialties are
excluded from the calculation of PE RVUs but included in maintaining
overall PFS budget neutrality. (See ``Specialties excluded from
ratesetting calculation'' later in this final rule.)
Step 19: Apply the phase-in of significant RVU reductions and its
associated adjustment. Section 1848(c)(7) of the Act specifies that for
services that are not new or revised codes, if the total RVUs for a
service for a year would otherwise be decreased by an estimated 20
percent or more as compared to the total RVUs for the previous year,
the applicable adjustments in work, PE, and MP RVUs shall be phased in
over a 2-year period. In implementing the phase-in, we consider a 19
percent reduction as the maximum 1-year reduction for any service not
described by a new or revised code. This approach limits the year one
reduction for the service to the maximum allowed amount (that is, 19
percent), and then phases in the remainder of the reduction. To comply
with section 1848(c)(7) of the Act, we adjust the PE RVUs to ensure
that the total RVUs for all services that are not new or revised codes
decrease by no more than 19 percent, and then apply a relativity
adjustment to ensure that the total pool of aggregate PE RVUs remains
relative to the pool of work and MP RVUs. For a more detailed
description of the methodology for the phase-in of significant RVU
changes, we refer readers to the CY 2016 PFS final rule with comment
period (80 FR 70927 through 70931).
(e) Setup File Information
Specialties excluded from ratesetting calculation: For the
purposes of calculating the PE RVUs, we exclude certain specialties,
such as certain NPPs paid at a percentage of the PFS and low-volume
specialties, from the calculation. These specialties are included for
the purposes of calculating the BN adjustment. They are displayed in
Table 2.
[[Page 35711]]
Table 2--Specialties Excluded From Ratesetting Calculation
------------------------------------------------------------------------
Specialty code Specialty description
------------------------------------------------------------------------
49........................... Ambulatory surgical center.
50........................... Nurse practitioner.
51........................... Medical supply company with certified
orthotist.
52........................... Medical supply company with certified
prosthetist.
53........................... Medical supply company with certified
prosthetist[dash]orthotist.
54........................... Medical supply company not included in
51, 52, or 53.
55........................... Individual certified orthotist.
56........................... Individual certified prosthetist.
57........................... Individual certified
prosthetist[dash]orthotist.
58........................... Medical supply company with registered
pharmacist.
59........................... Ambulance service supplier, e.g., private
ambulance companies, funeral homes, etc.
60........................... Public health or welfare agencies.
61........................... Voluntary health or charitable agencies.
73........................... Mass immunization roster biller.
74........................... Radiation therapy centers.
87........................... All other suppliers (e.g., drug and
department stores).
88........................... Unknown supplier/provider specialty.
89........................... Certified clinical nurse specialist.
96........................... Optician.
97........................... Physician assistant.
A0........................... Hospital.
A1........................... SNF.
A2........................... Intermediate care nursing facility.
A3........................... Nursing facility, other.
A4........................... HHA.
A5........................... Pharmacy.
A6........................... Medical supply company with respiratory
therapist.
A7........................... Department store.
B2........................... Pedorthic personnel.
B3........................... Medical supply company with pedorthic
personnel.
------------------------------------------------------------------------
Crosswalk certain low volume physician specialties:
Crosswalk the utilization of certain specialties with relatively low
PFS utilization to the associated specialties.
Physical therapy utilization: Crosswalk the utilization
associated with all physical therapy services to the specialty of
physical therapy.
Identify professional and technical services not
identified under the usual TC and 26 modifiers: Flag the services that
are PC and TC services but do not use TC and 26 modifiers (for example,
electrocardiograms). This flag associates the PC and TC with the
associated global code for use in creating the indirect PE RVUs. For
example, the professional service, CPT code 93010 (Electrocardiogram,
routine ECG with at least 12 leads; interpretation and report only), is
associated with the global service, CPT code 93000 (Electrocardiogram,
routine ECG with at least 12 leads; with interpretation and report).
Payment modifiers: Payment modifiers are accounted for in
the creation of the file consistent with current payment policy as
implemented in claims processing. For example, services billed with the
assistant at surgery modifier are paid 16 percent of the PFS amount for
that service; therefore, the utilization file is modified to only
account for 16 percent of any service that contains the assistant at
surgery modifier. Similarly, for those services to which volume
adjustments are made to account for the payment modifiers, time
adjustments are applied as well. For time adjustments to surgical
services, the intraoperative portion in the work time file is used;
where it is not present, the intraoperative percentage from the payment
files used by contractors to process Medicare claims is used instead.
Where neither is available, we use the payment adjustment ratio to
adjust the time accordingly. Table 3 details the manner in which the
modifiers are applied.
Table 3--Application of Payment Modifiers to Utilization Files
----------------------------------------------------------------------------------------------------------------
Modifier Description Volume adjustment Time adjustment
----------------------------------------------------------------------------------------------------------------
80, 81, 82......................... Assistant at Surgery.... 16%..................... Intraoperative portion.
AS................................. Assistant at Surgery-- 14% (85% * 16%)......... Intraoperative portion.
Physician Assistant.
50 or LT and RT.................... Bilateral Surgery....... 150%.................... 150% of work time.
51................................. Multiple Procedure...... 50%..................... Intraoperative portion.
52................................. Reduced Services........ 50%..................... 50%.
53................................. Discontinued Procedure.. 50%..................... 50%.
54................................. Intraoperative Care only Preoperative + Preoperative +
Intraoperative Intraoperative
Percentages on the portion.
payment files used by
Medicare contractors to
process Medicare claims.
55................................. Postoperative Care only. Postoperative Percentage Postoperative portion.
on the payment files
used by Medicare
contractors to process
Medicare claims.
[[Page 35712]]
62................................. Co-surgeons............. 62.5%................... 50%.
66................................. Team Surgeons........... 33%..................... 33%.
----------------------------------------------------------------------------------------------------------------
We also make adjustments to volume and time that correspond to
other payment rules, including special multiple procedure endoscopy
rules and multiple procedure payment reductions (MPPRs). We note that
section 1848(c)(2)(B)(v) of the Act exempts certain reduced payments
for multiple imaging procedures and multiple therapy services from the
BN calculation under section 1848(c)(2)(B)(ii)(II) of the Act. These
MPPRs are not included in the development of the RVUs.
For anesthesia services, we do not apply adjustments to volume
since we use the average allowed charge when simulating RVUs;
therefore, the RVUs as calculated already reflect the payments as
adjusted by modifiers, and no volume adjustments are necessary.
However, a time adjustment of 33 percent is made only for medical
direction of two to four cases since that is the only situation where a
single practitioner is involved with multiple beneficiaries
concurrently, so that counting each service without regard to the
overlap with other services would overstate the amount of time spent by
the practitioner furnishing these services.
Work RVUs: The setup file contains the work RVUs from this
proposed rule.
(6) Equipment Cost per Minute
The equipment cost per minute is calculated as:
(1/(minutes per year * usage)) * price * ((interest rate/(1-(1/((1 +
interest rate)[caret] life of equipment)))) + maintenance)
Where:
minutes per year = maximum minutes per year if usage were continuous
(that is, usage = 1); generally 150,000 minutes.
usage = variable, see discussion in this proposed rule.
price = price of the particular piece of equipment.
life of equipment = useful life of the particular piece of
equipment.
maintenance = factor for maintenance; 0.05.
interest rate = variable, see discussion in this proposed rule.
Usage: We currently use an equipment utilization rate assumption of
50 percent for most equipment, with the exception of expensive
diagnostic imaging equipment, for which we use a 90 percent assumption
as required by section 1848(b)(4)(C) of the Act.
Stakeholders have often suggested that particular equipment items
are used less frequently than 50 percent of the time in the typical
setting and that CMS should reduce the equipment utilization rate based
on these recommendations. We appreciate and share stakeholders'
interest in using the most accurate assumption regarding the equipment
utilization rate for particular equipment items. However, we believe
that absent robust, objective, auditable data regarding the use of
particular items, the 50 percent assumption is the most appropriate
within the relative value system. We welcome the submission of data
that illustrates an alternative rate.
Maintenance: This factor for maintenance was finalized in the CY
1998 PFS final rule with comment period (62 FR 33164). As we previously
stated in the CY 2016 final rule with comment period (80 FR 70897), we
do not believe the annual maintenance factor for all equipment is
precisely 5 percent, and we concur that the current rate likely
understates the true cost of maintaining some equipment. We also
believe it likely overstates the maintenance costs for other equipment.
When we solicited comments regarding sources of data containing
equipment maintenance rates, commenters were unable to identify an
auditable, robust data source that could be used by CMS on a wide
scale. We do not believe that voluntary submissions regarding the
maintenance costs of individual equipment items would be an appropriate
methodology for determining costs. As a result, in the absence of
publicly available datasets regarding equipment maintenance costs or
another systematic data collection methodology for determining
maintenance factor, we do not believe that we have sufficient
information at present to propose a variable maintenance factor for
equipment cost per minute pricing. We continue to investigate potential
avenues for determining equipment maintenance costs across a broad
range of equipment items.
Interest Rate: In the CY 2013 PFS final rule with comment period
(77 FR 68902), we updated the interest rates used in developing an
equipment cost per minute calculation (see 77 FR 68902 for a thorough
discussion of this issue). The interest rate was based on the Small
Business Administration (SBA) maximum interest rates for different
categories of loan size (equipment cost) and maturity (useful life). We
are not proposing any changes to these interest rates for CY 2019. The
interest rates are listed in Table 4.
Table 4--SBA Maximum Interest Rates
------------------------------------------------------------------------
Interest
Price Useful life rate (%)
------------------------------------------------------------------------
<$25K............................... <7 Years............... 7.50
$25K to $50K........................ <7 Years............... 6.50
>$50K............................... <7 Years............... 5.50
<$25K............................... 7+ Years............... 8.00
$25K to $50K........................ 7+ Years............... 7.00
>$50K............................... 7+ Years............... 6.00
------------------------------------------------------------------------
3. Changes to Direct PE Inputs for Specific Services
This section focuses on specific PE inputs. The direct PE inputs
are included in the CY 2019 direct PE input database, which is
available on the CMS website under downloads for the CY 2019 PFS
proposed rule at http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched/PFS-Federal-Regulation-Notices.html.
a. Standardization of Clinical Labor Tasks
As we noted in the CY 2015 PFS final rule with comment period (79
FR 67640-67641), we continue to make improvements to the direct PE
input database to provide the number of clinical labor minutes assigned
for each task for every code in the database instead of only including
the number of clinical labor minutes for the preservice, service, and
postservice periods for each code. In addition to increasing the
transparency of the information used to set PE RVUs, this level of
detail would allow us to compare clinical labor times for activities
associated with services across the PFS, which we believe is important
to maintaining the relativity of the direct PE inputs. This information
would facilitate the identification of the usual numbers of minutes for
clinical labor tasks and the identification of exceptions to the usual
values. It would also allow for greater transparency and consistency in
the assignment of
[[Page 35713]]
equipment minutes based on clinical labor times. Finally, we believe
that the detailed information can be useful in maintaining standard
times for particular clinical labor tasks that can be applied
consistently to many codes as they are valued over several years,
similar in principle to the use of physician preservice time packages.
We believe that setting and maintaining such standards would provide
greater consistency among codes that share the same clinical labor
tasks and could improve relativity of values among codes. For example,
as medical practice and technologies change over time, changes in the
standards could be updated simultaneously for all codes with the
applicable clinical labor tasks, instead of waiting for individual
codes to be reviewed.
In the CY 2016 PFS final rule with comment period (80 FR 70901), we
solicited comments on the appropriate standard minutes for the clinical
labor tasks associated with services that use digital technology. After
consideration of comments received, we finalized standard times for
clinical labor tasks associated with digital imaging at 2 minutes for
``Availability of prior images confirmed'', 2 minutes for ``Patient
clinical information and questionnaire reviewed by technologist, order
from physician confirmed and exam protocoled by radiologist'', 2
minutes for ``Review examination with interpreting MD'', and 1 minute
for ``Exam documents scanned into PACS. Exam completed in RIS system to
generate billing process and to populate images into Radiologist work
queue.'' In the CY 2017 PFS final rule (81 FR 80184 through 80186), we
finalized a proposal to establish a range of appropriate standard
minutes for the clinical labor activity, ``Technologist QCs images in
PACS, checking for all images, reformats, and dose page.'' These
standard minutes will be applied to new and revised codes that make use
of this clinical labor activity when they are reviewed by us for
valuation. We finalized a proposal to establish 2 minutes as the
standard for the simple case, 3 minutes as the standard for the
intermediate case, 4 minutes as the standard for the complex case, and
5 minutes as the standard for the highly complex case. These values
were based upon a review of the existing minutes assigned for this
clinical labor activity; we determined that 2 minutes is the duration
for most services and a small number of codes with more complex forms
of digital imaging have higher values.
We also finalized standard times for clinical labor tasks
associated with pathology services in the CY 2016 PFS final rule with
comment period (80 FR 70902) at 4 minutes for ``Accession specimen/
prepare for examination'', 0.5 minutes for ``Assemble and deliver
slides with paperwork to pathologists'', 0.5 minutes for ``Assemble
other light microscopy slides, open nerve biopsy slides, and clinical
history, and present to pathologist to prepare clinical pathologic
interpretation'', 1 minute for ``Clean room/equipment following
procedure'', 1 minute for ``Dispose of remaining specimens, spent
chemicals/other consumables, and hazardous waste'', and 1 minute for
``Prepare, pack and transport specimens and records for in-house
storage and external storage (where applicable).'' We do not believe
these activities would be dependent on number of blocks or batch size,
and we believe that these values accurately reflect the typical time it
takes to perform these clinical labor tasks.
Historically, the RUC has submitted a ``PE worksheet'' that details
the recommended direct PE inputs for our use in developing PE RVUs. The
format of the PE worksheet has varied over time and among the medical
specialties developing the recommendations. These variations have made
it difficult for both the RUC's development and our review of code
values for individual codes. Beginning with its recommendations for CY
2019, the RUC has mandated the use of a new PE worksheet for purposes
of their recommendation development process that standardizes the
clinical labor tasks and assigns them a clinical labor activity code.
We believe the RUC's use of the new PE worksheet in developing and
submitting recommendations will help us to simplify and standardize the
hundreds of different clinical labor tasks currently listed in our
direct PE database. As we did for CY 2018, to facilitate rulemaking for
CY 2019, we are continuing to display two versions of the Labor Task
Detail public use file: One version with the old listing of clinical
labor tasks, and one with the same tasks cross-walked to the new
listing of clinical labor activity codes. These lists are available on
the CMS website under downloads for the CY 2019 PFS proposed rule at
http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched/PFS-Federal-Regulation-Notices.html.
In reviewing the RUC-recommended direct PE inputs for CY 2019, we
noticed that the 3 minutes of clinical labor time traditionally
assigned to the ``Prepare room, equipment and supplies'' (CA013)
clinical labor activity were split into 2 minutes for the ``Prepare
room, equipment and supplies'' activity and 1 minute for the ``Confirm
order, protocol exam'' (CA014) activity. These RUC-reviewed codes do
not currently have clinical labor time assigned for the ``Confirm
order, protocol exam'' clinical labor task, and we do not have any
reason to believe that the services being furnished by the clinical
staff have changed, only the way in which this clinical labor time has
been presented on the PE worksheets.
As a result, we are proposing to maintain the 3 minutes of clinical
labor time for the ``Prepare room, equipment and supplies'' activity
and remove the clinical labor time for the ``Confirm order, protocol
exam'' activity wherever we observed this pattern in the RUC-
recommended direct PE inputs. If we had received RUC recommendations
for codes that currently include clinical labor time for the ``Confirm
order, protocol exam'' clinical labor task, we would have left the
recommended clinical labor times unchanged, but there were no such
codes reviewed for CY 2019. We note that there is no effect on the
total clinical labor direct costs in these situations, since the same 3
minutes of clinical labor time is still being used in the calculation
of PE RVUs.
b. Equipment Recommendations for Scope Systems
During our routine reviews of direct PE input recommendations, we
have regularly found unexplained inconsistencies involving the use of
scopes and the video systems associated with them. Some of the scopes
include video systems bundled into the equipment item, some of them
include scope accessories as part of their price, and some of them are
standalone scopes with no other equipment included. It is not always
clear which equipment items related to scopes fall into which of these
categories. We have also frequently found anomalies in the equipment
recommendations, with equipment items that consist of a scope and video
system bundle recommended, along with a separate scope video system.
Based on our review, the variations do not appear to be consistent with
the different code descriptions.
To promote appropriate relativity among the services and facilitate
the transparency of our review process, during the review of the
recommended direct PE inputs for the CY 2017 PFS proposed rule, we
developed a structure that separates the scope, the associated video
system, and any scope accessories that might be typical as distinct
equipment items for each code. Under this approach, we proposed
standalone
[[Page 35714]]
prices for each scope, and separate prices for the video systems and
accessories that are used with scopes.
(1) Scope Equipment
Beginning in the CY 2017 proposed rule (81 FR 46176 through 46177),
we proposed standardizing refinements to the way scopes have been
defined in the direct PE input database. We believe that there are four
general types of scopes: Non-video scopes; flexible scopes; semi-rigid
scopes, and rigid scopes. Flexible scopes, semi-rigid scopes, and rigid
scopes would typically be paired with one of the scope video systems,
while the non-video scopes would not. The flexible scopes can be
further divided into diagnostic (or non-channeled) and therapeutic (or
channeled) scopes. We proposed to identify for each anatomical
application: (1) A rigid scope; (2) a semi-rigid scope; (3) a non-video
flexible scope; (4) a non-channeled flexible video scope; and (5) a
channeled flexible video scope. We proposed to classify the existing
scopes in our direct PE database under this classification system, to
improve the transparency of our review process and improve appropriate
relativity among the services. We planned to propose input prices for
these equipment items through future rulemaking.
We proposed these changes only for the reviewed codes for CY 2017
that made use of scopes, along with updated prices for the equipment
items related to scopes utilized by these services. But, we did not
propose to apply these policies to codes with inputs reviewed prior to
CY 2017. We also solicited comment on this separate pricing structure
for scopes, scope video systems, and scope accessories, which we could
consider proposing to apply to other codes in future rulemaking. We did
not finalize price increases for a series of other scopes and scope
accessories, as the invoices submitted for these components indicated
that they are different forms of equipment with different product IDs
and different prices. We did not receive any data to indicate that the
equipment on the newly submitted invoices was more typical in its use
than the equipment that we were currently using for pricing.
We did not make further changes to existing scope equipment in CY
2017 to allow the RUC's PE Subcommittee the opportunity to provide
feedback. However, we believed there was some miscommunication on this
point, as the RUC's PE Subcommittee workgroup that was created to
address scope systems stated that no further action was required
following the finalization of our proposal. Therefore, we made further
proposals in CY 2018 (82 FR 33961 through 33962) to continue clarifying
scope equipment inputs, and sought comments regarding the new set of
scope proposals. We considered creating a single scope equipment code
for each of the five categories detailed in this rule: (1) A rigid
scope; (2) a semi-rigid scope; (3) a non-video flexible scope; (4) a
non-channeled flexible video scope; and (5) a channeled flexible video
scope. Under the current classification system, there are many
different scopes in each category depending on the medical specialty
furnishing the service and the part of the body affected. We stated our
belief that the variation between these scopes was not significant
enough to warrant maintaining these distinctions, and we believed that
creating and pricing a single scope equipment code for each category
would help provide additional clarity. We sought public comment on the
merits of this potential scope organization, as well as any pricing
information regarding these five new scope categories.
After considering the comments on the CY 2018 proposed rule, we did
not finalize our proposal to create and price a single scope equipment
code for each of the five categories previously identified. Instead, we
supported the recommendation from the commenters to create scope
equipment codes on a per-specialty basis for six categories of scopes
as applicable, including the addition of a new sixth category of multi-
channeled flexible video scopes. Our goal is to create an
administratively simple scheme that will be easier to maintain and help
to reduce administrative burden. We look forward to receiving detailed
recommendations from expert stakeholders regarding the scope equipment
items that would be typically required for each scope category, as well
as the proper pricing for each scope.
(2) Scope Video System
We proposed in the CY 2017 PFS proposed rule (81 FR 46176 through
46177) to define the scope video system as including: (1) A monitor;
(2) a processor; (3) a form of digital capture; (4) a cart; and (5) a
printer. We believe that these equipment components represent the
typical case for a scope video system. Our model for this system was
the ``video system, endoscopy (processor, digital capture, monitor,
printer, cart)'' equipment item (ES031), which we proposed to re-price
as part of this separate pricing approach. We obtained current pricing
invoices for the endoscopy video system as part of our investigation of
these issues involving scopes, which we proposed to use for this re-
pricing. In response to comments, we finalized the addition of a
digital capture device to the endoscopy video system (ES031) in the CY
2017 PFS final rule (81 FR 80188). We finalized our proposal to price
the system at $33,391, based on component prices of $9,000 for the
processor, $18,346 for the digital capture device, $2,000 for the
monitor, $2,295 for the printer, and $1,750 for the cart. In the CY
2018 PFS final rule (82 FR 52991 through 52993), we outlined, but did
not finalize, a proposal to add an LED light source into the cost of
the scope video system (ES031), which would remove the need for a
separate light source in these procedures. We also described a proposal
to increase the price of the scope video system by $1,000 to cover the
expense of miscellaneous small equipment associated with the system
that falls below the threshold of individual equipment pricing as scope
accessories (such as cables, microphones, foot pedals, etc.). With the
addition of the LED light (equipment code EQ382 at a price of $1,915),
the updated total price of the scope video system would be set at
$36,306. We did not finalize this updated pricing to the scope video
system in CY 2018, and indicated our intention to address these changes
in CY 2019 to incorporate feedback from expert stakeholders.
(3) Scope Accessories
We understand that there may be other accessories associated with
the use of scopes. We finalized a proposal in the CY 2017 PFS final
rule (81 FR 80188) to separately price any scope accessories outside
the use of the scope video system, and individually evaluate their
inclusion or exclusion as direct PE inputs for particular codes as
usual under our current policy based on whether they are typically used
in furnishing the services described by the particular codes.
(4) Scope Proposals for CY 2019
We understand that the RUC has convened a Scope Equipment
Reorganization Workgroup that will be incorporating feedback from
expert stakeholders with the intention of making recommendations to us
on scope organization and scope pricing. Since the workgroup was not
convened in time to submit recommendations for the CY 2019 PFS
rulemaking cycle, we are proposing to delay proposals for any further
changes to scope equipment until CY 2020 so that we can incorporate the
feedback from the aforementioned workgroup. However,
[[Page 35715]]
we are proposing to update the price of the scope video system (ES031)
from its current price of $33,391 to a price of $36,306 to reflect the
addition of the LED light and miscellaneous small equipment associated
with the system that falls below the threshold of individual equipment
pricing as scope accessories, as we explained in detail in the CY 2018
PFS final rule (82 FR 52992 through 52993). We are also proposing to
update the name of the ES031 equipment item from ``video system,
endoscopy (processor, digital capture, monitor, printer, cart)'' to
``scope video system (monitor, processor, digital capture, cart,
printer, LED light)'' to reflect the fact that the use of the ES031
scope video system is not limited to endoscopy procedures.
c. Balloon Sinus Surgery Kit (SA106) Comment Solicitation
Several stakeholders contacted CMS with regard to the use of the
kit, sinus surgery, balloon (maxillary, frontal, or sphenoid) (SA106)
supply in CPT codes 31295 (Nasal/sinus endoscopy, surgical; with
dilation of maxillary sinus ostium (e.g., balloon dilation)),
transnasal or via canine fossa), 31296 (Nasal/sinus endoscopy,
surgical; with dilation of frontal sinus ostium (e.g., balloon
dilation)), and 31297 (Nasal/sinus endoscopy, surgical; with dilation
of sphenoid sinus ostium (e.g., balloon dilation)). The stakeholders
stated that the price of the SA106 supply (currently $2,599.86) had
decreased significantly since it was priced through rulemaking for CY
2011 (75 FR 73351 through 75532), and that the Medicare payment for
these three CPT codes using the supply no longer seemed to be in
proportion to what the kits cost. They also indicated that the same
catheter could be used to treat multiple sinuses rather than being a
disposable one-time use supply. The stakeholders stated that marketing
firms and sales representatives are advertising these CPT codes as a
method for generating additional profits due to the payment for the
procedures exceeding the resources typically needed to furnish the
services, and requested that CMS investigate the use of the SA106
supply in these codes.
We appreciate the information supplied by the stakeholders
regarding the use of the balloon sinus surgery kit. When CPT codes
31295-31297 were initially reviewed during the CY 2011 and CY 2012 PFS
rulemaking cycles (75 FR 73251, and 76 FR 73184 through 73186,
respectively), we expressed our reservations about the pricing and the
typical quantity of this supply item used in furnishing these services.
The RUC recommended for the CY 2012 rulemaking cycle that CMS remove
the balloon sinus surgery kit from each of these codes and implement
separately billable alpha-numeric HCPCS codes to allow practitioners to
be paid the cost of the disposable kits per patient encounter instead
of per CPT code. We stated at the time, and we continue to believe,
that this option presents a series of potential problems that we have
addressed previously in the context of the broader challenges regarding
our ability to price high cost disposable supply items. (For a
discussion of this issue, we direct the reader to our discussion in the
CY 2011 PFS final rule with comment period (75 FR 73251)). We stated at
the time that since the balloon sinus surgery kits can be used when
furnishing more than one service to the same beneficiary on the same
day, we believed that it would be appropriate to include 0.5 balloon
sinus surgery kits for each of the three codes, and we have maintained
this 0.5 supply quantity when CPT codes 31295-31297 were recently
reviewed again in CY 2018.
In light of the additional information supplied by the
stakeholders, we are soliciting comments on two aspects of the use of
the balloon sinus surgery kit (SA106) supply. First, we are soliciting
comments on whether the 0.5 supply quantity of the balloon sinus
surgery kit in CPT codes 31295-31297 would be typical for these
procedures. We are concerned that the same kit can be used when
furnishing more than one service to the same beneficiary on the same
day, and that even the 0.5 supply quantity may be overstating the
resources typically needed to furnish each service. Second, we are
soliciting comments on the pricing of the balloon sinus surgery kit,
given that we have received letters stating that the price has
decreased since the initial pricing in the CY 2011 final rule. See
Table 5 for the current component pricing of the balloon sinus surgery
kit.
Table 5--Balloon Sinus Surgery Kit (SA106) Price
----------------------------------------------------------------------------------------------------------------
Supply components Quantity Unit Price
----------------------------------------------------------------------------------------------------------------
kit, sinus surgery, balloon (maxillary, .............. kit............................... $2599.86
frontal, or sphenoid).
Sinus Guide Catheter........................ 1 item.............................. 444.00
Sinus Balloon Catheter...................... 1 item.............................. 820.80
Sinus Illumination System (100 cm lighted 1 item.............................. 454.80
guidewire).
Light Guide Cable (8 ft).................... 1 item.............................. 514.80
ACMI/Stryker Adaptor........................ 1 item.............................. 42.00
Sinus Guide Catheter Handle................. 1 item.............................. 66.00
Sinus Irrigation Catheter (22 cm)........... 1 item.............................. 150.00
Sinus Balloon Catheter Inflation Device..... 1 item.............................. 89.46
Extension Tubing (High Pressure) (20 in).... 1 item.............................. 18.00
----------------------------------------------------------------------------------------------------------------
We are interested in any information regarding possible changes in
the pricing for this kit or its individual components since the initial
pricing we adopted in CY 2011.
d. Technical Corrections to Direct PE Input Database and Supporting
Files
Subsequent to the publication of the CY 2018 PFS final rule,
stakeholders alerted us to several clerical inconsistencies in the
direct PE database. We are proposing to correct these inconsistencies
as described in this proposed rule and reflected in the CY 2019
proposed direct PE input database displayed on the CMS website under
downloads for the CY 2019 PFS proposed rule at http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched/PFS-Federal-Regulation-Notices.html.
For CY 2019, we are proposing to address the following
inconsistencies:
The RUC alerted us that there are 165 CPT codes billed
with an office E/M code more than 50 percent of the time in the
nonfacility setting that have more minimum multi-specialty visit supply
packs (SA048) than post-operative visits included in the code's global
period. This indicates that either the inclusion of office E/M services
was not accounted for in the code's global period when these codes were
initially reviewed by the PE Subcommittee, or
[[Page 35716]]
that the PE Subcommittee initially approved a minimum multi-specialty
visit supply pack for these codes without considering the resulting
overlap of supplies between SA048 and the E/M supply pack (SA047). The
RUC regarded these overlapping supply packs as a duplication, due to
the fact that the quantity of the SA048 supply exceeded the number of
postoperative visits, and requested that CMS remove the appropriate
number of supply item SA048 from 165 codes. After reviewing the
quantity of the SA048 supply pack included for the codes in question,
we are proposing to refine the quantity of minimum multi-specialty
visit packs as displayed in Table 6.
Table 6--Proposed Refinements--Minimum Multispecialty Visit Pack (SA048)
----------------------------------------------------------------------------------------------------------------
Proposed CY
CY 2018 2019
Number of nonfacility nonfacility
CPT code post-op office quantity of quantity of
visits minimum visit minimum visit
pack (SA048) pack (SA048)
----------------------------------------------------------------------------------------------------------------
10040........................................................... 1 2 1
10060........................................................... 1 2 1
10061........................................................... 2 3 2
10080........................................................... 1 2 1
10120........................................................... 1 2 1
10121........................................................... 1 2 1
10180........................................................... 1 2 1
11200........................................................... 1 2 1
11300........................................................... 0 1 0
11301........................................................... 0 1 0
11302........................................................... 0 1 0
11303........................................................... 0 1 0
11306........................................................... 0 1 0
11307........................................................... 0 1 0
11310........................................................... 0 1 0
11311........................................................... 0 1 0
11312........................................................... 0 1 0
11400........................................................... 1 2 1
11750........................................................... 1 2 1
11900........................................................... 0 1 0
11901........................................................... 0 1 0
12001........................................................... 0 1 0
12002........................................................... 0 1 0
12004........................................................... 0 1 0
12011........................................................... 0 1 0
12013........................................................... 0 1 0
16020........................................................... 0 1 0
17000........................................................... 1 2 1
17004........................................................... 1 2 1
17110........................................................... 1 2 1
17111........................................................... 1 2 1
17260........................................................... 1 2 1
17270........................................................... 1 2 1
17280........................................................... 1 2 1
19100........................................................... 0 1 0
20005........................................................... 1 2 1
20520........................................................... 1 2 1
21215........................................................... 6 7 6
21550........................................................... 1 2 1
21920........................................................... 1 2 1
22310........................................................... 1.5 2.5 1.5
23500........................................................... 2.5 3.5 2.5
23570........................................................... 2.5 3.5 2.5
23620........................................................... 3 4 3
24500........................................................... 4 5 4
24530........................................................... 4 5 4
24650........................................................... 3 4 3
24670........................................................... 3 4 3
25530........................................................... 3 4 3
25600........................................................... 5 6 5
25605........................................................... 5 6 5
25622........................................................... 3.5 4.5 3.5
25630........................................................... 3 4 3
26600........................................................... 4 5 4
26720........................................................... 2 3 2
26740........................................................... 2.5 3.5 2.5
26750........................................................... 2 3 2
27508........................................................... 4 5 4
27520........................................................... 3.5 4.5 3.5
[[Page 35717]]
27530........................................................... 4 5 4
27613........................................................... 1 2 1
27750........................................................... 3.5 4.5 3.5
27760........................................................... 4 5 4
27780........................................................... 3.5 4.5 3.5
27786........................................................... 3.5 4.5 3.5
27808........................................................... 4 5 4
28190........................................................... 1 2 1
28400........................................................... 3 4 3
28450........................................................... 2.5 3.5 2.5
28490........................................................... 1.5 2.5 1.5
28510........................................................... 1.5 2.5 1.5
30901........................................................... 0 1 0
30903........................................................... 0 1 0
30905........................................................... 0 1 0
31000........................................................... 1 2 1
31231........................................................... 0 1 0
31233........................................................... 0 1 0
31235........................................................... 0 1 0
31238........................................................... 0 1 0
31525........................................................... 0 1 0
31622........................................................... 0 1 0
32554........................................................... 0 1 0
36600........................................................... 0 1 0
38220........................................................... 0 1 0
40490........................................................... 0 1 0
42800........................................................... 1 2 1
43200........................................................... 0 1 0
45330........................................................... 0 1 0
46040........................................................... 3 4 3
46050........................................................... 1 2 1
46083........................................................... 1 2 1
46320........................................................... 0.5 1.5 0.5
46600........................................................... 0 1 0
46604........................................................... 0 1 0
46900........................................................... 1 2 1
51102........................................................... 0 2 0
51701........................................................... 0 1 0
51702........................................................... 0 1 0
51703........................................................... 0 1 0
51710........................................................... 0 1 0
51725........................................................... 0 1 0
51736........................................................... 0 1 0
51741........................................................... 0 1 0
51792........................................................... 0 1 0
51798........................................................... 0 1 0
52000........................................................... 0 1 0
52001........................................................... 0 1 0
52214........................................................... 0 1 0
52265........................................................... 0 1 0
52281........................................................... 0 1 0
52285........................................................... 0 1 0
53601........................................................... 0 1 0
53621........................................................... 0 1 0
53660........................................................... 0 1 0
53661........................................................... 0 1 0
54050........................................................... 1 2 1
54056........................................................... 1 2 1
54100........................................................... 0 1 0
54235........................................................... 0 1 0
54450........................................................... 0 1 0
55000........................................................... 0 1 0
56405........................................................... 1 2 1
56605........................................................... 0 1 0
56820........................................................... 0 1 0
57061........................................................... 1 2 1
57100........................................................... 0 1 0
[[Page 35718]]
57420........................................................... 0 1 0
57500........................................................... 0 1 0
57505........................................................... 1 2 1
62252........................................................... 0 1 0
62367........................................................... 0 1 0
62368........................................................... 0 1 0
62370........................................................... 0 1 0
64413........................................................... 0 1 0
64420........................................................... 0 1 0
64450........................................................... 0 1 0
64611........................................................... 1 2 1
69000........................................................... 1 2 1
69100........................................................... 0 1 0
69145........................................................... 1.5 2.5 1.5
69210........................................................... 0 1 0
69420........................................................... 1 2 1
69433........................................................... 1 2 1
69610........................................................... 1 2 1
93292........................................................... 0 1 0
93303........................................................... 0 1 0
94667........................................................... 0 1 0
95044........................................................... 0 0.028 0
95870........................................................... 0 1 0
95921........................................................... 0 1 0
95922........................................................... 0 1 0
95924........................................................... 0 1 0
95972........................................................... 0 1 1
96904........................................................... 0 1 1
----------------------------------------------------------------------------------------------------------------
In general, we are proposing to align the number of minimum multi-
specialty visit packs with the number of post-operative office visits
included in these codes. We are not proposing any supply pack quantity
refinements for CPT codes 11100, 95974, or 95978 since they are being
deleted for CY 2019. We are also not proposing any supply pack quantity
refinements for CPT codes 45300, 46500, 57150, 57160, 58100, 64405,
95970, or HCPCS code G0268 since these codes were reviewed by the RUC
this year and their previous direct PE inputs will be superseded by the
new direct PE inputs we establish through this rulemaking process for
CY 2019.
A stakeholder notified us regarding a potential rank order
anomaly in the direct PE inputs established for the Shaving of
Epidermal or Dermal Lesions code family through PFS rulemaking for CY
2013. Three of these CPT codes describe benign shave removal of
increasing lesion sizes: CPT code 11310 (Shaving of epidermal or dermal
lesion, single lesion, face, ears, eyelids, nose, lips, mucous
membrane; lesion diameter 0.5 cm or less), CPT code 11311 (Shaving of
epidermal or dermal lesion, single lesion, face, ears, eyelids, nose,
lips, mucous membrane; lesion diameter 0.6 to 1.0 cm), and CPT code
11312 (Shaving of epidermal or dermal lesion, single lesion, face,
ears, eyelids, nose, lips, mucous membrane; lesion diameter 1.1 to 2.0
cm). Each of these codes has a progressively higher work RVU
corresponding to the increasing lesion diameter, and the recommended
direct PE inputs also increase progressively from CPT codes 11310 to
11311 to 11312. However, the nonfacility PE RVU we established for CPT
code 11311 is lower than the nonfacility PE RVU for CPT code 11310,
which the stakeholder suggested may represent a rank order anomaly.
We reviewed the direct PE inputs for CPT code 11311 and found that
there were clerical inconsistencies in the data entry that resulted in
the assignment of the lower nonfacility PE RVU for CPT code 11311. We
propose to revise the direct PE inputs to reflect the ones previously
finalized through rulemaking for CPT code 11311.
In CY 2018, we inadvertently assigned too many minutes of
clinical labor time for the ``Obtain vital signs'' task to three
therapy codes, given that these codes are typically billed in multiple
units and in conjunction with other therapy codes for the same patient
on the same day, and we do not believe that it would be typical for
clinical staff to obtain vital signs for each time a code is reported.
The codes are: CPT code 97124 (Therapeutic procedure, 1 or more areas,
each 15 minutes; massage, including effleurage, petrissage and/or
tapotement (stroking, compression, percussion)); CPT code 97750
(Physical performance test or measurement (e.g., musculoskeletal,
functional capacity), with written report, each 15 minutes); and CPT
code 97755 (Assistive technology assessment (e.g., to restore, augment
or compensate for existing function, optimize functional tasks and/or
maximize environmental accessibility), direct one-on-one contact, with
written report, each 15 minutes).
Therefore, we are proposing to refine the ``Obtain vital signs''
clinical labor task for these three codes back to their previous times
of 1 minute for CPT codes 97124 and 97750 and to 3 minutes for CPT code
97755. We are also proposing to refine the equipment time for the
table, mat, hi-lo, 6 x 8 platform (EF028) for CPT code 97124 to reflect
the change in the clinical labor time.
We received a letter from a stakeholder alerting us to an
anomaly in
[[Page 35719]]
the direct PE inputs for CPT code 52000 (Cystourethroscopy (separate
procedure)). The stakeholder stated that the inclusion of an endoscope
disinfector, rigid or fiberoptic, w-cart equipment item (ES005) was
inadvertently overlooked in the recommendations for CPT code 52000 when
it was reviewed during PFS rulemaking for CY 2017, and that the
equipment would be necessary for endoscope sterilization. The
stakeholder requested that this essential piece of equipment should be
added to the direct PE inputs for CPT code 52000.
After reviewing the direct PE inputs for this code, we agree with
the stakeholder and we are proposing to add the endoscope disinfector
(ES005) to CPT code 52000, and to add 22 minutes of equipment time for
that item to match the equipment time of the other non-scope items
included in this code.
e. Updates to Prices for Existing Direct PE Inputs
In the CY 2011 PFS final rule with comment period (75 FR 73205), we
finalized a process to act on public requests to update equipment and
supply price and equipment useful life inputs through annual
rulemaking, beginning with the CY 2012 PFS proposed rule. For CY 2019,
we are proposing the following price updates for existing direct PE
inputs.
We are proposing to update the price of four supplies and one
equipment item in response to the public submission of invoices. As
these pricing updates were each part of the formal review for a code
family, we are proposing that the new pricing take effect for CY 2019
for these items instead of being phased in over 4 years. For the
details of these proposed price updates, please refer to section II.H
of this proposed rule Table 16: Invoices Received for Existing Direct
PE Inputs.
(1) Market-Based Supply and Equipment Pricing Update
Section 220(a) of the Protecting Access to Medicare Act of 2014
(PAMA) provides that the Secretary may collect or obtain information
from any eligible professional or any other source on the resources
directly or indirectly related to furnishing services for which payment
is made under the PFS, and that such information may be used in the
determination of relative values for services under the PFS. Such
information may include the time involved in furnishing services; the
amounts, types and prices of PE inputs; overhead and accounting
information for practices of physicians and other suppliers, and any
other elements that would improve the valuation of services under the
PFS.
As part of our authority under section 1848(c)(2)(M) of the Act, as
added by the PAMA, we initiated a market research contract with
StrategyGen to conduct an in-depth and robust market research study to
update the PFS direct PE inputs (DPEI) for supply and equipment pricing
for CY 2019. These supply and equipment prices were last systematically
developed in 2004-2005. StrategyGen has submitted a report with updated
pricing recommendations for approximately 1300 supplies and 750
equipment items currently used as direct PE inputs. This report is
available as a public use file displayed on the CMS website under
downloads for the CY 2019 PFS proposed rule at http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched/PFS-Federal-Regulation-Notices.html.
The StrategyGen team of researchers, attorneys, physicians, and
health policy experts conducted a market research study of the supply
and equipment items currently used in the PFS direct PE input database.
Resources and methodologies included field surveys, aggregate
databases, vendor resources, market scans, market analysis, physician
substantiation, and statistical analysis to estimate and validate
current prices for medical equipment and medical supplies. StrategyGen
conducted secondary market research on each of the 2,072 DPEI medical
equipment and supply items that CMS identified from the current DPEI.
The primary and secondary resources StrategyGen used to gather price
data and other information were:
Telephone surveys with vendors for top priority items
(Vendor Survey).
Physician panel validation of market research results,
prioritized by total spending (Physician Panel).
The General Services Administration system (GSA).
An aggregate health system buyers database with discounted
prices (Buyers).
Publicly available vendor resources, that is, Amazon
Business, Cardinal Health (Vendors).
Federal Register, current DPEI data, historical proposed
and final rules prior to FY 2018, and other resources; that is, AMA RUC
reports (References).
StrategyGen prioritized the equipment and supply research based on
current share of PE RVUs attributable by item provided by CMS.
StrategyGen developed the preliminary Recommended Price (RP)
methodology based on the following rules in hierarchical order
considering both data representativeness and reliability:
1. If the market share, as well as the sample size, for the top
three commercial products were available, the weighted average price
(weighted by percent market share) was the reported RP. Commercial
price, as a weighted average of market share, represents a more robust
estimate for each piece of equipment and a more precise reference for
the RP.
2. If StrategyGen did not have market share for commercial
products, then they used a weighted average (weighted by sample size)
of the commercial price and GSA price for the RP. The impact of the GSA
price may be nominal in some of these cases since it is proportionate
to the commercial samples sizes.
3. Otherwise, if single price points existed from alternate
supplier sites, the RP was the weighted average of the commercial price
and the GSA price.
4. Finally, if no data were available for commercial products, the
GSA average price was used as the RP; and when StrategyGen could find
no market research for a particular piece of equipment or supply item,
the current CMS prices were used as the RP.
StrategyGen found that despite technological advancements, the
average commercial price for medical equipment and supplies has
remained relatively consistent with the current CMS price.
Specifically, preliminary data indicate that there was no statistically
significant difference between the estimated commercial prices and the
current CMS prices for both equipment and supplies. This cumulative
stable pricing for medical equipment and supplies appears similar to
the pricing impacts of non-medical technology advancements where some
historically high-priced equipment (that is, desktop PCs) has been
increasingly substituted with current technology (that is, laptops and
tablets) at similar or lower price points. However, while there were no
statistically significant differences in pricing at the aggregate
level, medical specialties will experience increases or decreases in
their Medicare payments if CMS were to adopt the pricing updates
recommended by StrategyGen. At the service level, there may be large
shifts in PE RVUs for individual codes that happened to contain
supplies and/or equipment with major changes in pricing, although we
note that codes with a sizable PE RVU decrease would be limited by the
requirement to phase in significant reductions in RVUs, as required by
section 1848(c)(7) of the Act. The phase-in requirement limits the
maximum
[[Page 35720]]
RVU reduction for codes that are not new or revised to 19 percent in
any individual calendar year.
After reviewing the StrategyGen report, we are proposing to adopt
the updated direct PE input prices for supplies and equipment as
recommended by StrategyGen. We believe that it is important to make use
of the most current information available for supply and equipment
pricing instead of continuing to rely on pricing information that is
more than a decade old. Given the potentially significant changes in
payment that would occur, both for specific services and more broadly
at the specialty level, we are proposing to phase in our use of the new
direct PE input pricing over a 4-year period using a 25/75 percent (CY
2019), 50/50 percent (CY 2020), 75/25 percent (CY 2021), and 100/0
percent (CY 2022) split between new and old pricing. This approach is
consistent with how we have previously incorporated significant new
data into the calculation of PE RVUs, such as the 4-year transition
period finalized in CY 2007 PFS final rule with comment period when
changing to the ``bottom-up'' PE methodology (71 FR 69641). This
transition period will not only ease the shift to the updated supply
and equipment pricing, but will also allow interested parties an
opportunity to review and respond to the new pricing information
associated with their services.
We are proposing to implement this phase-in over 4 years so that
supply and equipment values transition smoothly from the prices we
currently include to the final updated prices in CY 2022. We are
proposing to implement this pricing transition such that one quarter of
the difference between the current price and the fully phased in price
is implemented for CY 2019, one third of the difference between the CY
2019 price and the final price is implemented for CY 2020, and one half
of the difference between the CY 2020 price and the final price is
implemented for CY 2021, with the new direct PE prices fully
implemented for CY 2022. An example of the proposed transition from the
current to the fully-implemented new pricing is provided in Table 7.
Table 7--Example of Direct PE Pricing Transition
------------------------------------------------------------------------
------------------------------------------------------------------------
Current Price..................... $100 ....................
Final Price....................... 200 ....................
Year 1 (CY 2019) Price............ 125 \1/4\ difference
between $100 and
$200.
Year 2 (CY 2020) Price............ 150 \1/3\ difference
between $125 and
$200.
Year 3 (CY 2021) Price............ 175 \1/2\ difference
between $150 and
$200.
Final (CY 2022) Price............. 200 ....................
------------------------------------------------------------------------
For new supply and equipment codes for which we establish prices
during the transition years (CYs 2019, 2020 and 2021) based on the
public submission of invoices, we are proposing to fully implement
those prices with no transition since there are no current prices for
these supply and equipment items. These new supply and equipment codes
would immediately be priced at their newly established values. We are
also proposing that, for existing supply and equipment codes, when we
establish prices based on invoices that are submitted as part of a
revaluation or comprehensive review of a code or code family, they will
be fully implemented for the year they are adopted without being phased
in over the 4-year pricing transition. The formal review process for a
HCPCS code includes a review of pricing of the supplies and equipment
included in the code. When we find that the price on the submitted
invoice is typical for the item in question, we believe it would be
appropriate to finalize the new pricing immediately along with any
other revisions we adopt for the code valuation.
For existing supply and equipment codes that are not part of a
comprehensive review and valuation of a code family and for which we
establish prices based on invoices submitted by the public, we are
proposing to implement the established invoice price as the updated
price and to phase in the new price over the remaining years of the
proposed 4-year pricing transition. During the proposed transition
period, where price changes for supplies and equipment are adopted
without a formal review of the HCPCS codes that include them (as is the
case for the many updated prices we are proposing to phase in over the
4-year transition period), we believe it is important to include them
in the remaining transition toward the updated price. We are also
proposing to phase in any updated pricing we establish during 4-year
transition period for very commonly used supplies and equipment that
are included in 100 or more codes, such as sterile gloves (SB024) or
exam tables (EF023), even if invoices are provided as part of the
formal review of a code family. We would implement the new prices for
any such supplies and equipment over the remaining years of the
proposed 4-year transition period. Our proposal is intended to minimize
any potential disruptive effects during the proposed transition period
that could be caused by other sudden shifts in RVUs due to the high
number of services that make use of these very common supply and
equipment items (meaning that these items are included in 100 or more
codes).
We believe that implementing the proposed updated prices with a 4-
year phase-in will improve payment accuracy, while maintaining
stability and allowing stakeholders the opportunity to address
potential concerns about changes in payment for particular items.
Updating the pricing of direct PE inputs for supplies and equipment
over a longer time frame will allow more opportunities for public
comment and submission of additional, applicable data. We welcome
feedback from stakeholders on the proposed updated supply and equipment
pricing, including the submission of additional invoices for
consideration. We are particularly interested in comments regarding the
supply and equipment pricing for CPT codes 95165 and 95004 that are
frequently used by the Allergy/Immunology specialty. The Allergy/
Immunology specialty was disproportionately affected by the updated
pricing, even with a 4-year phase-in. The direct PE costs for CPT code
95165 would go down from $8.43 to $8.17 as a result of the updated
supply and equipment pricing information. This would result in the PE
RVU for CPT code 96165 to decrease from 0.30 to 0.26. We are seeking
feedback on the supply and equipment pricing for the affected codes
typically performed by this specialty and whether the direct PE inputs
should be reviewed along with the pricing. The full report from the
contractor, including the updated supply and equipment pricing as it is
proposed to be implemented over the proposed 4-year transition period,
will be made available as a public use file displayed on the CMS
website
[[Page 35721]]
under downloads for the CY 2019 PFS proposed rule at http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched/PFS-Federal-Regulation-Notices.html.
To maintain relativity between the clinical labor, supplies, and
equipment portions of the PE methodology, we believe that the rates for
the clinical labor staff should also be updated along with the updated
pricing for supplies and equipment. We seek public comment regarding
whether to update the clinical labor wages used in developing PE RVUs
in future calendar years during the 4-year pricing transition for
supplies and equipment, or whether it would be more appropriate to
update the clinical labor wages at a later date following the
conclusion of the transition for supplies and equipment, for example,
to avoid other potentially large shifts in PE RVUs during the 4-year
pricing transition period.
(2) Breast Biopsy Software (EQ370)
Following the publication of the CY 2018 PFS final rule, a
stakeholder contacted us and requested that we update the price for the
Breast Biopsy software (EQ370) equipment. This equipment item currently
lacks a price in the direct PE database, and when an invoice for the
Breast Biopsy software was first submitted during the CY 2014 PFS rule,
we stated that this item served clinical functions similar to other
items already included in the Magnetic Resonance (MR) room equipment
package (EL008) included in the same CPT codes under review. Therefore,
we did not create new direct PE inputs for this equipment item (78 FR
74344 through 74345). The stakeholder suggested that this software is
used to subtract the imaging raw data series from the MRI Scanner,
reformat the images in multiple planes to allow accurate targeting of
the lesion to be biopsied, identify the location of a fiducial marker
on the patient's skin, and then target the location of the enhancing
lesion to be biopsied. The stakeholder requested that EQ370 be renamed
as ``Breast MRI computer aided detection and biopsy guidance software''
and added to existing CPT codes 19085 (Biopsy, breast, with placement
of breast localization device(s) (e.g., clip, metallic pellet), when
performed, and imaging of the biopsy specimen, when performed,
percutaneous; first lesion, including magnetic resonance guidance),
19086 (Biopsy, breast, with placement of breast localization device(s)
(e.g., clip, metallic pellet), when performed, and imaging of the
biopsy specimen, when performed, percutaneous; each additional lesion,
including magnetic resonance guidance), 19287 (Placement of breast
localization device(s) (e.g., clip, metallic pellet, wire/needle,
radioactive seeds), percutaneous; first lesion, including magnetic
resonance guidance), and 19288 (Placement of breast localization
device(s) (e.g., clip, metallic pellet, wire/needle, radioactive
seeds), percutaneous; each additional lesion, including magnetic
resonance guidance), as well as adding the equipment to two newly
created MR breast codes with CAD, CPT codes 77X51 (Magnetic resonance
imaging, breast, without and with contrast material(s), including
computer-aided detection (CAD-real time lesion detection,
characterization and pharmacokinetic analysis) when performed;
unilateral) and 77X52 (Magnetic resonance imaging, breast, without and
with contrast material(s), including computer-aided detection (CAD-real
time lesion detection, characterization and pharmacokinetic analysis)
when performed; bilateral). The stakeholder supplied an invoice with a
purchase price of $52,275 for the equipment.
After reviewing the use of the Breast Biopsy software (EQ370)
equipment in these six codes, we are not proposing to update the price
or add the software to these procedures. As we stated in the CY 2014
PFS final rule with comment period (78 FR 74345), we continue to
believe that equipment item EQ370 serves clinical functions similar to
other items already included in the MR room equipment package (EL008),
and that it would be duplicative to include this Breast Biopsy software
as a separate direct PE input. We also note that the RUC
recommendations for the new CPT codes 77X51 and 77X52 do not include
EQ370 in the recommended equipment for these procedures, and we do not
have any reason to believe that the inclusion of additional Breast
Biopsy software beyond what is already contained in the MR room
equipment package would be typical. However, we will update the name of
the EQ370 equipment item from ``Breast Biopsy software'' to the
requested ``Breast MRI computer aided detection and biopsy guidance
software'' to help better describe the equipment in question.
(3) Invoice Submission
We routinely accept public submission of invoices as part of our
process for developing payment rates for new, revised, and potentially
misvalued codes. Often these invoices are submitted in conjunction with
the RUC-recommended values for the codes. For CY 2019, we note that
some stakeholders have submitted invoices for new, revised, or
potentially misvalued codes after the February 10th deadline
established for code valuation recommendations. To be included in a
given year's proposed rule, we generally need to receive invoices by
the same February 10th deadline we noted for consideration of RUC
recommendations. However, we would consider invoices submitted as
public comments during the comment period following the publication of
this proposed rule, and would consider any invoices received after
February 10 or outside of the public comment process as part of our
established annual process for requests to update supply and equipment
prices.
4. Adjustment to Allocation of Indirect PE for Some Office-Based
Services
In the CY 2018 PFS final rule (82 FR 52999 through 53000), we
established criteria for identifying the services most affected by the
indirect PE allocation anomaly that does not allow for a site of
service differential that accurately reflects the relative indirect
costs involved in furnishing services in nonfacility settings. We also
finalized a modification in the PE methodology for allocating indirect
PE RVUS to better reflect the relative indirect PE resources involved
in furnishing these services. The methodology, as described, is based
on the difference between the ratio of indirect PE to work RVUs for
each of the codes meeting eligibility criteria and the ratio of
indirect PE to work RVU for the most commonly reported visit code. We
refer readers to the CY 2018 PFS final rule (82 FR 52999 through 53000)
for a discussion of our process for selecting services subject to the
revised methodology, as well as a description of the methodology, which
we began implementing for CY 2018 as the first year of a 4-year
transition. For CY 2019, we are proposing to continue with the second
year of the transition of this adjustment to the standard process for
allocating indirect PE.
C. Determination of Malpractice Relative Value Units (RVUs)
1. Overview
Section 1848(c) of the Act requires that the payment amount for
each service paid under the PFS be composed of three components: Work;
PE; and malpractice (MP) expense. As required by section
1848(c)(2)(C)(iii) of the Act, beginning in CY 2000, MP RVUs are
resource-based. Section 1848(c)(2)(B)(i) of the Act also requires that
we review, and if necessary adjust, RVUs no less often than every 5
years. In the CY 2015
[[Page 35722]]
PFS final rule with comment period, we implemented the third review and
update of MP RVUs. For a comprehensive discussion of the third review
and update of MP RVUs see the CY 2015 proposed rule (79 FR 40349
through 40355) and final rule with comment period (79 FR 67591 through
67596).
To determine MP RVUs for individual PFS services, our MP
methodology is composed of three factors: (1) Specialty-level risk
factors derived from data on specialty-specific MP premiums incurred by
practitioners; (2) service level risk factors derived from Medicare
claims data of the weighted average risk factors of the specialties
that furnish each service; and (3) an intensity/complexity of service
adjustment to the service level risk factor based on either the higher
of the work RVU or clinical labor RVU. Prior to CY 2016, MP RVUs were
only updated once every 5 years, except in the case of new and revised
codes.
In the CY 2016 PFS final rule with comment period (80 FR 70906
through 70910), we finalized a policy to begin conducting annual MP RVU
updates to reflect changes in the mix of practitioners providing
services (using Medicare claims data), and to adjust MP RVUs for risk,
intensity and complexity (using the work RVU or clinical labor RVU). We
also finalized a policy to modify the specialty mix assignment
methodology (for both MP and PE RVU calculations) to use an average of
the 3 most recent years of data instead of a single year of data. Under
this approach, for new and revised codes, we generally assign a
specialty risk factor to individual codes based on the same utilization
assumptions we make regarding the specialty mix we use for calculating
PE RVUs and for PFS budget neutrality. We continue to use the work RVU
or clinical labor RVU to adjust the MP RVU for each code for intensity
and complexity. In finalizing this policy, we stated that the
specialty-specific risk factors would continue to be updated through
notice and comment rulemaking every 5 years using updated premium data,
but would remain unchanged between the 5-year reviews.
In CY 2017, we finalized the 8th GPCI update, which reflected
updated MP premium data. We did not propose to use the updated MP
premium data to propose updates for CY 2017 to the specialty risk
factors used in the calculation of MP RVUs because it was inconsistent
with the policy we previously finalized in the CY 2016 PFS final rule
with comment period. That is, we indicated that the specialty-specific
risk factors would continue to be updated through notice and comment
rulemaking every 5 years using updated premium data, but would remain
unchanged between the 5-year reviews. However, we solicited comment on
whether we should consider doing so, perhaps as early as for CY 2018,
prior to the fourth review and update of MP RVUs that must occur no
later than CY 2020. After consideration of the comments received, we
stated in the CY 2017 PFS final rule that we would consider the
possibility of using the updated MP data to update the specialty risk
factors used in the calculation of the MP RVUs prior to the next 5-year
update in future rulemaking (81 FR 80191 through 80192).
In the CY 2018 PFS proposed rule, we proposed to use the updated MP
data to update the specialty risk factors used in calculation of the MP
RVUs prior to the next 5-year update (CY 2020). However, in the CY 2018
PFS final rule (82 FR 53000 through 53006), after consideration of the
comments received and some differences we observed in the descriptions
on the raw rate filings as compared to how those data were categorized
to conform with the CMS specialties, we did not finalize our proposal
to use the updated MP data. We are required to review, and if
necessary, adjust the MP RVUs by CY 2020. We appreciate the feedback
provided by commenters in response to the CY 2018 PFS proposed rule,
and we are seeking additional comment regarding the next MP RVU update
which must occur by CY 2020. Specifically, we are seeking comment on
how we might improve the way that specialties in the state-level raw
rate filings data are crosswalked for categorization into CMS specialty
codes which are used to develop the specialty-level risk factors and
the MP RVUs.
D. Modernizing Medicare Physician Payment by Recognizing Communication
Technology-Based Services
The health care community uses the term ``telehealth'' broadly to
refer to medical services furnished via communication technology. Under
current PFS payment rules, Medicare routinely pays for many of these
kinds of services. This includes some kinds of remote patient
monitoring (either as separate services or as parts of bundled
services), interpretations of diagnostic tests when furnished remotely,
and, under conditions specified in section 1834(m) of the Act, services
that would otherwise be furnished in person but are instead furnished
via real-time, interactive communication technology. Over the past
several years, CMS has also established several PFS policies to
explicitly pay for non-face-to-face services included as part of
ongoing care management.
While all of the kinds of services stated above might be called
``telehealth'' by patients, other payers and health care providers, we
have generally used the term ``Medicare telehealth services'' to refer
to the subset of services defined in section 1834(m) of the Act.
Section 1834(m) of the Act defines Medicare telehealth services and
specifies the payment amounts and circumstances under which Medicare
makes payment for a discrete set of services, all of which must
ordinarily be furnished in-person, when they are instead furnished
using interactive, real-time telecommunication technology. Section
1834(m)(4)(F)(i) of the Act enumerates certain Medicare telehealth
services and section 1834(m)(4)(F)(ii) of the Act allows the Secretary
to specify additional Medicare telehealth services using an annual
process to add or delete services from the Medicare telehealth list.
Section 1834(m)(4)(C) of the Act limits the scope of Medicare
telehealth services for which payment may be made to those furnished to
a beneficiary who is located in certain types of originating sites in
certain, mostly rural, areas. Section 1834(m)(1) of the Act permits
only physicians and certain other types of practitioners to furnish and
be paid for Medicare telehealth services. Although section
1834(m)(4)(F)(ii) of the Act grants the Secretary the authority to add
services to, and delete services from, the list of telehealth services
based on the established annual process, it does not provide any
authority to change the limitations relating to geography, patient
setting, or type of furnishing practitioner because these requirements
are specified in statute. However, we note that sections 50302, 50324,
and 50325 of the Bipartisan Budget Act of 2018 (BBA 18) have modified
or removed the limitations relating to geography and patient setting
for certain telehealth services, including for certain home dialysis
end-stage renal disease-related services, services furnished by
practitioners in certain Accountable Care Organizations, and acute
stroke-related services, respectively.
In the CY 2018 PFS proposed rule, we sought information from the
public regarding ways that we might further expand access to telehealth
services within the current statutory authority and pay appropriately
for services that take full advantage of communication technologies.
Commenters were very supportive of CMS expanding access to these kinds
of services. Many
[[Page 35723]]
commenters noted that Medicare payment for telehealth services is
restricted by statute, but encouraged CMS to recognize and support
technological developments in healthcare.
We believe that the provisions in section 1834(m) of the Act apply
particularly to the kinds of professional services explicitly
enumerated in the statutory provisions, like professional
consultations, office visits, and office psychiatry services.
Generally, the services we have added to the telehealth list are
similar to these kinds of services. As has long been the case, certain
other kinds of services that are furnished remotely using
communications technology are not considered ``Medicare telehealth
services'' and are not subject to the restrictions articulated in
section 1834(m) of the Act. This is true for services that were
routinely paid separately prior to the enactment of the provisions in
section 1834(m) of the Act and do not usually include patient
interaction (such as remote interpretation of diagnostic imaging
tests), and for services that were not discretely defined or separately
paid for at the time of enactment and that do include patient
interaction (such as chronic care management services).
As we considered the concerns expressed by commenters about the
statutory restrictions on Medicare telehealth services, we recognized
that the concerns were not limited to the barriers to payment for
remotely furnished services like those described by the office visit
codes. The commenters also expressed concerns pertaining to the
limitations on appropriate payment for evolving physicians' services
that are inherently furnished via communication technology, especially
as technology and its uses have evolved in the decades since the
Medicare telehealth services statutory provision was enacted.
In recent years, we have sought to recognize significant changes in
health care practice, especially innovations in the active management
and ongoing care of chronically ill patients, and have relied on the
medical community to identify and define discrete physicians' services
through the CPT Editorial Panel (82 FR 53163). In response to our
comment solicitation on Medicare telehealth services in the CY 2018 PFS
proposed rule (82 FR 53012), commenters provided many suggestions for
how CMS could expand access to telehealth services within the current
statutory authority and pay appropriately for services that take full
advantage of communication technologies, such as waiving portions of
the statutory restrictions using demonstration authority. After
considering those comments we recognize that concerns regarding the
provisions in section 1834(m) of the Act may have been limiting the
degree to which the medical community developed coding for new kinds of
services that inherently utilize communication technology. We have come
to believe that section 1834(m) of the Act does not apply to all kinds
of physicians' services whereby a medical professional interacts with a
patient via remote communication technology. Instead, we believe that
section 1834(m) of the Act applies to a discrete set of physicians'
services that ordinarily involve, and are defined, coded, and paid for
as if they were furnished during an in-person encounter between a
patient and a health care professional.
For CY 2019, we are aiming to increase access for Medicare
beneficiaries to physicians' services that are routinely furnished via
communication technology by clearly recognizing a discrete set of
services that are defined by and inherently involve the use of
communication technology. Accordingly, we have several proposals for
modernizing Medicare physician payment for communication technology-
based services, described below. These services would not be subject to
the limitations on Medicare telehealth services in section 1834(m) of
the Act because, as we have explained, we do not consider them to be
Medicare telehealth services; instead, they would be paid under the PFS
like other physicians' services. Additionally, we note that in
furnishing these proposed services, practitioners would need to comply
with any applicable privacy and security laws, including the HIPAA
Privacy Rule.
1. Brief Communication Technology-Based Service, e.g., Virtual Check-In
(HCPCS Code GVCI1)
The traditional office visit codes describe a broad range of
physicians' services. Historically, we have considered any routine non-
face-to-face communication that takes place before or after an in-
person visit to be bundled into the payment for the visit itself. In
recent years, we have recognized payment disparities that arise when
the amount of non-face-to-face work for certain kinds of patients is
disproportionately higher than for others, and created coding and
separate payment to recognize care management services such as chronic
care management and behavioral health integration services (81 FR
80226). We now recognize that advances in communication technology have
changed patients' and practitioners' expectations regarding the
quantity and quality of information that can be conveyed via
communication technology. From the ubiquity of synchronous, audio/video
applications to the increased use of patient-facing health portals, a
broader range of services can be furnished by health care professionals
via communication technology as compared to 20 years ago.
Among these services are the kinds of brief check-in services
furnished using communication technology that are used to evaluate
whether or not an office visit or other service is warranted. When
these kinds of check-in services are furnished prior to an office
visit, then we would currently consider them to be bundled into the
payment for the resulting visit, such as through an evaluation and
management (E/M) visit code. However, in cases where the check-in
service does not lead to an office visit, then there is no office visit
with which the check-in service can be bundled. To the extent that
these kinds of check-ins become more effective at addressing patient
concerns and needs using evolving technology, we believe that the
overall payment implications of considering the services to be broadly
bundled becomes more problematic. This is especially true in a
resource-based relative value payment system. Effectively, the better
practitioners are in leveraging technology to furnish effective check-
ins that mitigate the need for potentially unnecessary office visits,
the fewer billable services they furnish. Given the evolving
technological landscape, we believe this creates incentives that are
inconsistent with current trends in medical practice and potentially
undermines payment accuracy.
Therefore, we are proposing to pay separately, beginning January 1,
2019, for a newly defined type of physicians' service furnished using
communication technology. This service would be billable when a
physician or other qualified health care professional has a brief non-
face-to-face check-in with a patient via communication technology, to
assess whether the patient's condition necessitates an office visit. We
understand that the kinds of communication technology used to furnish
these kinds of services has broadened over time and has enhanced the
capacity for medical professionals to care for patients. We are seeking
comment on what types of communication technology are utilized by
physicians or other qualified health care professionals in furnishing
these
[[Page 35724]]
services, including whether audio-only telephone interactions are
sufficient compared to interactions that are enhanced with video or
other kinds of data transmission.
The proposed code would be described as GVCI1 (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). We further propose that in instances when the brief
communication technology-based service originates from a related E/M
service provided within the previous 7 days by the same physician or
other qualified health care professional, that this service would be
considered bundled into that previous E/M service and would not be
separately billable, which is consistent with code descriptor language
for CPT code 99441 (Telephone evaluation and management service by a
physician or other qualified health care professional who may report
evaluation and management services provided to an established patient,
parent, or guardian 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) on which this service is partially modeled. We
propose that in instances when the brief communication technology-based
service leads to an E/M in-person service with the same physician or
other qualified health care professional, this service would be
considered bundled into the pre- or post-visit time of the associated
E/M service, and therefore, would not be separately billable. We also
note that this service could be used as part of a treatment regimen for
opioid use disorders and other substance use disorders, since there are
several components of Medication Assisted Therapy (MAT) that could be
done virtually, or to assess whether the patient's condition requires
an office visit.
We propose pricing this distinct service at a rate lower than
existing E/M in-person visits to reflect the low work time and
intensity and to account for the resource costs and efficiencies
associated with the use of communication technology. We expect that
these services would be initiated by the patient, especially since many
beneficiaries would be financially liable for sharing in the cost of
these services. For the same reason, we believe it is important for
patients to consent to receiving these services, and we are
specifically seeking comment on whether we should require, for example,
verbal consent that would be noted in the medical record for each
service. We are also proposing that this service can only be furnished
for established patients because we believe that the practitioner needs
to have an existing relationship with the patient, and therefore, basic
knowledge of the patient's medical condition and needs, in order to
perform this service. We are not proposing to apply a frequency limit
on the use of this code by the same practitioner with the same patient,
but we want to ensure that this code is appropriately utilized for
circumstances when a patient needs a brief non-face-to-face check-in to
assess whether an office visit is necessary. We are seeking comment on
whether it would be clinically appropriate to apply a frequency
limitation on the use of this code by the same practitioner with the
same patient, and on what would be a reasonable frequency limitation.
We are also seeking comment on the timeframes under which this service
would be separately billable compared to when it would be bundled. We
believe the general construct of bundling the services that lead
directly to a billable visit is important, but we are concerned that
establishing strict timeframes may create unintended consequences
regarding scheduling of care. For example, we do not want to bundle
only the services that occur within 24 hours of a visit only to see a
significant number of visits occurring at 25 hours after the initial
service. In order to mitigate these incentives, we are seeking comment
on whether we should consider broadening the window of time and/or
circumstances in which this service should be bundled into the
subsequent related visit. We note that these services, like any other
physicians' service, would need to be medically reasonable and
necessary in order to be paid by Medicare. We are seeking comment on
how clinicians could best document the medical necessity of this
service, consistent with documentation requirements necessary to
demonstrate the medical necessity of any service under the PFS. For
details related to developing utilization estimates for these services,
see section VII. Regulatory Impact Analysis, of this proposed rule. For
additional details related to valuation of these services, see section
II.H. Valuation of Specific Codes, of this proposed rule. We are
seeking comment on our proposed definition and valuation of this code.
2. Remote Evaluation of Pre-Recorded Patient Information (HCPCS Code
GRAS1)
Stakeholders have requested that CMS make separate Medicare payment
when a physician uses recorded video and/or images captured by a
patient in order to evaluate a patient's condition. These services
involve what is referred to under section 1834(m) of the Act as
``store-and-forward'' communication technology that provides for the
``asynchronous transmission of health care information.'' We note that
we believe these services involve pre-recorded patient-generated still
or video images. Other types of patient-generated information, such as
information from heart rate monitors or other devices that collect
patient health marker data, could potentially be reported with CPT
codes that describe remote patient monitoring. Under section 1834(m) of
the Act, payment for telehealth services furnished using such store-
and-forward technology is permitted only under Federal telemedicine
demonstration programs conducted in Alaska or Hawaii, and these
telehealth services remain subject to the other statutory restrictions
governing Medicare telehealth services. Much like the virtual check-in
described above, these services are not meant to substitute for an in-
person service currently separately payable under the PFS, and
therefore, are distinct from the telehealth services described under
section 1834(m) of the Act. Effective January 1, 2019, we are proposing
to create specific coding that describes the remote professional
evaluation of patient-transmitted information conducted via pre-
recorded ``store and forward'' video or image technology. These
services would not be subject to the Medicare telehealth restrictions
in section 1834(m) of the Act, and the valuation would reflect the
resource costs associated with furnishing services utilizing
communication technology.
Much like the brief communication technology-based services
discussed above, these services may be used to determine whether or not
an office visit or other service is warranted. When the review of the
patient-submitted image and/or video results in an in-person E/M office
visit with the same physician or qualified health care professional, we
propose that this remote service would be considered bundled into that
office visit and therefore would not be separately billable. We further
propose
[[Page 35725]]
that in instances when the remote service originates from a related E/M
service provided within the previous 7 days by the same physician or
qualified health care professional, that this service would be
considered bundled into that previous E/M service and also would not be
separately billable. In summary, we propose this service to be a stand-
alone service that could be separately billed to the extent that there
is no resulting E/M office visit and there is no related E/M office
visit within the previous 7 days of the remote service being furnished.
The proposed coding and separate payment for this service is consistent
with the progression of technology and its impact on the practice of
medicine in recent years, and would result in increased access to
services for Medicare beneficiaries. The proposed code for this service
would be described as GRAS1 (Remote evaluation of recorded video and/or
images submitted by the patient (e.g., store and forward), including
interpretation with verbal 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). We are
seeking comment as to whether these services should be limited to
established patients; or whether there are certain cases, like
dermatological or ophthalmological services, where it might be
appropriate for a new patient to receive these services. For example,
when a patient seeks care for a specific skin condition from a
dermatologist with whom she does not have a prior relationship, and
part of the inquiry is an assessment of whether the patient needs an
in-person visit, the patient could share, and the dermatologist could
remotely evaluate, pre-recorded information. We also note that this
service is distinct from the brief communication technology-based
service described above in that this service involves the
practitioner's evaluation of a patient-generated still or video image,
and the subsequent communication of the resulting response to the
patient, while the brief communication technology-based service
describes a service that occurs in real time and does not involve the
transmission of any recorded image.
For details related to developing utilization estimates for these
services, see section VII. Regulatory Impact Analysis, of this proposed
rule. For further discussion related to valuation of this service,
please see the section II.H. Valuation of Specific Codes, of this
proposed rule. We are seeking public comment on our proposed definition
and valuation of the code.
3. Interprofessional Internet Consultation (CPT Codes 994X6, 994X0,
99446, 99447, 99448, and 99449)
As part of our standard rulemaking process, we received
recommendations from the RUC to assist in establishing values for six
CPT codes that describe interprofessional consultations. In 2013, CMS
received recommendations from the RUC for CPT codes 99446
(Interprofessional telephone/internet assessment and management service
provided by a consultative physician including a verbal and written
report to the patient's treating/requesting physician or other
qualified health care professional; 5-10 minutes of medical
consultative discussion and review), 99447 (Interprofessional
telephone/internet assessment and management service provided by a
consultative physician including a verbal and written report to the
patient's treating/requesting physician or other qualified health care
professional; 11-20 minutes of medical consultative discussion and
review), 99448 (Interprofessional telephone/internet assessment and
management service provided by a consultative physician including a
verbal and written report to the patient's treating/requesting
physician or other qualified health care professional; 21-30 minutes of
medical consultative discussion and review), and 99449
(Interprofessional telephone/internet assessment and management service
provided by a consultative physician including a verbal and written
report to the patient's treating/requesting physician or other
qualified health care professional; 31 minutes or more of medical
consultative discussion and review). CMS declined to make separate
payment, stating in the CY 2014 PFS final rule with comment period that
these kinds of services are considered bundled (78 FR 74343). For CY
2019, the CPT Editorial Panel created two new codes to describe
additional consultative services, including a code describing the work
of the treating physician when initiating a consult, and the RUC
recommended valuation for new codes, CPT codes 994X0 (Interprofessional
telephone/internet/electronic health record referral service(s)
provided by a treating/requesting physician or qualified health care
professional, 30 minutes) and 994X6 (Interprofessional telephone/
internet/electronic health record assessment and management service
provided by a consultative physician including a written report to the
patient's treating/requesting physician or other qualified health care
professional, 5 or more minutes of medical consultative time). The RUC
also reaffirmed their prior recommendations for the existing CPT codes.
The six codes describe assessment and management services conducted
through telephone, internet, or electronic health record consultations
furnished when a patient's treating physician or other qualified
healthcare professional requests the opinion and/or treatment advice of
a consulting physician or qualified healthcare professional with
specific specialty expertise to assist with the diagnosis and/or
management of the patient's problem without the need for the patient's
face-to-face contact with the consulting physician or qualified
healthcare professional. Currently, the resource costs associated with
seeking or providing such a consultation are considered bundled, which
in practical terms means that specialist input is often sought through
scheduling a separate visit for the patient when a phone or internet-
based interaction between the treating practitioner and the consulting
practitioner would have been sufficient. We believe that proposing
payment for these interprofessional consultations performed via
communications technology such as telephone or internet is consistent
with our ongoing efforts to recognize and reflect medical practice
trends in primary care and patient-centered care management within the
PFS.
Beginning in the CY 2012 PFS proposed rule (76 FR 42793), we have
recognized the changing focus in medical practice toward managing
patients' chronic conditions, many of which particularly challenge the
Medicare population, including heart disease, diabetes, respiratory
disease, breast cancer, allergies, Alzheimer's disease, and factors
associated with obesity. We have expressed concerns that the current E/
M coding does not adequately reflect the changes that have occurred in
medical practice, and the activities and resource costs associated with
the treatment of these complex patients in the primary care setting. In
the years since 2012, we have acknowledged the shift in medical
practice away from an episodic treatment-based approach to one that
involves comprehensive patient-centered care management, and have taken
steps through rulemaking to better reflect that approach in payment
under the PFS. In CY 2013, we established new codes to pay separately
for transitional care management (TCM)
[[Page 35726]]
services. Next, we finalized new coding and separate payment beginning
in CY 2015 for chronic care management (CCM) services provided by
clinical staff (81 FR 80226). In the CY 2017 PFS final rule, we
established separate payment for complex CCM services, an add-on code
to the visit during which CCM is initiated to reflect the work of the
billing practitioner in assessing the beneficiary and establishing the
CCM care plan, and established separate payment for Behavioral Health
Integration (BHI) services (81 FR 80226 through 80227).
As part of this shift in medical practice, and with the
proliferation of team-based approaches to care that are often
facilitated by electronic medical record technology, we believe that
making separate payment for interprofessional consultations undertaken
for the benefit of treating a patient will contribute to payment
accuracy for primary care and care management services. We are
proposing separate payment for these services, discussed in section
II.H. Valuation of Specific Codes, of this proposed rule.
While we are proposing to make separate payment for these services
because we believe they describe resource costs directly associated
with seeking a consultation for the benefit of the beneficiary, we do
have concerns about how these services can be distinguished from
activities undertaken for the benefit of the practitioner, such as
information shared as a professional courtesy or as continuing
education. We do not believe that those examples would constitute a
service directly attributable to a single Medicare beneficiary, and
therefore neither the Medicare program nor the beneficiary should be
responsible for those costs. We are therefore seeking comment on our
assumption that these are separately identifiable services, and the
extent to which they can be distinguished from similar services that
are nonetheless primarily for the benefit of the practitioner. We note
that there are program integrity concerns around making separate
payment for these interprofessional consultation services, including
around CMS' or its contractors' ability to evaluate whether an
interprofessional consultation is reasonable and necessary under the
particular circumstances. We are seeking comment on how best to
minimize potential program integrity issues, and are particularly
interested in information on whether these types of services are paid
separately by private payers and if so, what controls or limitations
private payers have put in place to ensure these services are billed
appropriately.
Additionally, since these codes describe services that are
furnished without the beneficiary being present, we are proposing to
require the treating practitioner to obtain verbal beneficiary consent
in advance of these services, which would be documented by the treating
practitioner in the medical record, similar to the conditions of
payment associated with the care management services under the PFS.
Obtaining advance consent includes ensuring that the patient is aware
of applicable cost sharing. We welcome comments on this proposal.
4. Medicare Telehealth Services Under Section 1834(m) of the Act
a. Billing and Payment for Medicare Telehealth Services Under Section
1834(m) of the Act
As discussed in prior rulemaking, several conditions must be met
for Medicare to make payment for telehealth services under the PFS. For
further details, see the full discussion of the scope of Medicare
telehealth services in the CY 2018 PFS final rule (82 FR 53006).
b. Adding Services to the List of Medicare Telehealth Services
In the CY 2003 PFS final rule with comment period (67 FR 79988), we
established a process for adding services to or deleting services from
the list of Medicare telehealth services in accordance with section
1834(m)(4)(F)(ii) of the Act. This process provides the public with an
ongoing opportunity to submit requests for adding services, which are
then reviewed by us. Under this process, we assign any submitted
request to add to the list of telehealth services to one of the
following two categories:
Category 1: Services that are similar to professional
consultations, office visits, and office psychiatry services that are
currently on the list of telehealth services. In reviewing these
requests, we look for similarities between the requested and existing
telehealth services for the roles of, and interactions among, the
beneficiary, the physician (or other practitioner) at the distant site
and, if necessary, the telepresenter, a practitioner who is present
with the beneficiary in the originating site. We also look for
similarities in the telecommunications system used to deliver the
service; for example, the use of interactive audio and video equipment.
Category 2: Services that are not similar to those on the
current list of telehealth services. Our review of these requests
includes an assessment of whether the service is accurately described
by the corresponding code when furnished via telehealth and whether the
use of a telecommunications system to furnish the service produces
demonstrated clinical benefit to the patient. Submitted evidence should
include both a description of relevant clinical studies that
demonstrate the service furnished by telehealth to a Medicare
beneficiary improves the diagnosis or treatment of an illness or injury
or improves the functioning of a malformed body part, including dates
and findings, and a list and copies of published peer reviewed articles
relevant to the service when furnished via telehealth. Our evidentiary
standard of clinical benefit does not include minor or incidental
benefits.
Some examples of clinical benefit include the following:
Ability to diagnose a medical condition in a patient
population without access to clinically appropriate in-person
diagnostic services.
Treatment option for a patient population without access
to clinically appropriate in-person treatment options.
Reduced rate of complications.
Decreased rate of subsequent diagnostic or therapeutic
interventions (for example, due to reduced rate of recurrence of the
disease process).
Decreased number of future hospitalizations or physician
visits.
More rapid beneficial resolution of the disease process
treatment.
Decreased pain, bleeding, or other quantifiable symptom.
Reduced recovery time.
The list of telehealth services, including the proposed additions
described below, is included in the Downloads section to this proposed
rule at https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched/PFS-Federal-Regulation-Notices.html.
Historically, requests to add services to the list of Medicare
telehealth services had to be submitted and received no later than
December 31 of each calendar year to be considered for the next
rulemaking cycle. However, for CY 2019 and onward, we intend to accept
requests through February 10, consistent with the deadline for our
receipt of code valuation recommendations from the RUC. To be
considered during PFS rulemaking for CY 2020, requests to add services
to the list of Medicare telehealth services must be submitted and
received by February 10, 2019. Each request to add a service to the
list of Medicare telehealth
[[Page 35727]]
services must include any supporting documentation the requester wishes
us to consider as we review the request. Because we use the annual PFS
rulemaking process as the vehicle to make changes to the list of
Medicare telehealth services, requesters should be advised that any
information submitted as part of a request is subject to public
disclosure for this purpose. For more information on submitting a
request to add services to the list of Medicare telehealth services,
including where to mail these requests, see our website at https://www.cms.gov/Medicare/Medicare-General-Information/Telehealth/index.html.
c. Submitted Requests To Add Services to the List of Telehealth
Services for CY 2019
Under our current policy, we add services to the telehealth list on
a Category 1 basis when we determine that they are similar to services
on the existing telehealth list for the roles of, and interactions
among, the beneficiary, physician (or other practitioner) at the
distant site and, if necessary, the telepresenter. As we stated in the
CY 2012 PFS final rule with comment period (76 FR 73098), we believe
that the Category 1 criteria not only streamline our review process for
publicly requested services that fall into this category, but also
expedite our ability to identify codes for the telehealth list that
resemble those services already on this list.
We received several requests in CY 2017 to add various services as
Medicare telehealth services effective for CY 2019. The following
presents a discussion of these requests, and our proposals for
additions to the CY 2019 telehealth list. Of the requests received, we
found that two services were sufficiently similar to services currently
on the telehealth list to be added on a Category 1 basis. Therefore, we
are proposing to add the following services to the telehealth list on a
Category 1 basis for CY 2019:
HCPCS codes G0513 and G0514 (Prolonged preventive
service(s) (beyond the typical service time of the primary procedure),
in the office or other outpatient setting requiring direct patient
contact beyond the usual service; first 30 minutes (list separately in
addition to code for preventive service) and (Prolonged preventive
service(s) (beyond the typical service time of the primary procedure),
in the office or other outpatient setting requiring direct patient
contact beyond the usual service; each additional 30 minutes (list
separately in addition to code G0513 for additional 30 minutes of
preventive service).
We found that the services described by HCPCS codes G0513 and G0514
are sufficiently similar to office visits currently on the telehealth
list. We believe that all the components of this service can be
furnished via interactive telecommunications technology. Additionally,
we believe that adding these services to the telehealth list would make
it administratively easier for practitioners who report these services
in connection with a preventive service that is furnished via
telehealth, as both the base code and the add-on code would be reported
with the telehealth place of service.
We also received requests to add services to the telehealth list
that do not meet our criteria for Medicare telehealth services. We are
not proposing to add to the Medicare telehealth services list the
following procedures for chronic care remote physiologic monitoring,
interprofessional internet consultation, and initial hospital care; or
to change the requirements for subsequent hospital care or subsequent
nursing facility care, for the reasons noted in the paragraphs that
follow.
(1) Chronic Care Remote Physiologic Monitoring: CPT Codes
CPT code 990X0 (Remote monitoring of physiologic
parameter(s) (e.g., weight, blood pressure, pulse oximetry, respiratory
flow rate), initial; set-up and patient education on use of equipment).
CPT code 990X1 (Remote monitoring of physiologic
parameter(s) (e.g., weight, blood pressure, pulse oximetry, respiratory
flow rate), initial; device(s) supply with daily recording(s) or
programmed alert(s) transmission, each 30 days).
CPT code 994X9 (Remote physiologic monitoring treatment
management services, 20 minutes or more of clinical staff/physician/
other qualified healthcare professional time in a calendar month
requiring interactive communication with the patient/caregiver during
the month).
In the CY 2016 PFS final rule with comment period (80 FR 71064), we
responded to a request to add CPT code 99490 (Chronic care management
services, at least 20 minutes of clinical staff time directed by a
physician or other qualified health care professional, per calendar
month, with the following required elements: Multiple (two or more)
chronic conditions expected to last at least 12 months, or until the
death of the patient; chronic conditions place the patient at
significant risk of death, acute exacerbation/decompensation, or
functional decline; comprehensive care plan established, implemented,
revised, or monitored) to the Medicare telehealth list. We discussed
that the services described by CPT code 99490 can be furnished without
the beneficiary's face-to-face presence and using any number of non-
face-to-face means of communication. We stated that it was therefore
unnecessary to add that service to the list of Medicare telehealth
services. Similarly, CPT codes 990X0, 990X1, and 994X9 describe
services that are inherently non face-to-face. As discussed in section
II.H. Valuation of Specific Codes, we instead are proposing to adopt
CPT codes 990X0, 990X1, and 994X9 for payment under the PFS. Because
these codes describe services that are inherently non face-to-face, we
do not consider them Medicare telehealth services under section 1834(m)
of the Act; therefore, we are not proposing to add them to the list of
Medicare telehealth services.
(2) Interprofessional Internet Consultation: CPT Codes
CPT code 994X0 (Interprofessional telephone/internet/
electronic health record referral service(s) provided by a treating/
requesting physician or qualified health care professional, 30
minutes).
CPT code 994X6 (Interprofessional telephone/internet/
electronic health record assessment and management service provided by
a consultative physician including a written report to the patient's
treating/requesting physician or other qualified health care
professional, 5 or more minutes of medical consultative time).
As discussed in section II.H. Valuation of Specific Codes, we are
proposing to adopt CPT codes 994X0 and 994X6 for payment under the PFS
as these are distinct services furnished via communication technology.
Because these codes describe services that are inherently non face-to-
face, we do not consider them as Medicare telehealth services under
section 1834(m) of the Act; therefore we are not proposing to add them
to the list of Medicare telehealth services for CY 2019.
(3) Initial Hospital Care Services: CPT Codes
CPT code 99221 (Initial hospital care, per day, for the
evaluation and management of a patient, which requires these 3 key
components: A detailed or comprehensive history; A detailed or
comprehensive examination; and Medical decision making that is
straightforward or of low complexity. Counseling and/or coordination of
care
[[Page 35728]]
with other physicians, other qualified health care professionals, or
agencies are provided consistent with the nature of the problem(s) and
the patient's and/or family's needs. Usually, the problem(s) requiring
admission are of low severity.)
CPT code 99222 (Initial hospital care, per day, for the
evaluation and management of a patient, which requires these 3 key
components: A comprehensive history; A comprehensive examination; and
Medical decision making of moderate complexity. Counseling and/or
coordination of care with other physicians, other qualified health care
professionals, or agencies are provided consistent with the nature of
the problem(s) and the patient's and/or family's needs. Usually, the
problem(s) requiring admission are of moderate severity.)
CPT code 99223 (Initial hospital care, per day, for the
evaluation and management of a patient, which requires these 3 key
components: A comprehensive history; A comprehensive examination; and
Medical decision making of high complexity. Counseling and/or
coordination of care with other physicians, other qualified health care
professionals, or agencies are provided consistent with the nature of
the problem(s) and the patient's and/or family's needs. Usually, the
problem(s) requiring admission are of high severity.)
We have previously considered requests to add these codes to the
telehealth list. As we stated in the CY 2011 PFS final rule with
comment period (75 FR 73315), while initial inpatient consultation
services are currently on the list of approved telehealth services,
there are no services on the current list of telehealth services that
resemble initial hospital care for an acutely ill patient by the
admitting practitioner who has ongoing responsibility for the patient's
treatment during the course of the hospital stay. Therefore, consistent
with prior rulemaking, we do not propose that initial hospital care
services be added to the Medicare telehealth services list on a
category 1 basis.
The initial hospital care codes describe the first visit of the
hospitalized patient by the admitting practitioner who may or may not
have seen the patient in the decision-making phase regarding
hospitalization. Based on the description of the services for these
codes, we believed it is critical that the initial hospital visit by
the admitting practitioner be conducted in person to ensure that the
practitioner with ongoing treatment responsibility comprehensively
assesses the patient's condition upon admission to the hospital through
a thorough in-person examination. Additionally, the requester submitted
no additional research or evidence that the use of a telecommunications
system to furnish the service produces demonstrated clinical benefit to
the patient; therefore, we also do not propose adding initial hospital
care services to the Medicare telehealth services list on a Category 2
basis.
We note that Medicare beneficiaries who are being treated in the
hospital setting can receive reasonable and necessary E/M services
using other HCPCS codes that are currently on the Medicare telehealth
list, including those for subsequent hospital care, initial and follow-
up telehealth inpatient and emergency department consultations, as well
as initial and follow-up critical care telehealth consultations.
Therefore, we are not proposing to add the initial hospital care
services to the list of Medicare telehealth services for CY 2019.
(4) Subsequent Hospital Care Services: CPT Codes
CPT code 99231 (Subsequent hospital care, per day, for the
evaluation and management of a patient, which requires at least 2 of
these 3 key components: A problem focused interval history; A problem
focused examination; Medical decision making that is straightforward or
of low complexity. Counseling and/or coordination of care with other
physicians, other qualified health care professionals, or agencies are
provided consistent with the nature of the problem(s) and the patient's
and/or family's needs. Usually, the patient is stable, recovering or
improving. Typically, 15 minutes are spent at the bedside and on the
patient's hospital floor or unit.)
CPT code 99232 (Subsequent hospital care, per day, for the
evaluation and management of a patient, which requires at least 2 of
these 3 key components: An expanded problem focused interval history;
an expanded problem focused examination; medical decision making of
moderate complexity. Counseling and/or coordination of care with other
physicians, other qualified health care professionals, or agencies are
provided consistent with the nature of the problem(s) and the patient's
and/or family's needs. Usually, the patient is responding inadequately
to therapy or has developed a minor complication. Typically, 25 minutes
are spent at the bedside and on the patient's hospital floor or unit.)
CPT code 99233 (Subsequent hospital care, per day, for the
evaluation and management of a patient, which requires at least 2 of
these 3 key components: A detailed interval history; a detailed
examination; Medical decision making of high complexity. Counseling
and/or coordination of care with other physicians, other qualified
health care professionals, or agencies are provided consistent with the
nature of the problem(s) and the patient's and/or family's needs.
Usually, the patient is unstable or has developed a significant
complication or a significant new problem. Typically, 35 minutes are
spent at the bedside and on the patient's hospital floor or unit.)
CPT codes 99231-99233 are currently on the list of Medicare
telehealth services, but can only be billed via telehealth once every 3
days. The requester asked that we remove the frequency limitation. We
stated in the CY 2011 PFS final rule with comment period (75 FR 73316)
that, while we still believed the potential acuity of hospital
inpatients is greater than those patients likely to receive Medicare
telehealth services that were on the list at that time, we also
believed that it would be appropriate to permit some subsequent
hospital care services to be furnished through telehealth in order to
ensure that hospitalized patients have frequent encounters with their
admitting practitioner. We also noted that we continue to believe that
the majority of these visits should be in-person to facilitate the
comprehensive, coordinated, and personal care that medically volatile,
acutely ill patients require on an ongoing basis. Because of our
concerns regarding the potential acuity of hospital inpatients, we
finalized the addition of CPT codes 99231-99233 to the list of Medicare
telehealth services, but limited the provision of these subsequent
hospital care services through telehealth to once every 3 days. We
continue to believe that admitting practitioners should continue to
make appropriate in-person visits to all patients who need such care
during their hospitalization. Our concerns and position on the
provision of subsequent hospital care services via telehealth have not
changed. Therefore, we are not proposing to remove the frequency
limitation on these codes.
(5) Subsequent Nursing Facility Care Services: CPT Codes
CPT code 99307 (Subsequent nursing facility care, per day,
for the evaluation and management of a patient, which requires at least
2 of these 3 key
[[Page 35729]]
components: A problem focused interval history; A problem focused
examination; Straightforward medical decision making. Counseling and/or
coordination of care with other physicians, other qualified health care
professionals, or agencies are provided consistent with the nature of
the problem(s) and the patient's and/or family's needs. Usually, the
patient is stable, recovering, or improving. Typically, 10 minutes are
spent at the bedside and on the patient's facility floor or unit.)
CPT code 99308 (Subsequent nursing facility care, per day,
for the evaluation and management of a patient, which requires at least
2 of these 3 key components: An expanded problem focused interval
history; an expanded problem focused examination; Medical decision
making of low complexity. Counseling and/or coordination of care with
other physicians, other qualified health care professionals, or
agencies are provided consistent with the nature of the problem(s) and
the patient's and/or family's needs. Usually, the patient is responding
inadequately to therapy or has developed a minor complication.
Typically, 15 minutes are spent at the bedside and on the patient's
facility floor or unit.)
CPT code 99309 (Subsequent nursing facility care, per day,
for the evaluation and management of a patient, which requires at least
2 of these 3 key components: A detailed interval history; a detailed
examination; Medical decision making of moderate complexity. Counseling
and/or coordination of care with other physicians, other qualified
health care professionals, or agencies are provided consistent with the
nature of the problem(s) and the patient's and/or family's needs.
Usually, the patient has developed a significant complication or a
significant new problem. Typically, 25 minutes are spent at the bedside
and on the patient's facility floor or unit.)
CPT code 99310 (Subsequent nursing facility care, per day,
for the evaluation and management of a patient, which requires at least
2 of these 3 key components: A comprehensive interval history; a
comprehensive examination; Medical decision making of high complexity.
Counseling and/or coordination of care with other physicians, other
qualified health care professionals, or agencies are provided
consistent with the nature of the problem(s) and the patient's and/or
family's needs. The patient may be unstable or may have developed a
significant new problem requiring immediate physician attention.
Typically, 35 minutes are spent at the bedside and on the patient's
facility floor or unit.)
CPT codes 99307-99310 are currently on the list of Medicare
telehealth services, but can only be billed via telehealth once every
30 days. The requester asked that we remove the frequency limitation
when these services are provided for psychiatric care. We stated in the
CY 2011 PFS final rule with comment period (75 FR 73317) that we
believed it would be appropriate to permit some subsequent nursing
facility care services to be furnished through telehealth to ensure
that complex nursing facility patients have frequent encounters with
their admitting practitioner, but because of our concerns regarding the
potential acuity and complexity of SNF inpatients, we limited the
provision of subsequent nursing facility care services furnished
through telehealth to once every 30 days. Since these codes are used to
report care for patients with a variety of diagnoses, including
psychiatric diagnoses, we do not think it would be appropriate to
remove the frequency limitation only for certain diagnoses. The
services described by these CPT codes are essentially the same service,
regardless of the patient's diagnosis. We also continue to have
concerns regarding the potential acuity and complexity of SNF
inpatients, and therefore, we are not proposing to remove the frequency
limitation for subsequent nursing facility care services in CY 2019.
In summary, we are proposing to add the following codes to the list
of Medicare telehealth services beginning in CY 2019 on a category 1
basis:
HCPCS code G0513 (Prolonged preventive service(s) (beyond
the typical service time of the primary procedure), in the office or
other outpatient setting requiring direct patient contact beyond the
usual service; first 30 minutes (list separately in addition to code
for preventive service).
HCPCS code G0514 (Prolonged preventive service(s) (beyond
the typical service time of the primary procedure), in the office or
other outpatient setting requiring direct patient contact beyond the
usual service; each additional 30 minutes (list separately in addition
to code G0513 for additional 30 minutes of preventive service).
5. Expanding the Use of Telehealth Under the Bipartisan Budget Act of
2018
a. Expanding Access to Home Dialysis Therapy Under the Bipartisan
Budget Act of 2018
Section 50302 of the BBA of 2018 amended sections 1881(b)(3) and
1834(m) of the Act to allow an individual determined to have end-stage
renal disease receiving home dialysis to choose to receive certain
monthly end-stage renal disease-related (ESRD-related) clinical
assessments via telehealth on or after January 1, 2019. The new section
1881(b)(3)(B)(ii) of the Act requires that such an individual must
receive a face-to-face visit, without the use of telehealth, at least
monthly in the case of the initial 3 months of home dialysis and at
least once every 3 consecutive months after the initial 3 months.
As added by section 50302(b)(1) of the BBA of 2018, subclauses (IX)
and (X) of section 1834(m)(4)(C)(ii) of the Act include a renal
dialysis facility and the home of an individual as telehealth
originating sites but only for the purposes of the monthly ESRD-related
clinical assessments furnished through telehealth provided under
section 1881(b)(3)(B) of the Act. Section 50302(b)(1) also added a new
section 1834(m)(5) of the Act which provides that the geographic
requirements for telehealth services under section 1834(m)(4)(C)(i) of
the Act do not apply to telehealth services furnished on or after
January 1, 2019 for purposes of the monthly ESRD-related clinical
assessments where the originating site is a hospital-based or critical
access hospital-based renal dialysis center, a renal dialysis facility,
or the home of an individual. Section 50302(b)(2) of the BBA of 2018
amended section 1834(m)(2)(B)(ii) of the Act to require that no
originating site facility fee is to be paid if the home of the
individual is the originating site.
Our current regulation at Sec. 410.78 specifies the conditions
that must be met in order for Medicare Part B to pay for covered
telehealth services included on the telehealth list when furnished by
an interactive telecommunications system. In accordance with the new
subclauses (IX) and (X) of section 1834(m)(4)(C)(ii) of the Act, we are
proposing to revise our regulation at Sec. 410.78(b)(3) to add a renal
dialysis facility and the home of an individual as Medicare telehealth
originating sites, but only for purposes of the home dialysis monthly
ESRD-related clinical assessment in section 1881(b)(3)(B) of the Act.
We propose to amend Sec. 414.65(b)(3) to reflect the requirement in
section 1834(m)(2)(B)(ii) of the Act that there is no originating site
facility fee paid when the originating site for these services is the
patient's home. Additionally, we are proposing to add new Sec.
410.78(b)(4)(iv)(A), to reflect the provision in section 1834(m)(5) of
the Act, added by section 50302 of the BBA
[[Page 35730]]
of 2018, specifying that the geographic requirements described in
section 1834(m)(4)(C)(i) of the Act do not apply with respect to
telehealth services furnished on or after January 1, 2019, in
originating sites that are hospital-based or critical access hospital-
based renal dialysis centers, renal dialysis facilities, or the
patient's home, respectively under sections 1834(m)(4)(C)(ii)(VI), (IX)
and (X) of the Act, for purposes of section 1881(b)(3)(B) of the Act.
b. Expanding the Use of Telehealth for Individuals With Stroke Under
the Bipartisan Budget Act of 2018
Section 50325 of the BBA of 2018 amended section 1834(m) of the Act
by adding a new paragraph (6) that provides special rules for
telehealth services furnished on or after January 1, 2019, for purposes
of diagnosis, evaluation, or treatment of symptoms of an acute stroke
(acute stroke telehealth services), as determined by the Secretary.
Specifically, section 1834(m)(6)(A) of the Act removes the restrictions
on the geographic locations and the types of originating sites where
acute stroke telehealth services can be furnished. Section
1834(m)(6)(B) of the Act specifies that acute stroke telehealth
services can be furnished in any hospital, critical access hospital,
mobile stroke units (as defined by the Secretary), or any other site
determined appropriate by the Secretary, in addition to the current
eligible telehealth originating sites. Section 1834(m)(6)(C) of the Act
limits payment of an originating site facility fee to acute stroke
telehealth services furnished in sites that meet the usual telehealth
restrictions under section 1834(m)(4)(C) of the Act.
To implement these requirements, we are proposing to create a new
modifier that would be used to identify acute stroke telehealth
services. The practitioner and, as appropriate, the originating site,
would append this modifier when clinically appropriate to the HCPCS
code when billing for an acute stroke telehealth service or an
originating site facility fee, respectively. We note that section 50325
of the BBA of 2018 did not amend section 1834(m)(4)(F) of the Act,
which limits the scope of telehealth services to those on the Medicare
telehealth list. Practitioners would be responsible for assessing
whether it would be clinically appropriate to use this modifier with
codes from the Medicare telehealth list. By billing with this modifier,
practitioners would be indicating that the codes billed were used to
furnish telehealth services for diagnosis, evaluation, or treatment of
symptoms of an acute stroke. We believe that the adoption of a service
level modifier is the least administratively burdensome means of
implementing this provision for practitioners, while also allowing CMS
to easily track and analyze utilization of these services.
In accordance with section 1834(m)(6)(B) of the Act, as added by
section 50325 of the BBA of 2018, we are also proposing to revise Sec.
410.78(b)(3) of our regulations to add mobile stroke unit as a
permissible originating site for acute stroke telehealth services. We
are proposing to define a mobile stroke unit as a mobile unit that
furnishes services to diagnose, evaluate, and/or treat symptoms of an
acute stroke and are seeking comment on this definition, as well as
additional information on how these units are used in current medical
practice. We are therefore proposing that mobile stroke units and the
current eligible telehealth originating sites, which include hospitals
and critical access hospitals as specified in section 1834(m)(6)(B) of
the Act, but excluding renal dialysis facilities and patient homes
because they are only allowable originating sites for purposes of home
dialysis monthly ESRD-related clinical assessments in section
1881(b)(3)(B) of the Act, would be permissible originating sites for
acute stroke telehealth services.
We also seek comment on other possible appropriate originating
sites for telehealth services furnished for the diagnosis, evaluation,
or treatment of symptoms of an acute stroke. Any additional sites would
be adopted through future rulemaking. As required under section
1834(m)(6)(C) of the Act, the originating site facility fee would not
apply in instances where the originating site does not meet the
originating site type and geographic requirements under section
1834(m)(4)(C) of the Act. Additionally, we are proposing to add Sec.
410.78(b)(4)(iv)(B) to specify that the requirements in section
1834(m)(4)(C) of the Act do not apply with respect to telehealth
services furnished on or after January 1, 2019, for purposes of
diagnosis, evaluation, or treatment of symptoms of an acute stroke.
6. Modifying Sec. 414.65 Regarding List of Telehealth Services
In the CY 2015 PFS final rule with comment period, we finalized a
proposal to change our regulation at Sec. 410.78(b) by deleting the
description of the individual services for which Medicare payment can
be made when furnished via telehealth, noting that we revised Sec.
410.78(f) to indicate that a list of Medicare telehealth codes and
descriptors is available on the CMS website (79 FR 67602). In
accordance with that change, we are proposing a technical revision to
also delete the description of individual services and exceptions for
Medicare payment for telehealth services in Sec. 414.65, by amending
Sec. 414.65(a) to note that Medicare payment for telehealth services
is addressed in Sec. 410.78 and by deleting Sec. 414.65(a)(1).
7. Comment Solicitation on Creating a Bundled Episode of Care for
Management and Counseling Treatment for Substance Use Disorders
There is an evidence base that suggests that routine counseling,
either associated with medication assisted treatment (MAT) or on its
own, can increase the effectiveness of treatment for substance use
disorders (SUDs). According to a study in the Journal of Substance
Abuse Treatment,\1\ patients treated with a combination of web-based
counseling as part of a substance abuse treatment program demonstrated
increased treatment adherence and satisfaction. The federal guidelines
for opioid treatment programs describe that MAT and wrap-around
psychosocial and support services can include the following services:
Physical exam and assessment; psychosocial assessment; treatment
planning; counseling; medication management; drug administration;
comprehensive care management and supportive services; care
coordination; management of care transitions; individual and family
support services; and health promotion (https://store.samhsa.gov/shin/content/PEP15-FEDGUIDEOTP/PEP15-FEDGUIDEOTP.pdf). Creating separate
payment for a bundled episode of care for components of MAT such as
management and counseling treatment for substance use disorders (SUD),
including opioid use disorder, treatment planning, and medication
management or observing drug dosing for treatment of SUDs under the PFS
could provide opportunities to better leverage services furnished with
communication technology while expanding access to treatment for SUDs.
---------------------------------------------------------------------------
\1\ Van L. King, Robert K. Brooner, Jessica M. Peirce, Ken
Kolodner, Michael S. Kidorf, ``A randomized trial of Web based
videoconferencing for substance abuse counseling,'' Journal of
Substance Abuse Treatment, Volume 46, Issue 1, 2014, Pages 36-42,
http://www.sciencedirect.com/science/article/pii/S0740547213001876.
---------------------------------------------------------------------------
We also believe making separate payment for a bundled episode of
care for management and counseling for SUDs could be effective in
preventing the need for more acute services. For example, according to
the Healthcare
[[Page 35731]]
Cost and Utilization Project,\2\ Medicare pays for one-third of opioid-
related hospital stays, and Medicare has seen the largest annual
increase in the number of these stays over the past 2 decades. We
believe that separate payment for a bundled episode of care could help
avoid such hospital admissions by supporting access to management and
counseling services that could be important in preventing hospital
admissions and other acute care events.
---------------------------------------------------------------------------
\2\ Pamela L. Owens, Ph.D., Marguerite L. Barrett, M.S., Audrey
J. Weiss, Ph.D., Raynard E. Washington, Ph.D., and Richard Kronick,
Ph.D. ``Hospital Inpatient Utilization Related to Opioid Overuse
Among Adults 1993-2012,'' Statistical Brief #177. Healthcare Cost
and Utilization Project (HCUP). July 2014. Agency for Healthcare
Research and Quality, Rockville, MD, https://www.hcup-us.ahrq.gov/reports/statbriefs/sb177-Hospitalizations-for-Opioid-Overuse.jsp.
---------------------------------------------------------------------------
As indicated above, we are considering whether it would be
appropriate to develop a separate bundled payment for an episode of
care for treatment of SUDs. We are seeking public comment on whether
such a bundled episode-based payment would be beneficial to improve
access, quality and efficiency for SUD treatment. Further, we are
seeking public comment on developing coding and payment for a bundled
episode of care for treatment for SUDs that could include overall
treatment management, any necessary counseling, and components of a MAT
program such as treatment planning, medication management, and
observation of drug dosing. Specifically, we are seeking public
comments related to what assumptions we might make about the typical
number of counseling sessions as well as the duration of the service
period, which types of practitioners could furnish these services, and
what components of MAT could be included in the bundled episode of
care. We are interested in stakeholder feedback regarding how to define
and value this bundle and what conditions of payment should be
attached. Additionally, we are seeking comment on whether the concept
of a global period, similar to the currently existing global periods
for surgical procedures, might be applicable to treatment for SUDs.
We also seek comment on whether the counseling portion and other
MAT components could also be provided by qualified practitioners
``incident to'' the services of the billing physician who would
administer or prescribe any necessary medications and manage the
overall care, as well as supervise any other counselors participating
in the treatment, similar to the structure of the Behavioral Health
Integration codes which include services provided by other members of
the care team under the direction of the billing practitioner on an
``incident to'' basis (81 FR 80231). We welcome comments on potentially
creating a bundled episode of care for management and counseling
treatment for SUDs, which we will consider for future rulemaking.
Additionally, we invite public comment and suggestions for
regulatory and subregulatory changes to help prevent opioid use
disorder and improve access to treatment under the Medicare program. We
seek comment on methods for identifying non-opioid alternatives for
pain treatment and management, along with identifying barriers that may
inhibit access to these non-opioid alternatives including barriers
related to payment or coverage. Consistent with our ``Patients Over
Paperwork'' Initiative, we are interested in suggestions to improve
existing requirements in order to more effectively address the opioid
epidemic.
E. Potentially Misvalued Services Under the PFS
1. Background
Section 1848(c)(2)(B) of the Act directs the Secretary to conduct a
periodic review, not less often than every 5 years, of the RVUs
established under the PFS. Section 1848(c)(2)(K) of the Act requires
the Secretary to periodically identify potentially misvalued services
using certain criteria and to review and make appropriate adjustments
to the relative values for those services. Section 1848(c)(2)(L) of the
Act also requires the Secretary to develop a process to validate the
RVUs of certain potentially misvalued codes under the PFS, using the
same criteria used to identify potentially misvalued codes, and to make
appropriate adjustments.
As discussed in section II.H. of this proposed rule, each year we
develop appropriate adjustments to the RVUs taking into account
recommendations provided by the RUC, MedPAC, and other stakeholders.
For many years, the RUC has provided us with recommendations on the
appropriate relative values for new, revised, and potentially misvalued
PFS services. We review these recommendations on a code-by-code basis
and consider these recommendations in conjunction with analyses of
other data, such as claims data, to inform the decision-making process
as authorized by law. We may also consider analyses of work time, work
RVUs, or direct PE inputs using other data sources, such as Department
of Veteran Affairs (VA), National Surgical Quality Improvement Program
(NSQIP), the Society for Thoracic Surgeons (STS), and the Physician
Quality Reporting System (PQRS) databases. In addition to considering
the most recently available data, we assess the results of physician
surveys and specialty recommendations submitted to us by the RUC for
our review. We also consider information provided by other
stakeholders. We conduct a review to assess the appropriate RVUs in the
context of contemporary medical practice. We note that section
1848(c)(2)(A)(ii) of the Act authorizes the use of extrapolation and
other techniques to determine the RVUs for physicians' services for
which specific data are not available and requires us to take into
account the results of consultations with organizations representing
physicians who provide the services. In accordance with section 1848(c)
of the Act, we determine and make appropriate adjustments to the RVUs.
In its March 2006 Report to the Congress (http://www.medpac.gov/docs/default-source/congressional-testimony/testimony-report-to-the-congress-medicare-payment-policy-march-2006-.pdf?sfvrsn=0), MedPAC
discussed the importance of appropriately valuing physicians' services,
noting that misvalued services can distort the market for physicians'
services, as well as for other health care services that physicians
order, such as hospital services. In that same report, MedPAC
postulated that physicians' services under the PFS can become misvalued
over time. MedPAC stated, ``When a new service is added to the
physician fee schedule, it may be assigned a relatively high value
because of the time, technical skill, and psychological stress that are
often required to furnish that service. Over time, the work required
for certain services would be expected to decline as physicians become
more familiar with the service and more efficient in furnishing it.''
We believe services can also become overvalued when PE declines. This
can happen when the costs of equipment and supplies fall, or when
equipment is used more frequently than is estimated in the PE
methodology, reducing its cost per use. Likewise, services can become
undervalued when physician work increases or PE rises.
As MedPAC noted in its March 2009 Report to Congress (http://www.medpac.gov/docs/default-source/reports/march-2009-report-to-congress-medicare-payment-policy.pdf), in the intervening years since
MedPAC made the initial recommendations, CMS and the RUC have taken
several steps to
[[Page 35732]]
improve the review process. Also, section 1848(c)(2)(K)(ii) of the Act
augments our efforts by directing the Secretary to specifically
examine, as determined appropriate, potentially misvalued services in
the following categories:
Codes that have experienced the fastest growth.
Codes that have experienced substantial changes in PE.
Codes that describe new technologies or services within an
appropriate time period (such as 3 years) after the relative values are
initially established for such codes.
Codes which are multiple codes that are frequently billed
in conjunction with furnishing a single service.
Codes with low relative values, particularly those that
are often billed multiple times for a single treatment.
Codes that have not been subject to review since
implementation of the fee schedule.
Codes that account for the majority of spending under the
PFS.
Codes for services that have experienced a substantial
change in the hospital length of stay or procedure time.
Codes for which there may be a change in the typical site
of service since the code was last valued.
Codes for which there is a significant difference in
payment for the same service between different sites of service.
Codes for which there may be anomalies in relative values
within a family of codes.
Codes for services where there may be efficiencies when a
service is furnished at the same time as other services.
Codes with high intraservice work per unit of time.
Codes with high PE RVUs.
Codes with high cost supplies.
Codes as determined appropriate by the Secretary.
Section 1848(c)(2)(K)(iii) of the Act also specifies that the
Secretary may use existing processes to receive recommendations on the
review and appropriate adjustment of potentially misvalued services. In
addition, the Secretary may conduct surveys, other data collection
activities, studies, or other analyses, as the Secretary determines to
be appropriate, to facilitate the review and appropriate adjustment of
potentially misvalued services. This section also authorizes the use of
analytic contractors to identify and analyze potentially misvalued
codes, conduct surveys or collect data, and make recommendations on the
review and appropriate adjustment of potentially misvalued services.
Additionally, this section provides that the Secretary may coordinate
the review and adjustment of any RVU with the periodic review described
in section 1848(c)(2)(B) of the Act. Section 1848(c)(2)(K)(iii)(V) of
the Act specifies that the Secretary may make appropriate coding
revisions (including using existing processes for consideration of
coding changes) that may include consolidation of individual services
into bundled codes for payment under the PFS.
2. Progress in Identifying and Reviewing Potentially Misvalued Codes
To fulfill our statutory mandate, we have identified and reviewed
numerous potentially misvalued codes as specified in section
1848(c)(2)(K)(ii) of the Act, and we intend to continue our work
examining potentially misvalued codes in these areas over the upcoming
years. As part of our current process, we identify potentially
misvalued codes for review, and request recommendations from the RUC
and other public commenters on revised work RVUs and direct PE inputs
for those codes. The RUC, through its own processes, also identifies
potentially misvalued codes for review. Through our public nomination
process for potentially misvalued codes established in the CY 2012 PFS
final rule with comment period, other individuals and stakeholder
groups submit nominations for review of potentially misvalued codes as
well.
Since CY 2009, as a part of the annual potentially misvalued code
review and Five-Year Review process, we have reviewed approximately
1,700 potentially misvalued codes to refine work RVUs and direct PE
inputs. We have assigned appropriate work RVUs and direct PE inputs for
these services as a result of these reviews. A more detailed discussion
of the extensive prior reviews of potentially misvalued codes is
included in the CY 2012 PFS final rule with comment period (76 FR 73052
through 73055). In the CY 2012 PFS final rule with comment period (76
FR 73055 through 73958), we finalized our policy to consolidate the
review of physician work and PE at the same time, and established a
process for the annual public nomination of potentially misvalued
services.
In the CY 2013 PFS final rule with comment period, we built upon
the work we began in CY 2009 to review potentially misvalued codes that
have not been reviewed since the implementation of the PFS (so-called
``Harvard-valued codes''). In CY 2009 (73 FR 38589), we requested
recommendations from the RUC to aid in our review of Harvard-valued
codes that had not yet been reviewed, focusing first on high-volume,
low intensity codes. In the fourth Five-Year Review (76 FR 32410), we
requested recommendations from the RUC to aid in our review of Harvard-
valued codes with annual utilization of greater than 30,000 services.
In the CY 2013 PFS final rule with comment period, we identified
specific Harvard-valued services with annual allowed charges that total
at least $10,000,000 as potentially misvalued. In addition to the
Harvard-valued codes, in the CY 2013 PFS final rule with comment period
we finalized for review a list of potentially misvalued codes that have
stand-alone PE (codes with physician work and no listed work time and
codes with no physician work that have listed work time).
In the CY 2016 PFS final rule with comment period, we finalized for
review a list of potentially misvalued services, which included eight
codes in the neurostimulators analysis-programming family (CPT codes
95970-95982). We also finalized as potentially misvalued 103 codes
identified through our screen of high expenditure services across
specialties.
In the CY 2017 PFS final rule, we finalized for review a list of
potentially misvalued services, which included eight codes in the end-
stage renal disease home dialysis family (CPT codes 90963-90970). We
also finalized as potentially misvalued 19 codes identified through our
screen for 0-day global services that are typically billed with an
evaluation and management (E/M) service with modifier 25.
In the CY 2018 PFS final rule, we finalized arthrodesis of
sacroiliac joint (CPT code 27279) as potentially misvalued. Through the
use of comment solicitations with regard to specific codes, we also
examined the valuations of other services, in addition to, new
potentially misvalued code screens (82 FR 53017 through 53018).
3. CY 2019 Identification and Review of Potentially Misvalued Services
In the CY 2012 PFS final rule with comment period (76 FR 73058), we
finalized a process for the public to nominate potentially misvalued
codes. The public and stakeholders may nominate potentially misvalued
codes for review by submitting the code with supporting documentation
by February 10 of each year. Supporting documentation for codes
nominated for the annual review of potentially misvalued codes may
include the following:
[[Page 35733]]
Documentation in peer reviewed medical literature or other
reliable data that there have been changes in physician work due to one
or more of the following: Technique, knowledge and technology, patient
population, site-of-service, length of hospital stay, and work time.
An anomalous relationship between the code being proposed
for review and other codes.
Evidence that technology has changed physician work.
Analysis of other data on time and effort measures, such
as operating room logs or national and other representative databases.
Evidence that incorrect assumptions were made in the
previous valuation of the service, such as a misleading vignette,
survey, or flawed crosswalk assumptions in a previous evaluation.
Prices for certain high cost supplies or other direct PE
inputs that are used to determine PE RVUs are inaccurate and do not
reflect current information.
Analyses of work time, work RVU, or direct PE inputs using
other data sources (for example, VA, NSQIP, the STS National Database,
and the PQRS databases).
National surveys of work time and intensity from
professional and management societies and organizations, such as
hospital associations.
We evaluate the supporting documentation submitted with the
nominated codes and assess whether the nominated codes appear to be
potentially misvalued codes appropriate for review under the annual
process. In the following year's PFS proposed rule, we publish the list
of nominated codes and indicate whether we proposed each nominated code
as a potentially misvalued code. The public has the opportunity to
comment on these and all other proposed potentially misvalued codes. In
that year's final rule, we finalize our list of potentially misvalued
codes.
a. Public Nominations
We received one submission that nominated several high-volume codes
for review under the potentially misvalued code initiative. In their
request, the submitter noted a systemic overvaluation of work RVUs in
certain procedures and tests based ``on a number of Government
Accountability Office (GAO) and the Medicare Payment Advisory
Commission (MedPAC) reports, media reports regarding time inflation of
specific services, and the January 19, 2017 Urban Institute report for
CMS.'' The submitter suggested that the times CMS assumes in estimating
work RVUs are inaccurate for procedures, especially due to substantial
overestimates of preservice and postservice time, including follow-up
inpatient and outpatient visits that do not take place. According to
the submitter, the time estimates for tests and some other procedures
are primarily overstated as part of the intraservice time. Furthermore,
the submitter stated that previous RUC reviews of these services did
not result in reductions in valuation that adequately reflected
reductions in surveyed times.
Based on these analyses, the submitter requested that the codes
listed in Table 8 be prioritized for reviewed under the potentially
misvalued code initiative.
Table 8--Public Nominations Due to Overvaluation
------------------------------------------------------------------------
CPT code Short description
------------------------------------------------------------------------
27130................................ Total hip arthroplasty.
27447................................ Total knee arthroplasty.
43239................................ Egd biopsy single/multiple.
45385................................ Colonoscopy w/lesion removal.
70450................................ CT head w/o contrast.
93000................................ Electrocardiogram complete.
93306................................ Tte w/doppler complete.
------------------------------------------------------------------------
Another commenter requested that CPT codes 92992 (Atrial septectomy
or septostomy; transvenous method, balloon (e.g., Rashkind type)
(includes cardiac catheterization)) and 92993 (Atrial septectomy or
septostomy; blade method (Park septostomy) (includes cardiac
catheterization)) be reviewed under the potentially misvalued code
initiative in order to establish national RVU values for these services
under the MPFS. These codes are currently priced by the Medicare
Administrative Contractors (MACs).
b. Update on the Global Surgery Data Collection
CMS currently bundles payment for postoperative care within 10 or
90 days after many surgical procedures. Historically, we have not
collected data on how many postoperative visits are actually performed
during the global period. Section 523 of the MACRA added a new
paragraph 1848(c)(8) to the Act, and section 1848(c)(8)(B) required CMS
to use notice and comment rulemaking to implement a process to collect
data on the number and level of postoperative visits and use these data
to assess the accuracy of global surgical package valuation. In the CY
2017 PFS final rule, we adopted a policy to collect postoperative visit
data.
Beginning July 1, 2017, CMS required practitioners in groups with
10 or more practitioners in nine states (Florida, Kentucky, Louisiana,
Nevada, New Jersey, North Dakota, Ohio, Oregon, and Rhode Island) to
use the no-pay CPT code 99024 (Postoperative follow-up visit, normally
included in the surgical package, to indicate that an E/M service was
performed during a postoperative period for a reason(s) related to the
original procedure) to report postoperative visits. Practitioners who
only practice in practices with fewer than 10 practitioners are
exempted from required reporting, but are encouraged to report if
feasible. The 293 procedures for which reporting is required are those
furnished by more than 100 practitioners, and either are nationally
furnished more than 10,000 times annually or have more than $10 million
in annual allowed charges. A list of the procedures for which reporting
is required is updated annually to reflect any coding changes and is
posted on the CMS website at https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched/Global-Surgery-Data-Collection-.html.
In these nine states, from July 1, 2017 through December 31, 2017,
there were 990,581 postoperative visits reported using CPT code 99024.
Of the 32,573 practitioners who furnished at least one of the 293
procedures during this period and who, based on Tax Identification
Numbers in claims data, were likely to meet the practice size
threshold, only 45 percent reported one or more visit using CPT code
99024 during this 6-month period. The share of practitioners who
reported any CPT code 99024 claims varied by specialty. Among surgical
oncology, hand surgery, and orthopedic surgeons, reporting rates were
92, 90, and 87 percent, respectively. In contrast, the reporting rate
for emergency medicine physicians was 4 percent. (See Table 9.)
[[Page 35734]]
Table 9--Share of Practitioners Who Reported Any CPT Code 99024 Claims, by Specialty
----------------------------------------------------------------------------------------------------------------
Number of
Practitioner specialty Number of reporting Percent
practitioners * practitioners ** reporting
----------------------------------------------------------------------------------------------------------------
ALL....................................................... 32,642 14,627 45
Family practice........................................... 3,912 707 18
Emergency medicine........................................ 3,612 153 4
Physician Assistant....................................... 2,751 758 28
Orthopedic surgery........................................ 2,725 2,360 87
General surgery........................................... 2,317 1,879 81
Nurse Practitioner........................................ 2,217 438 20
Internal medicine......................................... 1,476 161 11
Ophthalmology............................................. 1,319 1,069 81
Urology................................................... 1,186 1,014 85
Dermatology............................................... 1,025 698 68
Diagnostic radiology...................................... 982 34 3
Obstetrics/gynecology..................................... 966 612 63
Otolaryngology............................................ 872 652 75
Podiatry.................................................. 761 502 66
Neurosurgery.............................................. 614 512 83
Cardiology................................................ 574 307 53
Neurology................................................. 525 19 4
Vascular surgery.......................................... 405 342 84
Pathologic anatomy, clinical pathology.................... 355 281 79
Thoracic surgery.......................................... 320 270 84
Gastroenterology.......................................... 315 6 2
Plastic and reconstructive surgery........................ 303 250 83
Physical medicine and rehabilitation...................... 275 63 23
Anesthesiology............................................ 254 73 29
Optometry................................................. 247 158 64
Pain Management........................................... 247 98 40
Colorectal surgery........................................ 225 189 84
Hand surgery.............................................. 214 193 90
Interventional radiology.................................. 201 19 9
Interventional Cardiology................................. 195 114 58
Cardiac surgery........................................... 176 148 84
Interventional Pain Management............................ 165 55 33
Surgical oncology......................................... 154 141 92
Gynecologist/oncologist................................... 143 121 85
General practice.......................................... 115 37 32
Peripheral vascular disease, medical or surgical.......... 106 84 79
Nephrology................................................ 74 9 12
Critical care............................................. 54 34 63
Pediatric medicine........................................ 39 4 10
Infectious disease........................................ 34 3 9
Maxillofacial surgery..................................... 25 18 72
Oral surgery.............................................. 20 11 55
Osteopathic manipulative therapy.......................... 18 6 33
Hematology/oncology....................................... 16 5 31
Geriatric medicine........................................ 15 2 13
Certified clinical nurse specialist....................... 12 1 8
Unknown physician specialty............................... 12 9 75
----------------------------------------------------------------------------------------------------------------
* Limited to practitioners who performed at least one of the 293 relevant global procedures and were affiliated
with a tax identification number with 10 or more practitioners.
** Practitioners who submitted one or more CPT code 99024 claims between July 1st, 2017 and December 31st, 2017.
The share of practitioners who reported CPT code 99024 on any
claims also varied by state as shown in Table 10.
Table 10--Share of Practitioners Who Reported Any CPT Code 99024 Claims,
by State
------------------------------------------------------------------------
Percentage of
State practitioners *
reporting **
------------------------------------------------------------------------
ALL................................................... 45
North Dakota.......................................... 56
Ohio.................................................. 49
Rhode Island.......................................... 49
Florida............................................... 48
New Jersey............................................ 43
Louisiana............................................. 42
Kentucky.............................................. 41
Oregon................................................ 35
Nevada................................................ 30
------------------------------------------------------------------------
* Limited to practitioners who performed at least one of the 293
relevant global procedures and were affiliated with a tax
identification number with 10 or more practitioners.
[[Page 35735]]
** Practitioners who submitted one or more CPT code 99024 claims between
July 1st, 2017 and December 31st, 2017.
Among 10-day global procedures performed from July 1, 2017 through
December 31, 2017, where it is possible to clearly match postoperative
visits to specific procedures, only 4 percent had one or more matched
visit reported with CPT code 99024. The percentage of 10-day global
procedures with a matched visit reported with CPT code 99024 varied by
specialty. Among procedures with 10-day global periods performed by
hand surgeons, critical care, and obstetrics/gynecology 44, 36, and 23
percent, respectively, of procedures had a matched visit reported using
CPT code 99024. In contrast, less than 5 percent of 10-day global
procedures performed by many other specialties had a matched visit
reported using CPT code 99024. (See Table 11.)
Table 11--Share of Procedures With Matched Post-Operative Visits
----------------------------------------------------------------------------------------------------------------
Number of 10-day Percentage of 10-
global day global
Number of 10-day procedures with procedures with
Provider specialty global 1 or more 1 or more
procedures * matched 99024 matched 99024
claims ** claims **
----------------------------------------------------------------------------------------------------------------
ALL....................................................... 436,063 16,802 4
Dermatology............................................... 205,594 6,920 3
Physician Assistant....................................... 57,749 908 2
Nurse Practitioner........................................ 31,937 509 2
Family practice........................................... 16,770 629 4
Ophthalmology............................................. 16,087 1,239 8
Podiatry.................................................. 12,639 547 4
General surgery........................................... 12,113 2,095 17
Diagnostic radiology...................................... 11,650 298 3
Neurology................................................. 8,075 68 1
Pain Management........................................... 6,923 210 3
Emergency medicine........................................ 6,012 209 3
Internal medicine......................................... 5,883 201 3
Interventional Pain Management............................ 5,210 106 2
Anesthesiology............................................ 4,666 105 2
Otolaryngology............................................ 4,598 383 8
Interventional radiology.................................. 4,197 89 2
Physical medicine and rehabilitation...................... 3,546 53 1
Vascular surgery.......................................... 3,447 256 7
Gastroenterology.......................................... 2,264 7 0
Plastic and reconstructive surgery........................ 1,939 403 21
Colorectal surgery........................................ 1,851 83 4
General practice.......................................... 1,807 45 2
Orthopedic surgery........................................ 1,688 318 19
Optometry................................................. 1,563 45 3
Urology................................................... 1,276 277 22
Neurosurgery.............................................. 1,148 241 21
Nephrology................................................ 1,008 25 2
Obstetrics/gynecology..................................... 760 171 23
Cardiology................................................ 456 14 3
Surgical oncology......................................... 440 41 9
Pathology................................................. 395 76 19
Pediatric medicine........................................ 323 4 1
Neuropsychiatry........................................... 296 2 1
Thoracic surgery.......................................... 276 40 14
Gynecologist/oncologist................................... 266 47 18
Interventional Cardiology................................. 192 5 3
Peripheral vascular disease, medical or surgical.......... 162 5 3
Cardiac surgery........................................... 144 25 17
Hand surgery.............................................. 124 54 44
Critical care............................................. 85 30 35
Infectious disease........................................ 67 3 4
Osteopathic manipulative therapy.......................... 55 1 2
Psychiatry................................................ 44 0 0
Geriatric medicine........................................ 43 0 0
Hospitalist............................................... 42 0 0
Maxillofacial surgery..................................... 37 5 14
Oral surgery.............................................. 34 1 3
Radiation oncology........................................ 31 1 3
Certified clinical nurse specialist....................... 26 2 8
Pulmonary disease......................................... 20 2 10
Hematology/oncology....................................... 19 0 0
Peripheral vascular disease............................... 17 0 0
Preventive medicine....................................... 15 0 0
Pathologic anatomy, clinical pathology.................... 12 1 8
[[Page 35736]]
Unknown physician specialty............................... 10 3 30
----------------------------------------------------------------------------------------------------------------
* Limited to the 293 procedures where postoperative visit reporting is required and to those performed by
practitioners who work in practices with 10 or more practitioners. Because matching may be unclear in these
circumstances, multiple procedures performed on a single day and procedures with overlapping global periods
were excluded.
** Matching was based on patient, service dates, and global period duration.
Among 90-day global procedures performed from July 1, 2017 through
December 31, 2017, where it is possible to clearly match postoperative
visits to specific procedures, 67 percent had one or more matched visit
reported using CPT code 99024. Again, this rate varied by specialty as
shown in Table 12. Under the PFS, procedures with 90-day global periods
have more than one postoperative visit. It should be noted that the
rates described in this and prior paragraphs are based on any matched
postoperative visit reported using CPT code 99024.
Table 12--Share of Procedures With Matched Post-Operative Visits, for Procedure Codes With 90-Day Global Periods
----------------------------------------------------------------------------------------------------------------
Number of 90-day Percentage of 90-
global day global
Number of 90-day procedures with procedures with
Provider specialty global 1 or more 1 or more
procedures* matched 99024 matched 99024
claims** claims**
----------------------------------------------------------------------------------------------------------------
ALL....................................................... 232,235 156,727 67
Orthopedic surgery........................................ 71,991 54,876 76
Ophthalmology............................................. 63,333 41,700 66
General surgery........................................... 25,593 17,559 69
Pathologic anatomy, clinical pathology.................... 10,149 4,371 43
Urology................................................... 8,481 4,828 57
Dermatology............................................... 7,692 4,160 54
Neurosurgery.............................................. 6,993 5,256 75
Cardiology................................................ 5,932 2,388 40
Vascular surgery.......................................... 5,400 3,552 66
Hand surgery.............................................. 4,783 3,718 78
Thoracic surgery.......................................... 3,700 2,859 77
Cardiac surgery........................................... 2,764 2,183 79
Plastic and reconstructive surgery........................ 2,500 1,670 67
Podiatry.................................................. 2,383 1,393 58
Otolaryngology............................................ 1,692 1,014 60
Physician Assistant....................................... 1,492 903 61
Colorectal surgery........................................ 1,316 869 66
Interventional Cardiology................................. 1,123 500 45
Peripheral vascular disease, medical or surgical.......... 753 524 70
Obstetrics/gynecology..................................... 752 469 62
Surgical oncology......................................... 716 511 71
Optometry................................................. 402 248 62
Gynecologist/oncologist................................... 322 219 68
Internal medicine......................................... 317 133 42
Emergency medicine........................................ 258 62 24
Nurse Practitioner........................................ 243 153 63
General practice.......................................... 217 125 58
Gastroenterology.......................................... 139 13 9
Osteopathic manipulative therapy.......................... 131 94 72
Family practice........................................... 115 65 57
Critical care............................................. 98 77 79
Neurology................................................. 87 64 74
Interventional radiology.................................. 65 22 34
Unknown physician specialty............................... 60 34 57
Diagnostic radiology...................................... 50 6 12
Nephrology................................................ 33 21 64
Maxillofacial surgery..................................... 29 23 79
Physical medicine and rehabilitation...................... 26 16 62
Interventional Pain Management............................ 14 2 14
Pathology................................................. 13 3 23
Hematology/oncology....................................... 12 12 100
[[Page 35737]]
Peripheral vascular disease............................... 10 5 50
----------------------------------------------------------------------------------------------------------------
* Limited to the 293 procedures where post-operative visit reporting is required and to those performed by
practitioners who work in practices with 10 or more practitioners. Because matching may be unclear in these
circumstances, multiple procedures performed on a single day and procedures with overlapping global periods
were excluded.
** Matching was based on patient, service dates, and global period duration.
One potential explanation for these findings is that many
practitioners are not consistently reporting postoperative visits using
CPT code 99024. We are soliciting suggestions as to how to encourage
reporting to ensure the validity of the data without imposing undue
burden. Specifically, we are soliciting comments on whether we need to
do more to make practitioners aware of their obligation and whether we
should consider implementing an enforcement mechanism.
Given the very small number of postoperative visits reported using
CPT code 99024 during 10-day global periods, we are seeking comment on
whether or not it might be reasonable to assume that many visits
included in the valuation of 10-day global packages are not being
furnished, or whether there are alternative explanations for what could
be a significant level of underreporting of postoperative visits. For
example, we are soliciting comments on whether it is likely that in
many cases the practitioner reporting the procedure code is not
performing the postoperative visit, or if the postoperative visit is
being furnished by a different practitioner. Alternatively, we are
soliciting comments on whether it is possible that some or all of the
postoperative visits are occurring after the global period ends and
are, therefore, reported and paid separately.
We conducted an analysis to try to assess the extent of
underreporting. We identified a set of ``robust reporters'' who
appeared to be regularly reporting post-operative visits using CPT code
99024. They were defined as practitioners who (a) furnished 10 or more
procedures with 90-day global periods where it is possible for us to
match specific procedures to reported post-operative visits without
ambiguity, and (b) reported a post-operative visit using CPT code 99024
for at least half of these 90-day global procedures. Among this subset
of practitioners and procedures, we found that 87 percent of procedures
with 90-day global periods had one or more associated post-operative
visits. However, only 16 percent of procedures with a 10-day global
period had an associated postoperative visit reported using CPT code
99024. These findings suggest that post-operative visits following
procedures with 10-day global periods are not typically being furnished
rather than not being reported.
Under current policy, in cases where practitioners agree on the
transfer of care for the postoperative portion of the global period,
the surgeon bills only for the surgical care using modifier 54 ``for
surgical care only'' and the practitioner who furnishes the
postoperative care bills using modifier 55 ``postoperative management
only.'' The global surgery payment is then split between the two
practitioners. However, practitioners are not required to report these
modifiers unless there is a formal transfer of postoperative care. We
are also soliciting comments on whether we should consider requiring
use of the modifiers in cases where the surgeon does not expect to
perform the postoperative visits, regardless of whether or not the
transfer of care is formalized.
We are also seeking comment on the best approach to 10-day global
codes for which the preliminary data suggest that postoperative visits
are rarely performed by the practitioner reporting the global code.
That is, we are seeking comments on whether we should consider changing
the global period and reviewing the code valuation.
Finally, we note that claims-based data collection using CPT code
99024 is intended to collect information on the number of post-
operative visits but not the level of post-operative visits. We
anticipate beginning, in the near future, a separate survey-based data
collection effort on the level of post-operative visits including the
time, staff, and activities involved in furnishing post-operative
visits and non-face-to-face services. The survey component is intended
to address concerns from the physician community that information on
the number of visits alone cannot capture differences between
specialties, specific procedure codes, and setting in terms of the time
and effort spent on post-operative visits and non-face-to-face services
included in global periods.
RAND developed a survey that collects information on the time,
staff, and activities related to five post-operative visits furnished
by sampled practitioners. The CY 2017 PFS final rule (81 FR 80222)
described a sampling approach for the survey that would have collected
data on post-operative visits related to the full range of procedures
with 10-day and 90-day global periods using a stratified random sample
of approximately 5,000 practitioners. RAND piloted the post-operative
visit survey in a small subsample of practitioners and found a very low
response rate. This low response rate raised concerns that the survey
would not yield useful or representative information on post-operative
visits if the survey were fielded in the full sample.
In an effort to increase response rate and collect sufficient data
on the level of visits associated with at least some procedures with
10-day and 90-day global periods, we refocused the survey effort to
collect information on post-operative visits and non-face-to-face
services associated with a small number of high-volume procedure codes.
The survey sampling frame includes practitioners who perform above a
threshold volume of the selected high-volume procedure codes.
Practitioner participation in the survey-based data collection effort
is important to ensure that CMS collects useful and representative data
to understand the range of activities, staff, and time involved in
furnishing post-operative visits. Future survey-based data collection
may cover post-operative visits and non-face-to-face services
associated with a broader range of procedures with 10-day and 90-day
global periods.
[[Page 35738]]
F. Radiologist Assistants
In accordance with Sec. 410.32(b)(3), except as otherwise
provided, all diagnostic X-ray and other diagnostic tests covered under
section 1861(s)(3) of the Act and payable under the physician fee
schedule must be furnished under at least a general level of physician
supervision as defined in paragraph (b)(3)(i) of this regulation. In
addition, some of these tests require either direct or personal
supervision as defined in paragraph (b)(3)(ii) or (iii) of this
regulation, respectively. We list the required minimum physician
supervision level for each diagnostic X-ray and other diagnostic test
service along with the codes and relative values for these services in
the PFS Relative Value File, which is posted on the CMS website at
https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched/PFS-Relative-Value-Files.html. For most diagnostic
imaging procedures, this required physician supervision level applies
only to the technical component (TC) of the procedure.
In response to the Request for Information on CMS Flexibilities and
Efficiencies (RFI) that was issued in the CY 2018 PFS proposed rule (82
FR 34172 through 34173), many commenters recommended that we revise the
physician supervision requirements at Sec. 410.32(b) for diagnostic
tests with a focus on those that are typically furnished by a
radiologist assistant under the supervision of a physician.
Specifically, the commenters stated that all diagnostic tests, when
performed by radiologist assistants (RAs), can be furnished under
direct supervision rather than personal supervision of a physician, and
that we should revise the Medicare supervision requirements so that
when RAs conduct diagnostic imaging tests that would otherwise require
personal supervision, they only need to do so under direct supervision.
In addition to increasing efficiency, stakeholders suggested that the
current supervision requirements for certain diagnostic imaging
services unduly restrict RAs from conducting tests that they are
permitted to do under current law in many states.
After consideration of these comments on the RFI, as well as
information provided by stakeholders, we are proposing to revise our
regulations to specify that all diagnostic imaging tests may be
furnished under the direct supervision of a physician when performed by
an RA in accordance with state law and state scope of practice rules.
Stakeholders representing the radiology community have provided us with
information showing that the RA designation includes registered
radiologist assistants (RRAs) who are certified by The American
Registry of Radiologic Technologists, and radiology practitioner
assistants (RPAs) who are certified by the Certification Board for
Radiology Practitioner Assistants. We are proposing to revise our
regulation at Sec. 410.32 to add a new paragraph (b)(4) to state that
diagnostic tests performed by an RRA or an RPA require only a direct
level of physician supervision, when permitted by state law and state
scope of practice regulations. We note that for diagnostic imaging
tests requiring a general level of physician supervision, this proposal
would not change the level of physician supervision to direct
supervision. Otherwise, the diagnostic imaging tests must be performed
as specified elsewhere under Sec. 410.32(b). We based this proposal on
recommendations from the practitioner community which included specific
recommendations on how to implement the change. We received information
submitted by representatives of the practitioner community, including
information on the education and clinical experience of RAs, which we
took into consideration in determining if this proposal would pose a
significant risk to patient safety, and we determined that it would
not. In addition, we considered information provided by stakeholders
that indicates that 28 states have statutes or regulations that
recognize RAs, and these states have general or direct supervision
requirements for RAs.
G. Payment Rates Under the Medicare PFS for Nonexcepted Items and
Services Furnished by Nonexcepted Off-Campus Provider-Based Departments
of a Hospital
1. Background
Sections 1833(t)(1)(B)(v) and (t)(21) of the Act require that
certain items and services furnished by certain off-campus provider-
based departments (PBDs) (collectively referenced here as nonexcepted
items and services furnished by nonexcepted off-campus PBDs) shall not
be considered covered outpatient department services for purposes of
payment under the Hospital Outpatient Prospective Payment System
(OPPS), and payment for those nonexcepted items and services furnished
on or after January 1, 2017 shall be made under the applicable payment
system under Medicare Part B if the requirements for such payment are
otherwise met. These requirements were enacted in section 603 of the
Bipartisan Budget Act of 2015 (Pub. L. 114-74). In the CY 2017 OPPS/
Ambulatory Surgical Center (ASC) final rule with comment period (81 FR
79699 through 79719), we established several policies and provisions to
define the scope of nonexcepted items and services in nonexcepted off-
campus PBDs. We also finalized the PFS as the applicable payment system
for most nonexcepted items and services furnished by nonexcepted off-
campus PBDs. At the same time, we issued an interim final rule with
comment period (81 FR 79720 through 79729) in which we established
payment policies under the PFS for nonexcepted items and services
furnished on or after January 1, 2017. In the following paragraphs, we
summarize the policies that we adopted for CY 2017 and CY 2018, and we
propose payment policies for CY 2019. For issues related to the
excepted status of off-campus PBDs or the excepted status of items and
services, please see the CY 2019 OPPS/ASC proposed rule.
2. Payment Mechanism
In establishing the PFS as the applicable payment system for most
nonexcepted items and services in nonexcepted off-campus PBDs under
sections 1833(t)(1)(B)(v) and (t)(21) of the Act, we recognized that
there was no technological capability, at least in the near term, to
allow off-campus PBDs to bill under the PFS for those nonexcepted items
and services. Off-campus PBDs bill under the OPPS for their services on
an institutional claim, while physicians and other suppliers bill under
the PFS on a practitioner claim. The two systems that process these
different types of claims, the Fiscal Intermediary Standard System
(``FISS'') and the Multi-Carrier System (``MCS'') system, respectively,
were not designed to accept or process claims of a different type. To
permit an off-campus PBD to bill directly under a different payment
system than the OPPS would have required significant changes to these
complex systems as well as other systems involved in the processing of
Medicare Part B claims. Consequently, we proposed and finalized a
policy for CY 2017 and CY 2018 in which nonexcepted off-campus PBDs
continue to bill for nonexcepted items and services on the
institutional claim utilizing a new claim line modifier ``PN'' to
indicate that an item or service is a nonexcepted item or service.
We implemented requirements under section 1833(t)(1)(B) of the Act
for CY 2017 and CY 2018 by applying an overall downward scaling factor,
called
[[Page 35739]]
the PFS Relativity Adjuster to payments for nonexcepted items and
services furnished in nonexcepted off campus PBDs. The PFS Relativity
Adjuster generally reflects the average (weighted by claim line volume
times rate) of the site-specific rate under the PFS compared to the
rate under the OPPS (weighted by claim line volume times rate) for
nonexcepted items and services furnished in nonexcepted off-campus
PBDs. As we have discussed extensively in prior rulemaking (81 FR 97920
through 97929 and 82 FR 53021), we established a new set of site-
specific payment rates under the PFS that reflect the relative resource
cost of furnishing the technical component (TC) of services furnished
in nonexcepted off-campus PBDs. For the majority of HCPCS codes, these
rates are based on either (1) the difference between the PFS
nonfacility payment rate and the PFS facility rate, (2) the technical
component, or (3) in instances where payment would have been made only
to the facility or to the physician, the full nonfacility rate. The PFS
Relativity Adjuster refers to the percentage of the OPPS payment amount
paid under the PFS for a nonexcepted item or service to the nonexcepted
off-campus PBD.
To operationalize the PFS Relativity Adjuster as a mechanism to pay
for nonexcepted items and services furnished by nonexcepted off-campus
PBDs, we adopted the packaging payment rates and multiple procedure
payment reduction (MPPR) percentage that applies under the OPPS. We
also incorporated the claims processing logic that is used for payments
under the OPPS for comprehensive APCs (C-APCs), conditionally and
unconditionally packaged items and services, and major procedures. As
we noted in the CY 2017 interim final rule (82 FR 53024), we believe
that this maintains the integrity of the cost-specific relativity of
current payments under the OPPS compared with those under the PFS.
In CY 2017, we implemented a PFS Relativity Adjuster of 50 percent
of the OPPS rate for nonexcepted items and services furnished in
nonexcepted off-campus PBDs. For a detailed explanation of how we
developed the PFS Relativity Adjuster of 50 percent for CY 2017,
including assumptions and exclusions, we refer readers to the CY 2017
OPPS/ASC interim final rule with comment period (81 FR 79720 through
79729). Beginning for CY 2018, we adopted a PFS Relativity Adjuster of
40 percent of the OPPS rate. For a detailed explanation of how we
developed the PFS Relativity Adjuster of 40 percent, we refer readers
to the CY 2018 PFS final rule (82 FR 53019 through 53042). A brief
overview of the general approach we took for CY 2018 and how it differs
from the proposal for CY 2019 appears below.
3. The PFS Relativity Adjuster
The PFS Relativity Adjuster reflects the overall relativity of the
applicable payment rate for nonexcepted items and services furnished in
nonexcepted off-campus PBDs under the PFS compared with the rate under
the OPPS. To develop the PFS Relativity Adjuster for CY 2017, we did
not have all of the claims data needed to identify the mix of items and
services that would be billed using the ``PN'' modifier. Instead, we
analyzed hospital outpatient claims data from January 1 through August
25, 2016, that contained the ``PO'' modifier, which was a new mandatory
reporting requirement for CY 2016 for claims that were billed by an
off-campus department of a hospital. We limited our analysis to those
claims billed on the 13X Type of Bill because those claims were used
for Medicare Part B billing under the OPPS. We then identified the 25
most frequently billed major codes that were billed by claim line; that
is, items and services that were separately payable or conditionally
packaged. Specifically, we restricted our analysis to codes with OPPS
status indicators (SI) ``J1'', ``J2'', ``Q1'', ``Q2'', ``Q3'', ``S'',
``T'', or ``V''. The most frequently billed service with the ``PO''
modifier in CY 2016 was described by HCPCS code G0463 (Hospital
outpatient clinic visit for the assessment and management of a
patient), which, in CY 2016, was paid under APC 5012 at a rate of
$102.12; the total number of claim lines for this service was
approximately 6.7 million as of August 2016. Under the PFS, there are
ten CPT codes describing different levels of office visits for new and
established payments. We compared the payment rate under OPPS for G0463
($102.12) to the average of the difference between the nonfacility and
facility rates for CPT code 99213 (Level III office visit for an
established patient) and CPT code 99214 (Level IV office visit for an
established patient) in CY 2016 and found that the relative payment
difference was approximately 22 percent. We did not include HCPCS code
G0463 in our calculation of the PFS Relativity Adjuster for CY 2017
because we were concerned that there was no single, directly comparable
code under the PFS. As we stated in the CY 2017 interim final rule (81
FR 79723), we wanted to mitigate the risk of underestimating the
overall relativity between the PFS and OPPS rates. From the remaining
top 24 most frequently billed codes, we excluded HCPCS code 36591
(Collection of blood specimen from a completely implantable venous
access device) because, under PFS policies, the service was only
separately payable under the PFS when no other code was on the claim.
We also removed HCPCS code G0009 (Administration of Pneumococcal
Vaccine) because there was no payment for this code under the PFS. For
the remaining top 22 codes furnished with the ``PO'' modifier in CY
2016, the average (weighted by claim line volume times rate) of the
nonfacility payment rate estimate for the PFS compared to the estimate
for the OPPS was 45 percent. We indicated that, because of our
inability to estimate the effect of the packaging difference between
the OPPS and the PFS, we would assume a 5 percentage point adjustment
upward from the calculated amount of 45 percent; therefore, we
established the PFS Relativity Adjuster of 50 percent for CY 2017.
In establishing the PFS Relativity Adjuster for CY 2018, we still
did not have claims data for items and services furnished reported with
a ``PN'' modifier. However, we updated the list of the 25 most
frequently billed HCPCS codes using an entire year (CY 2016) of claims
data for services submitted with a ``PO'' modifier and we updated the
corresponding utilization weights for the codes used in the analysis.
The order and composition of the top 25 separately payable HCPCS codes,
based on the full year of claims from CY 2016 submitted with the ``PO''
modifier, changed minimally from the codes we used in our original
analysis for the CY 2017 OPPS/ASC interim final rule with comment
period. For a detailed list of the HCPCS codes we used in calculating
the CY 2017 PFS Relativity Adjuster and the CY 2018 PFS Relativity
Adjuster, we refer readers to the CY 2018 PFS final rule (82 FR 53030
through 53031). As noted earlier, in establishing the PFS Relativity
Adjuster of 50 percent for CY 2017, we did not include in the weighted
average code comparison, the relative rate for the most frequently
billed service furnished in off-campus PBDs, HCPCS code G0463 (Hospital
outpatient clinic visit for assessment and management of a patient), in
part to ensure that we were not underestimating the overall relativity
between the PFS and the OPPS. In contrast, in the CY 2018 PFS final
rule, we stated that our objective for CY 2018 was to ensure that we
did not overestimate the appropriate overall payment relativity, and
that the payment made to nonexcepted off-campus PBDs better aligned
with the
[[Page 35740]]
services that are most frequently furnished in the setting. Therefore,
in addition to using updated claims data, we revised the PFS Relativity
Adjuster to incorporate the relative payment rate for HCPCS code G0463
into our analysis. We followed all other exclusions and assumptions
that were made in calculating the CY 2017 PFS Relativity Adjuster. Our
analysis resulted in a 35 percent relative difference in payment rates.
Similar to our stated rationale in the CY 2017 PFS final rule, we
increased the PFS Relativity Adjuster to 40 percent, acknowledging the
difficulty of estimating the effect of the packaging differences
between the OPPS and the PFS.
4. Proposed Payment Policies for CY 2019
In prior rulemaking, we stated our expectation that our general
approach of adjusting OPPS payments using a single scaling factor, the
PFS Relativity Adjuster, would continue to be an appropriate payment
mechanism to implement provisions of section 603 of the Bipartisan
Budget Act of 2015, and would remain in place until we are able to
establish code-specific reductions that represent the technical
component of services furnished under the PFS or until we are able to
implement system changes needed to enable nonexcepted off-campus PBDs
to bill for nonexcepted items and services under the PFS directly (82
FR 53029). As we continue to explore alternative options related to
requirements under section 1833(t)(21)(C) of the Act, we believe that
this overall approach is still appropriate, and we are proposing to
continue to allow nonexcepted off-campus PBDs to bill for nonexcepted
items and services on an institutional claim using a ``PN'' modifier
until we identify a workable alternative mechanism that would improve
payment accuracy.
We made several adjustments to our methodology for calculating the
PFS Relativity Adjuster for CY 2019. Most importantly, we had access to
a full year of claims data from CY 2017 for services submitted with the
``PN'' modifier. Incorporating these data allows us to improve the
accuracy of the PFS Relativity Adjuster by accounting for the specific
mix of nonexcepted items and services furnished in nonexcepted off-
campus PBDs. In analyzing the CY 2017 claims data, we identified just
under 2,000 unique OPPS HCPCS/SI pairs reported in CY 2017 with status
indicators ``J1'', ``J2'', ``Q1'', ``Q2'', ``Q3'', ``S'', ``T'', or
``V''. The data reinforce our previous observation that the single most
frequently reported service furnished in nonexcepted off-campus PBDs is
HCPCS code G0463 (Hospital outpatient clinic visit for assessment and
management of a patient). Nearly half (49 percent) of all claim lines
for separately payable or conditionally packaged services furnished by
nonexcepted off-campus PBDs included HCPCS code G0463 in CY 2017,
representing 30 percent of total Medicare payments for separately
payable or conditionally packaged services. The top 30 HCPCS/SI
combinations accounted for 80 percent of all claim lines and
approximately 60 percent of Medicare payments for services that are
separately billable. In contrast with prior analyses, we also looked at
claims units, which reflects HCPCS/SI combinations that are billed more
than once on a claim line. Certain HCPCS codes are much more frequently
billed in multiple units than others. For instance, HCPCS code G0463,
which appears in nearly half of all claim lines, only represents eight
percent of all claims units with a SI for separately payable or
conditionally packaged services. The largest differences between the
number of claim lines and the number of claims units are for injections
and immunizations, which are not typically separately payable or
conditionally packaged under the OPPS. For instance, HCPCS code Q9967
(Low osmolar contrast material, 300-399 mg/ml iodine concentration, per
ml) was reported in 12,268 claim lines, but 1,168,393 times (claims
units) in the aggregate. HCPCS code Q9967 has an OPPS status indicator
of ``N'', meaning that there is no separate payment under OPPS (items
and services are packaged into APC rates).
To calculate the PFS Relativity Adjuster using the full range of
claims data submitted with a ``PN'' modifier in CY 2017, we first
established site-specific rates under the PFS that reflect the
technical component (TC) of items and services furnished by nonexcepted
off-campus PBDs in CY 2017. These HCPCS-level rates reflect our best
current estimate of the amount that would have been paid for the
service in the office setting under the PFS for practice expenses not
associated with the professional component of the service. As discussed
in prior rulemaking (81 FR 79720 through 79729), we believe the most
appropriate code-level comparison would reflect the technical component
(TC) of each HCPCS code under the PFS. However, we do not currently
calculate a separate TC rate for all HCPCS codes under the PFS--only
for those for which the professional component (PC) and TC of the
service are distinct and can be separately billed by two different
practitioners or other suppliers under the PFS. For most of the
remainder of services that do not have a separately payable TC under
the PFS, we estimated the site-specific rate as (1) the difference
between the PFS nonfacility rate and the PFS facility rate, or (2) in
instances where payment would have been made only to the facility or
only to the physician, the full nonfacility rate. As with the PFS rates
that we developed when calculating the PFS Relativity Adjuster for CY
2017 and CY 2018, there were large code-level differences between the
applicable PFS rate and the OPPS rate.
In calculating the proposed PFS Relativity Adjuster for CY 2019, we
employed the same fundamental methodology that we used to calculate the
PFS Relativity Adjuster for CY 2017 and CY 2018. We began by limiting
our analysis to the items and services billed in CY 2017 with a ``PN''
modifier that are separately payable or conditionally packaged under
the OPPS (SI = ``J1'', ``J2'', ``Q1'', ``Q2'', ``Q3'', ``S'', ``T'', or
``V'') and compared the rates for these codes under the OPPS with the
site-specific rates under the PFS. Next, we imputed PFS rates for a
limited number of items and services that are separately payable or
conditionally packaged under the OPPS but are contractor priced under
the PFS. We also imputed PFS rates for some HCPCS codes that are not
separately payable under the OPPS (SI = ``N''), but are separately
payable under the PFS. This includes items and services with an
indicator status of `X' under the PFS, which are statutorily excluded
from payment under the PFS, but may be paid under a different fee
schedule, such as the Clinical Lab Fee Schedule (CLFS). We summed the
HCPCS-level rates under the PFS across all nonexcepted items and
services, weighted by the number of HCPCS claims for each service.
Next, we calculated the sum of the HCPCS-level OPPS rate for items and
services that are separately payable or conditionally packaged, also
weighted by the number of HCPCS claims. We compared the weighted sum of
the site-specific PFS rate with the weighted sum of the OPPS rate for
items and services reported in CY 2017 and we found that our updated
analysis supports maintaining a PFS Relativity Adjuster of 40 percent.
In view of this analysis, we propose to continue applying a PFS
Relativity Adjuster of 40 percent for CY 2019. Moreover, we propose to
maintain this PFS Relativity Adjuster for future years
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until updated data or other considerations indicate that an alternative
adjuster or a change to our approach is warranted, which we would then
propose through notice and comment rulemaking. We discuss some of our
ongoing data analyses and future plans regarding implementation of
section 603 of the Bipartisan Budget Act of 2015 below.
5. Policies Related to Supervision, Beneficiary Cost-Sharing, and
Geographic Adjustments
In the CY 2018 PFS final rule (81FR 53019 through 53031), we
finalized policies related to supervision rules, beneficiary cost
sharing, and geographic adjustments. We finalized that supervision
rules in nonexcepted off-campus PBDs that furnish nonexcepted items and
services are the same as those that apply for hospitals, in general. We
also finalized that all beneficiary cost sharing rules that apply under
the PFS in accordance with sections 1848(g) and 1866(a)(2)(A) of the
Act continue to apply when payment is made under the PFS for
nonexcepted items and services furnished by nonexcepted off-campus
PBDs, regardless of cost sharing obligations under the OPPS. Lastly, we
finalized the policy to apply the same geographic adjustments used
under the OPPS to nonexcepted items and services furnished in
nonexcepted off-campus PBDs. We note that we are maintaining these
policies as finalized in CY 2018 PFS final rule.
6. Partial Hospitalization
a. Partial Hospitalization Services
Partial hospitalization programs (PHPs) are intensive outpatient
psychiatric day treatment programs furnished to patients as an
alternative to inpatient psychiatric hospitalization, or as a stepdown
to shorten an inpatient stay and transition a patient to a less
intensive level of care. Section 1861(ff)(3)(A) of the Act specifies
that a PHP is a program furnished by a hospital, to its outpatients, or
by a Community Mental Health Center (CMHC). In the CY 2017 OPPS/ASC
proposed rule (81 FR 45690), in the discussion of the proposed
implementation of section 603 of Bipartisan Budget Act of 2015, we
noted that because CMHCs also furnish PHP services and are ineligible
to be provider-based to a hospital, a nonexcepted off-campus PBD would
be eligible for PHP payment if the entity enrolls and bills as a CMHC
for payment under the OPPS. We further noted that a hospital may choose
to enroll a nonexcepted off-campus PBD as a CMHC, provided it meets all
Medicare requirements and conditions of participation.
Commenters expressed concern that without a clear payment mechanism
for PHP services furnished by nonexcepted off-campus PBDs, access to
partial hospitalization services would be limited, and pointed out the
critical role PHPs play in the continuum of mental health care. Many
commenters believed that the Congress did not intend for partial
hospitalization services to no longer be paid for by Medicare when such
services are furnished by nonexcepted off-campus PBDs. Several
commenters disagreed with the notion of enrolling as a CMHC in order to
receive payment for PHP services. These commenters stated that
hospital-based PHPs and CMHCs are inherently different in structure,
operation, and payment, and noted that the conditions of participation
for hospital departments and CMHCs are different. Several commenters
requested that CMS find a mechanism to pay hospital-based PHPs in
nonexcepted off-campus PBDs.
Because we shared the commenters' concerns, in the CY 2017 OPPS/ASC
final rule with comment period and interim final rule with comment
period (81 FR 79715, 79717, and 79727), we adopted payment for partial
hospitalization items and services furnished by nonexcepted off-campus
PBDs under the PFS. When billed in accordance with the CY 2017 interim
final rule, these partial hospitalization services are paid at the CMHC
per diem rate for APC 5853, for providing three or more partial
hospitalization services per day (81 FR 79727).
In the CY 2017 OPPS/ASC proposed rule (81 FR 45681), the CY 2017
OPPS/ASC final rule with comment period, and the interim final rule
with comment period (81 FR 79717 and 79727), we noted that when a
beneficiary receives outpatient services in an off-campus department of
a hospital, the total Medicare payment for those services is generally
higher than when those same services are provided in a physician's
office. Similarly, when partial hospitalization services are provided
in a hospital-based PHP, Medicare pays more than when those same
services are provided by a CMHC. Our rationale for adopting the CMHC
per diem rate for APC 5853 as the PFS payment amount for nonexcepted
off-campus PBDs providing PHP services is because CMHCs are
freestanding entities that are not part of a hospital, but they provide
the same PHP services as hospital-based PHPs (81 FR 79727). This is
similar to the differences between freestanding entities paid under the
PFS that furnish other services also provided by hospital-based
entities. Similar to other entities currently paid for their technical
component services under the PFS, we believe CMHCs would typically have
lower cost structures than hospital-based PHPs, largely due to lower
overhead costs and other indirect costs such as administration,
personnel, and security. We believe that paying for nonexcepted
hospital-based partial hospitalization services at the lower CMHC per
diem rate aligns with section 603 of Bipartisan Budget Act of 2015,
while also preserving access to PHP services. In addition, nonexcepted
off-campus PBDs will not be required to enroll as CMHCs in order to
bill and be paid for providing partial hospitalization services.
However, a nonexcepted off-campus PBD that wishes to provide PHP
services may still enroll as a CMHC if it chooses to do so and meets
the relevant requirements. Finally, we recognize that because hospital-
based PHPs are providing partial hospitalization services in the
hospital outpatient setting, they can offer benefits that CMHCs do not
have, such as an easier patient transition to and from inpatient care,
and easier sharing of health information between the PHP and the
inpatient staff.
In the CY 2018 PFS final rule, we did not require these PHPs to
enroll as CMHCs but instead we continued to pay nonexcepted off-campus
PBDs providing PHP items and services under the PFS. Further, in that
CY 2018 PFS final rule, we continued to adopt the CMHC per diem rate
for APC 5853 as the PFS payment amount for nonexcepted off-campus PBDs
providing three or more PHP services per day in CY 2018 (82 FR 53025 to
53026).
For CY 2019, we propose to continue to identify the PFS as the
applicable payment system for PHP services furnished by nonexcepted
off-campus PBDs, and propose to continue to set the PFS payment rate
for these PHP services as the per diem rate that would be paid to a
CMHC in CY 2019. We further propose to maintain these policies for
future years until updated data or other considerations indicate that a
change to our approach is warranted, which we would then propose
through notice and comment rulemaking.
7. Future Years
We continue to believe the amendments made by section 603 of the
Bipartisan Budget Act of 2015 were intended to eliminate the Medicare
payment incentive for hospitals to purchase physician offices, convert
them to off-campus PBDs, and bill
[[Page 35742]]
under the OPPS for items and services they furnish there. Therefore, we
continue to believe the payment policy under this provision should
ultimately equalize payment rates between nonexcepted off-campus PBDs
and physician offices to the greatest extent possible, while allowing
nonexcepted off-campus PBDs to bill in a straight-forward way for
services they furnish.
Under the proposed methodology for CY 2019 as described previously,
we use updated claims data for CY 2019, in combination with the
expanded number of site specific, technical component rates for
nonexcepted items and services furnished in nonexcepted off campus
PBDs, in order to ensure that Medicare payment to hospitals billing for
nonexcepted items and services furnished by nonexcepted off-campus PBDs
reflects the relative resources involved in furnishing the items and
services. We recognize that for certain specialties, service lines, and
nonexcepted off-campus PBD types, total Medicare payments for the same
services might be either higher or lower when furnished by a
nonexcepted off-campus PBD rather than in a physician office. We also
note that our approach adopts packaging rules and MPPR rules under the
OPPS.
As noted above, we intend to continue to examine the claims data in
order to assess whether a different PFS Relativity Adjuster is
warranted and also to consider whether additional adjustments to the
methodology are appropriate. In particular, we are monitoring claims
for shifts in the mix of services furnished in nonexcepted off campus
PBDs that may affect the relativity between the PFS and OPPS. An
increase over time in the share of nonexcepted items and services with
lower technical component rates under the PFS compared with APC rates
under the OPPS might result in a lower PFS Relativity Adjuster, for
example. We will also carefully assess annual payment policy updates to
the PFS and OPPS fee schedule rules, respectively, to identify changes
in overall relativity resulting from any new or modified policies such
as expanded packaging under the OPPS or an increase in the number of
HCPCS codes with global periods under the PFS. As part of these ongoing
efforts, we are also analyzing PFS claims data to identify patterns of
services furnished together on the same day. We anticipate that this
will ultimately allow us to make refinements to the PFS Relativity
Adjuster to better account for the more extensive packaging of services
under the OPPS and the potential underreporting of services that are
not separately payable under the OPPS but are paid separately under the
PFS.
Another dimension of our ongoing efforts to improve implementation
of section 603 of the Bipartisan Budget Act of 2015 is the development
and refinement of a new set of payment rates under the PFS that reflect
the relative resource costs of furnishing the technical component of
items and services furnished in nonexcepted off campus PBDs. Although
we believe that our site-specific HCPCS-level rates reflect the best
available estimate of the amount that would have been paid for the
service in the office setting under the PFS for practice expenses not
associated with the professional component of the service, for the
majority of HCPCS codes there is no established methodology for
separately valuing the resource costs incurred by a provider while
furnishing a service from those incurred exclusively by the facility in
which the service is furnished. We continue to explore alternatives to
our current estimates that would better reflect the TC of services
furnished in nonexcepted off campus PBDs. We are broadly interested in
stakeholder feedback and recommendations for ways in which CMS can
improve pricing and transparency with regard to the differences in the
payment rates across sites of service.
We expect that our continued analyses of claims data and our
ongoing exploration of systems changes that are needed to allow
nonexcepted off campus PBDs to bill directly for the TC portion of
nonexcepted items and services may lead us to consider a different
approach for implementing section 603 of the Bipartisan Budget Act of
2015. On the whole, however, we believe that the proposed PFS
Relativity Adjuster for CY 2019 of 40 percent would advance the effort
to equalize payment rates in the aggregate between physician offices
and nonexcepted off-campus PBDs. Maintaining our policy of applying an
overall scaling factor to OPPS payments allows hospitals to continue
billing through a facility claim form and permits continued use of the
packaging rules and cost report-based relative payment rate
determinations for nonexcepted services.
H. Valuation of Specific Codes
1. Background: Process for Valuing New, Revised, and Potentially
Misvalued Codes
Establishing valuations for newly created and revised CPT codes is
a routine part of maintaining the PFS. Since the inception of the PFS,
it has also been a priority to revalue services regularly to make sure
that the payment rates reflect the changing trends in the practice of
medicine and current prices for inputs used in the PE calculations.
Initially, this was accomplished primarily through the 5-year review
process, which resulted in revised work RVUs for CY 1997, CY 2002, CY
2007, and CY 2012, and revised PE RVUs in CY 2001, CY 2006, and CY
2011, and revised MP RVUs in CY 2010 and CY 2015. Under the 5-year
review process, revisions in RVUs were proposed and finalized via
rulemaking. In addition to the 5-year reviews, beginning with CY 2009,
CMS and the RUC identified a number of potentially misvalued codes each
year using various identification screens, as discussed in section
II.E. of this proposed rule. Historically, when we received RUC
recommendations, our process had been to establish interim final RVUs
for the potentially misvalued codes, new codes, and any other codes for
which there were coding changes in the final rule with comment period
for a year. Then, during the 60-day period following the publication of
the final rule with comment period, we accepted public comment about
those valuations. For services furnished during the calendar year
following the publication of interim final rates, we paid for services
based upon the interim final values established in the final rule. In
the final rule with comment period for the subsequent year, we
considered and responded to public comments received on the interim
final values, and typically made any appropriate adjustments and
finalized those values.
In the CY 2015 PFS final rule with comment period, we finalized a
new process for establishing values for new, revised and potentially
misvalued codes. Under the new process, we include proposed values for
these services in the proposed rule, rather than establishing them as
interim final in the final rule with comment period. Beginning with the
CY 2017 PFS proposed rule, the new process was applicable to all codes,
except for new codes that describe truly new services. For CY 2017, we
proposed new values in the CY 2017 PFS proposed rule for the vast
majority of new, revised, and potentially misvalued codes for which we
received complete RUC recommendations by February 10, 2016. To complete
the transition to this new process, for codes for which we established
interim final values in the CY 2016 PFS final rule with comment period,
we reviewed the comments received during the 60-day public comment
period following release of the
[[Page 35743]]
CY 2016 PFS final rule with comment period, and re-proposed values for
those codes in the CY 2017 PFS proposed rule.
We considered public comments received during the 60-day public
comment period for the proposed rule before establishing final values
in the CY 2017 PFS final rule. As part of our established process, we
will adopt interim final values only in the case of wholly new services
for which there are no predecessor codes or values and for which we do
not receive recommendations in time to propose values. For CY 2017, we
did not identify any new codes that described such wholly new services.
Therefore, we did not establish any code values on an interim final
basis.
For CY 2018, we generally proposed the RUC-recommended work RVUs
for new, revised, and potentially misvalued codes. We proposed these
values based on our understanding that the RUC generally considers the
kinds of concerns we historically raised regarding appropriate
valuation of work RVUs. However, during our review of these recommended
values, we identified some concerns similar to those we recognized in
prior years. Given the relative nature of the PFS and our obligation to
ensure that the RVUs reflect relative resource use, we included
descriptions of potential alternative approaches we might have taken in
developing work RVUs that differed from the RUC-recommended values. We
sought comment on both the RUC-recommended values, as well as the
alternatives considered. Several commenters generally supported the
proposed use of the RUC-recommended work RVUs, without refinement.
Other commenters expressed concern about the effect of the misvalued
code reviews on particular specialties and settings and disappointment
with our proposed approach for valuing codes for CY 2018. A detailed
summary of the comments and our responses can be found in the CY 2018
PFS final rule (82 FR 53033-53035).
We clarified in response to commenters that we are not
relinquishing our obligation to independently establish appropriate
RVUs for services paid under the PFS. We will continue to thoroughly
review and consider information we receive from the RUC, the Health
Care Professionals Advisory Committee (HCPAC), public commenters,
medical literature, Medicare claims data, comparative databases,
comparison with other codes within the PFS, as well as consultation
with other physicians and healthcare professionals within CMS and the
federal government as part of our process for establishing valuations.
While generally proposing the RUC-recommended work RVUs for new,
revised, and potentially misvalued codes was our approach for CY 2018,
we note that we also included alternative values where we believed
there was a possible opportunity for increased precision. We also
clarified that as part of our obligation to establish RVUs for the PFS,
we annually make an independent assessment of the available
recommendations, supporting documentation, and other available
information from the RUC and other commenters to determine the
appropriate valuations. Where we concur that the RUC's recommendations,
or recommendations from other commenters, are reasonable and
appropriate and are consistent with the time and intensity paradigm of
physician work, we propose those values as recommended. Additionally,
we will continue to engage with stakeholders, including the RUC, with
regard to our approach for accurately valuing codes, and as we
prioritize our obligation to value new, revised, and potentially
misvalued codes. We continue to welcome feedback from all interested
parties regarding valuation of services for consideration through our
rulemaking process.
2. Methodology for Establishing Work RVUs
For each code identified in this section, we conducted a review
that included the current work RVU (if any), RUC-recommended work RVU,
intensity, time to furnish the preservice, intraservice, and
postservice activities, as well as other components of the service that
contribute to the value. Our reviews of recommended work RVUs and time
inputs generally included, but had not been limited to, a review of
information provided by the RUC, the HCPAC, and other public
commenters, medical literature, and comparative databases, as well as a
comparison with other codes within the PFS, consultation with other
physicians and health care professionals within CMS and the federal
government, as well as Medicare claims data. We also assessed the
methodology and data used to develop the recommendations submitted to
us by the RUC and other public commenters and the rationale for the
recommendations. In the CY 2011 PFS final rule with comment period (75
FR 73328 through 73329), we discussed a variety of methodologies and
approaches used to develop work RVUs, including survey data, building
blocks, crosswalks to key reference or similar codes, and magnitude
estimation (see the CY 2011 PFS final rule with comment period (75 FR
73328 through 73329) for more information). When referring to a survey,
unless otherwise noted, we mean the surveys conducted by specialty
societies as part of the formal RUC process.
Components that we used in the building block approach may have
included preservice, intraservice, or postservice time and post-
procedure visits. When referring to a bundled CPT code, the building
block components could include the CPT codes that make up the bundled
code and the inputs associated with those codes. We used the building
block methodology to construct, or deconstruct, the work RVU for a CPT
code based on component pieces of the code. Magnitude estimation refers
to a methodology for valuing work that determines the appropriate work
RVU for a service by gauging the total amount of work for that service
relative to the work for a similar service across the PFS without
explicitly valuing the components of that work. In addition to these
methodologies, we frequently utilized an incremental methodology in
which we value a code based upon its incremental difference between
another code and another family of codes. The statute specifically
defines the work component as the resources in time and intensity
required in furnishing the service. Also, the published literature on
valuing work has recognized the key role of time in overall work. For
particular codes, we refined the work RVUs in direct proportion to the
changes in the best information regarding the time resources involved
in furnishing particular services, either considering the total time or
the intraservice time.
Several years ago, to aid in the development of preservice time
recommendations for new and revised CPT codes, the RUC created
standardized preservice time packages. The packages include preservice
evaluation time, preservice positioning time, and preservice scrub,
dress and wait time. Currently, there are preservice time packages for
services typically furnished in the facility setting (for example,
preservice time packages reflecting the different combinations of
straightforward or difficult procedure, and straightforward or
difficult patient). Currently, there are three preservice time packages
for services typically furnished in the nonfacility setting.
We developed several standard building block methodologies to value
services appropriately when they have common billing patterns. In cases
where
[[Page 35744]]
a service is typically furnished to a beneficiary on the same day as an
evaluation and management (E/M) service, we believe that there is
overlap between the two services in some of the activities furnished
during the preservice evaluation and postservice time. Our longstanding
adjustments have reflected a broad assumption that at least one-third
of the work time in both the preservice evaluation and postservice
period is duplicative of work furnished during the E/M visit.
Accordingly, in cases where we believed that the RUC has not
adequately accounted for the overlapping activities in the recommended
work RVU and/or times, we adjusted the work RVU and/or times to account
for the overlap. The work RVU for a service is the product of the time
involved in furnishing the service multiplied by the intensity of the
work. Preservice evaluation time and postservice time both have a long-
established intensity of work per unit of time (IWPUT) of 0.0224, which
means that 1 minute of preservice evaluation or postservice time
equates to 0.0224 of a work RVU.
Therefore, in many cases when we removed 2 minutes of preservice
time and 2 minutes of postservice time from a procedure to account for
the overlap with the same day E/M service, we also removed a work RVU
of 0.09 (4 minutes x 0.0224 IWPUT) if we did not believe the overlap in
time had already been accounted for in the work RVU. The RUC has
recognized this valuation policy and, in many cases, now addresses the
overlap in time and work when a service is typically furnished on the
same day as an E/M service.
The following paragraphs contain a general discussion of our
approach to reviewing RUC recommendations and developing proposed
values for specific codes. When they exist we also include a summary of
stakeholder reactions to our approach. We note that many commenters and
stakeholders have expressed concerns over the years with our ongoing
adjustment of work RVUs based on changes in the best information we had
regarding the time resources involved in furnishing individual
services. We have been particularly concerned with the RUC's and
various specialty societies' objections to our approach given the
significance of their recommendations to our process for valuing
services and since much of the information we used to make the
adjustments is derived from their survey process. We are obligated
under the statute to consider both time and intensity in establishing
work RVUs for PFS services. As explained in the CY 2016 PFS final rule
with comment period (80 FR 70933), we recognize that adjusting work
RVUs for changes in time is not always a straightforward process, so we
have applied various methodologies to identify several potential work
values for individual codes.
We have observed that for many codes reviewed by the RUC,
recommended work RVUs have appeared to be incongruous with recommended
assumptions regarding the resource costs in time. This has been the
case for a significant portion of codes for which we recently
established or proposed work RVUs that are based on refinements to the
RUC-recommended values. When we have adjusted work RVUs to account for
significant changes in time, we have started by looking at the change
in the time in the context of the RUC-recommended work RVU. When the
recommended work RVUs do not appear to account for significant changes
in time, we have employed the different approaches to identify
potential values that reconcile the recommended work RVUs with the
recommended time values. Many of these methodologies, such as survey
data, building block, crosswalks to key reference or similar codes, and
magnitude estimation have long been used in developing work RVUs under
the PFS. In addition to these, we sometimes used the relationship
between the old time values and the new time values for particular
services to identify alternative work RVUs based on changes in time
components.
In so doing, rather than ignoring the RUC-recommended value, we
have used the recommended values as a starting reference and then
applied one of these several methodologies to account for the
reductions in time that we believe were not otherwise reflected in the
RUC-recommended value. If we believed that such changes in time were
already accounted for in the RUC's recommendation, then we did not made
such adjustments. Likewise, we did not arbitrarily apply time ratios to
current work RVUs to calculate proposed work RVUs. We used the ratios
to identify potential work RVUs and considered these work RVUs as
potential options relative to the values developed through other
options.
We do not imply that the decrease in time as reflected in survey
values should always equate to a one-to-one or linear decrease in newly
valued work RVUs. Instead, we have believed that, since the two
components of work are time and intensity, absent an obvious or
explicitly stated rationale for why the relative intensity of a given
procedure has increased, significant decreases in time should be
reflected in decreases to work RVUs. If the RUC's recommendation has
appeared to disregard or dismiss the changes in time, without a
persuasive explanation of why such a change should not be accounted for
in the overall work of the service, then we have generally used one of
the aforementioned methodologies to identify potential work RVUs,
including the methodologies intended to account for the changes in the
resources involved in furnishing the procedure.
Several stakeholders, including the RUC, have expressed general
objections to our use of these methodologies and deemed our actions in
adjusting the recommended work RVUs as inappropriate; other
stakeholders have also expressed general concerns with CMS refinements
to RUC recommended values in general. In the CY 2017 PFS final rule (81
FR 80272 through 80277) we responded in detail to several comments that
we received regarding this issue. In the CY 2017 PFS proposed rule, we
requested comments regarding potential alternatives to making
adjustments that would recognize overall estimates of work in the
context of changes in the resource of time for particular services;
however, we did not receive any specific potential alternatives. As
described earlier in this section, crosswalks to key reference or
similar codes is one of the many methodological approaches we have
employed to identify potential values that reconcile the RUC-recommend
work RVUs with the recommended time values when the RUC-recommended
work RVUs did not appear to account for significant changes in time.
We look forward to continuing to engage with stakeholders and
commenters, including the RUC, as we prioritize our obligation to value
new, revised, and potentially misvalued codes, and will continue to
welcome feedback from all interested parties regarding valuation of
services for consideration through our rulemaking process. We refer
readers to section II.H.4 of this proposed rule for a detailed
discussion of the proposed valuation, and alternative valuation
considered for specific codes. Table 13 contains a list of codes for
which we propose work RVUs; this includes all codes for which we
received RUC recommendations by February 10, 2018. The proposed work
RVUs, work time and other payment information for all proposed CY 2019
payable codes are available on the CMS website under downloads for the
CY 2019 PFS proposed rule. Table 13 also contains
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the CPT code descriptors for all proposed, new, revised, and
potentially misvalued codes discussed in this section.
3. Methodology for the Direct PE Inputs To Develop PE RVUs
a. Background
On an annual basis, the RUC provides us with recommendations
regarding PE inputs for new, revised, and potentially misvalued codes.
We review the RUC-recommended direct PE inputs on a code by code basis.
Like our review of recommended work RVUs, our review of recommended
direct PE inputs generally includes, but is not limited to, a review of
information provided by the RUC, HCPAC, and other public commenters,
medical literature, and comparative databases, as well as a comparison
with other codes within the PFS, and consultation with physicians and
health care professionals within CMS and the federal government, as
well as Medicare claims data. We also assess the methodology and data
used to develop the recommendations submitted to us by the RUC and
other public commenters and the rationale for the recommendations. When
we determine that the RUC's recommendations appropriately estimate the
direct PE inputs (clinical labor, disposable supplies, and medical
equipment) required for the typical service, are consistent with the
principles of relativity, and reflect our payment policies, we use
those direct PE inputs to value a service. If not, we refine the
recommended PE inputs to better reflect our estimate of the PE
resources required for the service. We also confirm whether CPT codes
should have facility and/or nonfacility direct PE inputs and refine the
inputs accordingly.
Our review and refinement of RUC-recommended direct PE inputs
includes many refinements that are common across codes, as well as
refinements that are specific to particular services. Table 14 details
our refinements of the RUC's direct PE recommendations at the code-
specific level. In this proposed rule, we address several refinements
that are common across codes, and refinements to particular codes are
addressed in the portions of this section that are dedicated to
particular codes. We note that for each refinement, we indicate the
impact on direct costs for that service. We note that, on average, in
any case where the impact on the direct cost for a particular
refinement is $0.30 or less, the refinement has no impact on the PE
RVUs. This calculation considers both the impact on the direct portion
of the PE RVU, as well as the impact on the indirect allocator for the
average service. We also note that nearly half of the refinements
listed in Table 14 result in changes under the $0.30 threshold and are
unlikely to result in a change to the RVUs.
We also note that the proposed direct PE inputs for CY 2019 are
displayed in the CY 2019 direct PE input database, available on the CMS
website under the downloads for the CY 2019 PFS proposed rule at http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched/PFS-Federal-Regulation-Notices.html. The inputs
displayed there have been used in developing the proposed CY 2019 PE
RVUs as displayed in Addendum B.
b. Common Refinements
(1) Changes in Work Time
Some direct PE inputs are directly affected by revisions in work
time. Specifically, changes in the intraservice portions of the work
time and changes in the number or level of postoperative visits
associated with the global periods result in corresponding changes to
direct PE inputs. The direct PE input recommendations generally
correspond to the work time values associated with services. We believe
that inadvertent discrepancies between work time values and direct PE
inputs should be refined or adjusted in the establishment of proposed
direct PE inputs to resolve the discrepancies.
(2) Equipment Time
Prior to CY 2010, the RUC did not generally provide CMS with
recommendations regarding equipment time inputs. In CY 2010, in the
interest of ensuring the greatest possible degree of accuracy in
allocating equipment minutes, we requested that the RUC provide
equipment times along with the other direct PE recommendations, and we
provided the RUC with general guidelines regarding appropriate
equipment time inputs. We appreciate the RUC's willingness to provide
us with these additional inputs as part of its PE recommendations.
In general, the equipment time inputs correspond to the service
period portion of the clinical labor times. We clarified this principle
over several years of rulemaking, indicating that we consider equipment
time as the time within the intraservice period when a clinician is
using the piece of equipment plus any additional time that the piece of
equipment is not available for use for another patient due to its use
during the designated procedure. For those services for which we
allocate cleaning time to portable equipment items, because the
portable equipment does not need to be cleaned in the room where the
service is furnished, we do not include that cleaning time for the
remaining equipment items, as those items and the room are both
available for use for other patients during that time. In addition,
when a piece of equipment is typically used during follow-up
postoperative visits included in the global period for a service, the
equipment time would also reflect that use.
We believe that certain highly technical pieces of equipment and
equipment rooms are less likely to be used during all of the preservice
or postservice tasks performed by clinical labor staff on the day of
the procedure (the clinical labor service period) and are typically
available for other patients even when one member of the clinical staff
may be occupied with a preservice or postservice task related to the
procedure. We also note that we believe these same assumptions would
apply to inexpensive equipment items that are used in conjunction with
and located in a room with non-portable highly technical equipment
items since any items in the room in question would be available if the
room is not being occupied by a particular patient. For additional
information, we refer readers to our discussion of these issues in the
CY 2012 PFS final rule with comment period (76 FR 73182) and the CY
2015 PFS final rule with comment period (79 FR 67639).
(3) Standard Tasks and Minutes for Clinical Labor Tasks
In general, the preservice, intraservice, and postservice clinical
labor minutes associated with clinical labor inputs in the direct PE
input database reflect the sum of particular tasks described in the
information that accompanies the RUC-recommended direct PE inputs,
commonly called the ``PE worksheets.'' For most of these described
tasks, there is a standardized number of minutes, depending on the type
of procedure, its typical setting, its global period, and the other
procedures with which it is typically reported. The RUC sometimes
recommends a number of minutes either greater than or less than the
time typically allotted for certain tasks. In those cases, we review
the deviations from the standards and any rationale provided for the
deviations. When we do not accept the RUC-recommended exceptions, we
refine the proposed direct PE inputs to conform to the standard times
for those tasks. In addition, in cases when a service is typically
billed with an E/M service, we remove the preservice
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clinical labor tasks to avoid duplicative inputs and to reflect the
resource costs of furnishing the typical service.
We refer readers to section II.B. of this proposed rule for more
information regarding the collaborative work of CMS and the RUC in
improvements in standardizing clinical labor tasks.
(4) Recommended Items That Are Not Direct PE Inputs
In some cases, the PE worksheets included with the RUC's
recommendations include items that are not clinical labor, disposable
supplies, or medical equipment or that cannot be allocated to
individual services or patients. We addressed these kinds of
recommendations in previous rulemaking (78 FR 74242), and we do not use
items included in these recommendations as direct PE inputs in the
calculation of PE RVUs.
(5) New Supply and Equipment Items
The RUC generally recommends the use of supply and equipment items
that already exist in the direct PE input database for new, revised,
and potentially misvalued codes. Some recommendations, however, include
supply or equipment items that are not currently in the direct PE input
database. In these cases, the RUC has historically recommended that a
new item be created and has facilitated our pricing of that item by
working with the specialty societies to provide us copies of sales
invoices. For CY 2019, we received invoices for several new supply and
equipment items. Tables 15 and 16 detail the invoices received for new
and existing items in the direct PE database. As discussed in section
II.B. of this proposed rule, we encourage stakeholders to review the
prices associated with these new and existing items to determine
whether these prices appear to be accurate. Where prices appear
inaccurate, we encourage stakeholders to submit invoices or other
information to improve the accuracy of pricing for these items in the
direct PE database during the 60-day public comment period for this
proposed rule. We expect that invoices received outside of the public
comment period would be submitted by February 10th of the following
year for consideration in future rulemaking, similar to our new process
for consideration of RUC recommendations.
We remind stakeholders that due to the relativity inherent in the
development of RVUs, reductions in existing prices for any items in the
direct PE database increase the pool of direct PE RVUs available to all
other PFS services. Tables 15 and 16 also include the number of
invoices received and the number of nonfacility allowed services for
procedures that use these equipment items. We provide the nonfacility
allowed services so that stakeholders will note the impact the
particular price might have on PE relativity, as well as to identify
items that are used frequently, since we believe that stakeholders are
more likely to have better pricing information for items used more
frequently. A single invoice may not be reflective of typical costs and
we encourage stakeholders to provide additional invoices so that we
might identify and use accurate prices in the development of PE RVUs.
In some cases, we do not use the price listed on the invoice that
accompanies the recommendation because we identify publicly available
alternative prices or information that suggests a different price is
more accurate. In these cases, we include this in the discussion of
these codes. In other cases, we cannot adequately price a newly
recommended item due to inadequate information. Sometimes, no
supporting information regarding the price of the item has been
included in the recommendation. In other cases, the supporting
information does not demonstrate that the item has been purchased at
the listed price (for example, vendor price quotes instead of paid
invoices). In cases where the information provided on the item allows
us to identify clinically appropriate proxy items, we might use
existing items as proxies for the newly recommended items. In other
cases, we included the item in the direct PE input database without any
associated price. Although including the item without an associated
price means that the item does not contribute to the calculation of the
proposed PE RVU for particular services, it facilitates our ability to
incorporate a price once we obtain information and are able to do so.
(6) Service Period Clinical Labor Time in the Facility Setting
Generally speaking, our proposed inputs do not include clinical
labor minutes assigned to the service period because the cost of
clinical labor during the service period for a procedure in the
facility setting is not considered a resource cost to the practitioner
since Medicare makes separate payment to the facility for these costs.
We address proposed code-specific refinements to clinical labor in the
individual code sections.
(7) Procedures Subject to the Multiple Procedure Payment Reduction
(MPPR) and the OPPS Cap
We note that the public use files for the PFS proposed and final
rules for each year display both the services subject to the MPPR lists
on diagnostic cardiovascular services, diagnostic imaging services,
diagnostic ophthalmology services, and therapy services. We also
include a list of procedures that meet the definition of imaging under
section 1848(b)(4)(B) of the Act, and therefore, are subject to the
OPPS cap for the upcoming calendar year. The public use files for CY
2019 are available on the CMS website under downloads for the CY 2019
PFS proposed rule at http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched/PFS-Federal-Regulation-Notices.html.
For more information regarding the history of the MPPR policy, we refer
readers to the CY 2014 PFS final rule with comment period (78 FR 74261-
74263). For more information regarding the history of the OPPS cap, we
refer readers to the CY 2007 PFS final rule with comment period (71 FR
69659-69662).
4. Proposed Valuation of Specific Codes for CY 2019
(1) Fine Needle Aspiration (CPT Codes 10021, 10X11, 10X12, 10X13,
10X14, 10X15, 10X16, 10X17, 10X18, 10X19, 76492, 77002 and 77021)
CPT code 10021 was identified as part of the OPPS cap payment
proposal in CY 2014 (78 FR 74246-74248), and it was reviewed by the RUC
for direct PE inputs only as part of the CY 2016 rule cycle.
Afterwards, CPT codes 10021 and 10022 were referred to the CPT
Editorial Panel to consider adding additional clarifying language to
the code descriptors and to include bundled imaging guidance due to the
fact that imaging had become typical with these services. In June 2017,
the CPT Editorial Panel deleted CPT code 10022, revised CPT code 10021,
and created nine new codes to describe fine needle aspiration
procedures with and without imaging guidance. These ten codes were
surveyed and reviewed for the October 2017 and January 2018 RUC
meetings. Several imaging services were also reviewed along with the
rest of the code family, although only CPT code 77021 was subject to a
new survey.
For CY 2019, we are proposing the RUC-recommended work RVU for
seven of the ten codes in this family. Specifically, we are proposing a
work RVU of 0.80 for CPT code 10X11 (Fine needle aspiration biopsy;
without
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imaging guidance; each additional lesion), a work RVU of 1.00 for CPT
code 10X13 (Fine needle aspiration biopsy, including ultrasound
guidance; each additional lesion), a work RVU of 1.81 for CPT code
10X14 (Fine needle aspiration biopsy, including fluoroscopic guidance;
first lesion), a work RVU of 1.18 for CPT code 10X15 (Fine needle
aspiration biopsy, including fluoroscopic guidance; each additional
lesion), and a work RVU of 1.65 for CPT code 10X17 (Fine needle
aspiration biopsy, including CT guidance; each additional lesion). We
are also proposing to assign the recommended contractor-priced status
to CPT codes 10X18 (Fine needle aspiration biopsy, including MR
guidance; first lesion) and 10X19 (Fine needle aspiration biopsy,
including MR guidance; each additional lesion) due to low utilization
until these services are more widely utilized. In addition, we are
proposing the recommended work RVU of 1.50 for CPT code 77021 (Magnetic
resonance guidance for needle placement (e.g., for biopsy, fine needle
aspiration biopsy, injection, or placement of localization device)
radiological supervision and interpretation), as well as proposing to
reaffirm the current work RVUs of 0.67 for CPT code 76942 (Ultrasonic
guidance for needle placement (e.g., biopsy, fine needle aspiration
biopsy, injection, localization device), imaging supervision and
interpretation) and 0.54 for 77002 (Fluoroscopic guidance for needle
placement (e.g., biopsy, fine needle aspiration biopsy, injection,
localization device)).
We disagree with the RUC-recommended work RVU of 1.20 for CPT code
10021 (Fine needle aspiration biopsy; without imaging guidance; first
lesion) and are proposing a work RVU of 1.03 based on a direct
crosswalk to CPT code 36440 (Push transfusion, blood, 2 years or
younger). CPT code 36440 is a recently reviewed code with the same
intraservice time of 15 minutes and 2 additional minutes of total time.
In reviewing CPT code 10021, we noted that the recommended intraservice
time is decreasing from 17 minutes to 15 minutes (12 percent
reduction), and the recommended total time is decreasing from 48
minutes to 33 minutes (32 percent reduction); however, the RUC-
recommended work RVU is only decreasing from 1.27 to 1.20, which is a
reduction of just over 5 percent. Although we do not imply that the
decrease in time as reflected in survey values must equate to a one-to-
one or linear decrease in the valuation of work RVUs, we believe that
since the two components of work are time and intensity, significant
decreases in time should be appropriately reflected in decreases to
work RVUs. In the case of CPT code 10021, we believe that it would be
more accurate to propose a work RVU of 1.03 based on a crosswalk to CPT
code 36440 to account for these decreases in the surveyed work time.
We disagree with the RUC-recommended work RVU of 1.63 for CPT code
10X12 (Fine needle aspiration biopsy, including ultrasound guidance;
first lesion) and are proposing a work RVU of 1.46. Although we
disagree with the RUC-recommended work RVU, we concur that the relative
difference in work between CPT codes 10021 and 10X12 is equivalent to
the recommended interval of 0.43 RVUs. Therefore, we are proposing a
work RVU of 1.46 for CPT code 10X12, based on the recommended interval
of 0.43 additional RVUs above our proposed work RVU of 1.03 for CPT
code 10021. The proposed increment of 0.43 RVUs above CPT code 10021 is
also based on the use of two crosswalk codes: CPT code 99225
(Subsequent observation care, per day, for the evaluation and
management of a patient, which requires at least 2 of 3 key
components); and CPT code 99232 (Subsequent hospital care, per day, for
the evaluation and management of a patient, which requires at least 2
of 3 key components). Both of these codes have the same intraservice
time and 1 additional minute of total time as compared with CPT code
10X12, and both crosswalk codes share a work RVU of 1.39.
We disagree with the RUC-recommended work RVU of 2.43 for CPT code
10X16 (Fine needle aspiration biopsy, including CT guidance; first
lesion) and we are proposing a work RVU of 2.26. Although we disagree
with the RUC-recommended work RVU, we concur that the relative
difference in work between CPT codes 10021 and 10X16 is equivalent to
the recommended interval of 1.23 RVUs. Therefore, we are proposing a
work RVU of 2.26 for CPT code 10X16, based on the recommended interval
of 1.23 additional RVUs above our proposed work RVU of 1.03 for CPT
code 10021. The proposed use of the recommended increment from CPT code
10021 is also based on the use of a crosswalk to CPT code 74263
(Computed tomographic (CT) colonography, screening, including image
postprocessing), another CT procedure with 38 minutes of intraservice
time and 50 minutes of total time at a work RVU of 2.28.
We note that the recommended work pool is increasing by
approximately 20 percent for the Fine Needle Aspiration family as a
whole, while the recommended work time pool for the same codes is only
increasing by about 2 percent. Since time is defined as one of the two
components of work, we believe that this indicates a discrepancy in the
recommended work values. We do not believe that the recoding of the
services in this family has resulted in an increase in their intensity,
only a change in the way in which they will be reported, and therefore,
we do not believe that it would serve the interests of relativity to
propose the recommended work values for all of the codes in this
family. We believe that, generally speaking, the recoding of a family
of services should maintain the same total work pool, as the services
themselves are not changing, only the coding structure under which they
are being reported. We also note that through the bundling of some of
these frequently reported services, it is reasonable to expect that the
new coding system will achieve savings via elimination of duplicative
assumptions of the resources involved in furnishing particular
servicers. For example, a practitioner would not be carrying out the
full preservice work twice for CPT codes 10022 and 76942, but
preservice times were assigned to both of the codes under the old
coding. We believe the new coding assigns more accurate work times and
thus reflects efficiencies in resource costs that existed regardless of
how the services were previously reported.
For the direct PE inputs, we are proposing to refine the clinical
labor time for the ``Prepare room, equipment and supplies'' (CA013)
activity to 3 minutes and to refine the clinical labor time for the
``Confirm order, protocol exam'' (CA014) activity to 0 minutes for CPT
code 77021. This code did not previously have clinical labor time
assigned for the ``Confirm order, protocol exam'' clinical labor task,
and we do not have any reason to believe that the services being
furnished by the clinical staff have changed, only the way in which
this clinical labor time has been presented on the PE worksheets. We
also note that there is no effect on the total clinical labor direct
costs in these situations, since the same 3 minutes of clinical labor
time is still being furnished. We are also proposing to refine the
equipment times in accordance with our standard equipment time
formulas.
(2) Biopsy of Nail (CPT Code 11755)
CPT code 11755 (Biopsy of nail unit (e.g., plate, bed, matrix,
hyponychium, proximal and lateral nail folds) (separate procedure)) was
identified as potentially
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misvalued on a screen of 0-day global services reported with an E/M
visit 50 percent of the time or more, on the same day of service by the
same patient and the same practitioner, that have not been reviewed in
the last 5 years with Medicare utilization greater than 20,000. For CY
2019, the HCPAC recommended a work RVU of 1.25 based on the survey
median value.
We disagree with the recommended value and are proposing a work RVU
of 1.08 for CPT code 11755 based on the survey 25th percentile value.
We note that the recommended intraservice time for CPT code 11755 is
decreasing from 25 minutes to 15 minutes (40 percent reduction), and
the recommended total time for CPT code 11755 is decreasing from 55
minutes to 39 minutes (29 percent reduction); however, the recommended
work RVU is only decreasing from 1.31 to 1.25, which is a reduction of
less than 5 percent. Although we do not imply that the decrease in time
as reflected in survey values must equate to a one-to-one or linear
decrease in the valuation of work RVUs, we believe that since the two
components of work are time and intensity, significant decreases in
time should be reflected in decreases to work RVUs. In the case of CPT
code 11755, we believe that it would be more accurate to propose the
survey 25th percentile work RVU than the survey median to account for
these decreases in the surveyed work time.
The proposed work RVU of 1.08 is also based on a crosswalk to CPT
code 11042 (Debridement, subcutaneous tissue (includes epidermis and
dermis, if performed); first 20 sq cm or less), which has a work RVU of
1.01, the same intraservice time of 15 minutes, and a similar total
time of 36 minutes. We also note that, generally speaking, working with
extremities like nails tends to be less intensive in clinical terms
than other services, especially as compared to surgical procedures. We
believe that this further supports our proposal of a work RVU of 1.08
for CPT code 11755.
We are proposing to refine the equipment times in accordance with
our standard equipment time formulas.
(3) Skin Biopsy (CPT Codes 11X02, 11X03, 11X04, 11X05, 11X06, and
11X07)
In CY 2016, CPT codes 11100 (Biopsy of skin, subcutaneous tissue
and/or mucous membrane (including simple closure), unless otherwise
listed; single lesion) and 11101 (Biopsy of skin, subcutaneous tissue
and/or mucous membrane (including simple closure), unless otherwise
listed; each separate/additional lesion) were identified as potentially
misvalued using a high expenditure services screen across specialties
with Medicare allowed charges of $10 million or more. Prior to the
January 2016 RUC meeting, the specialty society notified the RUC that
its survey data displayed a bimodal distribution of responses with more
outliers than usual. The RUC referred CPT codes 11100 and 11101 to the
CPT Editorial Panel. In February 2017, the CPT Editorial Panel deleted
these two codes and created six new codes for primary and additional
biopsy based on the thickness of the sample and the technique utilized.
For CY 2019, we are proposing the RUC-recommended work RVUs for
five of the six codes in the family. We are proposing a work RVU of
0.66 for CPT code 11X02 (Tangential biopsy of skin, (e.g., shave,
scoop, saucerize, curette), single lesion), a work RVU of 0.83 for CPT
code 11X04 (Punch biopsy of skin, (including simple closure when
performed), single lesion), a work RVU of 0.45 for CPT code 11X05
(Punch biopsy of skin, (including simple closure when performed), each
separate/additional lesion), a work RVU of 1.01 for CPT code 11X06
(Incisional biopsy of skin (e.g., wedge), (including simple closure
when performed), single lesion), and a work RVU of 0.54 for CPT code
11X07 (Incisional biopsy of skin (e.g., wedge), (including simple
closure when performed), each separate/additional lesion).
For CPT code 11X03 (Tangential biopsy of skin, (e.g., shave, scoop,
saucerize, curette), each separate/additional lesion), we disagree with
the RUC-recommended work RVU of 0.38 and are proposing a work RVU of
0.29. When we compared the RUC-recommended work RVU of 0.38 to other
add-on codes in the RUC database, we found that CPT code 11X03 would
have the second-highest work RVU for any code with 7 minutes or less of
total time, with the recommended work RVU noticeably higher than other
related add-on codes, and we did not agree that the tangential biopsy
service being performed should have an anomalously high work value in
comparison to other similar add-on codes. Our proposed work RVU of 0.29
is based on a crosswalk to CPT code 11201 (Removal of skin tags,
multiple fibrocutaneous tags, any area; each additional 10 lesions, or
part thereof), a clinically related add-on procedure with 5 minutes of
intraservice and total time as opposed to the surveyed 6 minutes for
CPT code 11X03. We also noted that the intraservice time ratio between
CPT code 11X03 and the recommended reference code, CPT code 11732
(Avulsion of nail plate, partial or complete, simple; each additional
nail plate), was 75 percent (6 minutes divided by 8 minutes). This 75
percent ratio when applied to the work RVU of CPT code 11732 also
produced a work RVU of 0.29 (0.38 * 0.75 = 0.29). Finally, we are also
supporting the proposed work RVU through a crosswalk to CPT code 33508
(Endoscopy, surgical, including video-assisted harvest of vein(s) for
coronary artery bypass procedure), which has a higher intraservice time
of 10 minutes but a similar work RVU of 0.31. We believe that our
proposed work RVU of 0.29 for CPT code 11X03 better serves the
interests of relativity, as well as better fitting with the other
recommended work RVUs within this family of codes.
For the direct PE inputs, we are proposing to remove the 2 minutes
of clinical labor time for the ``Review home care instructions,
coordinate visits/prescriptions'' (CA035) activity for CPT codes 11X02,
11X04, and 11X06. These codes are typically billed with a same day E/M
service, and we believe that it would be duplicative to assign clinical
labor time for reviewing home care instructions given that this task
would typically be done during the same day E/M service. We are also
proposing to refine the equipment times in accordance with our standard
equipment time formulas.
We are proposing to refine the quantity of the ``gown, staff,
impervious'' (SB024) and the ``mask, surgical, with face shield''
(SB034) supplies from 2 to 1 for CPT codes 11X02, 11X04, and 11X06. We
are proposing to remove one gown and one surgical mask from these codes
as duplicative since these supplies are also included within the
surgical instrument cleaning pack (SA043). We are also proposing to
remove all of the supplies in the three add-on procedures (CPT codes
11X03, 11X05, and 11X07) that were not contained in the previous add-on
procedure for this family, CPT code 11101. We do not believe that the
use of these supplies would be typical for the ``each additional
lesion'' add-on codes, as these supplies are all included in the base
codes and are not currently utilized in CPT code 11101. We note that
the recommended direct PE costs for the three new add-on codes
represent an increase of approximately 500 percent from the direct PE
costs for CPT code 11101, and believe that this is largely due to the
addition of these new supplies.
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(4) Injection Tendon Origin-Insertion (CPT Code 20551)
CPT code 20551 (Injection(s); single tendon origin/insertion) was
identified as potentially misvalued on a screen of 0-day global
services reported with an E/M visit 50 percent of the time or more, on
the same day of service by the same patient and the same practitioner,
that have not been reviewed in the last 5 years with Medicare
utilization greater than 20,000. For CY 2019, we are proposing the RUC-
recommended work RVU of 0.75 for CPT code 20551.
We are proposing to maintain the current work RVU for many of the
CPT codes identified as potentially misvalued on the screen of 0-day
global services reported with an E/M visit 50 percent of the time or
more. We note that regardless of the proposed work valuations for
individual codes, which may or may not retain the same work RVU, we
continue to have reservations about the valuation of 0-day global
services that are typically billed with a separate E/M service with the
use of Modifier 25 (indicating that a significant and separately
identifiable E/M service was provided on the same day). As we stated in
the CY 2017 PFS final rule (81 FR 80204), we continue to believe that
the routine billing of separate E/M services in conjunction with a
particular code may indicate a possible problem with the valuation of
the code bundle, which is intended to include all the routine care
associated with the service. We will continue to consider additional
ways to address the appropriate valuation for these services.
For the direct PE inputs, we are proposing to remove the clinical
labor time for the ``Provide education/obtain consent'' (CA011) and the
``Review home care instructions, coordinate visits/prescriptions''
(CA035) activities for CPT code 20551. This code is typically billed
with a same day E/M service, and we believe that it would be
duplicative to assign clinical labor time for obtaining consent or
reviewing home care instructions given that these tasks would typically
be done during the same day E/M service. We are also proposing to
refine the equipment times in accordance with our standard equipment
time formulas.
(5) Structural Allograft (CPT Codes 209X3, 209X4, and 209X5)
In February 2017, the CPT Editorial Panel created three new codes
to describe allografts. These codes were designated as add-on codes and
revised to more accurately describe the structural allograft procedures
they represent. For CY 2019, we are proposing the RUC-recommended work
RVUs for all three codes. We are proposing a work RVU of 13.01 for CPT
code 209X3 (Allograft, includes templating, cutting, placement and
internal fixation when performed; osteoarticular, including articular
surface and contiguous bone), a work RVU of 11.94 for CPT code 209X4
(Allograft, includes templating, cutting, placement and internal
fixation when performed; hemicortical intercalary, partial (i.e.,
hemicylindrical)), and a work RVU of 13.00 for CPT code 209X5
(Allograft, includes templating, cutting, placement and internal
fixation when performed; intercalary, complete (i.e., cylindrical)).
These three new codes are all facility-only procedures with no
recommended direct PE inputs.
(6) Knee Arthrography Injection (CPT Code 27X69)
CPT code 27370 (Injection of contrast for knee arthrography)
repeatedly appeared on high volume growth screens between 2008 and
2016, and the RUC expressed concern that the high volume growth for
this procedure was likely due to its being reported incorrectly as
arthrocentesis or aspiration. In June 2017, the CPT Editorial Panel
deleted CPT code 27370 and replaced it with a new code, 27X69, to
report injection procedure for knee arthrography or enhanced CT/MRI
knee arthrography.
The RUC recommended a work RVU for CPT code 27X69 of 0.96, which is
identical to the work RVU for CPT code 27370 (Injection of contrast for
knee arthrography). The RUC's recommendation is based on key reference
service, CPT code 23350 (Injection procedure for shoulder arthrography
or enhanced CT/MRI shoulder arthrography), with identical intraservice
time (15 minutes) and total time (28 minutes) as the new CPT code and a
work RVU of 1.00. The RUC notes that its recommendation is lower than
the 25th percentile from the survey results, but that the work
described by the service should be valued identically with the CPT code
being replaced. We disagree with the RUC's recommended work RVU for CPT
code 27X69. Both the total (28 minutes) and intraservice (15 minutes)
times for the new CPT code are considerably lower than the deleted CPT
code 27370. Based on the reduced times and the projected work RVU from
the reverse building block methodology (0.60 work RVUs), we believe
this CPT code should be valued at 0.77 work RVUs, supported by a
crosswalk to CPT code 29075 (Application, cast; elbow to finger (short
arm)), with total time of 27 minutes and intraservice time of 15
minutes. Therefore, we are proposing a work RVU of 0.77 for CPT code
27X69.
For the direct PE inputs, we are proposing to refine the clinical
labor time for the ``Prepare room, equipment and supplies'' (CA013)
activity to 3 minutes and to refine the clinical labor time for the
``Confirm order, protocol exam'' (CA014) activity to 0 minutes. The
predecessor code for 27X69, CPT code 27370, did not previously have
clinical labor time assigned for the ``Confirm order, protocol exam''
clinical labor task, and we do not have any reason to believe that the
services being furnished by the clinical staff have changed, only the
way in which this clinical labor time has been presented on the PE
worksheets. We also note that there is no effect on the total clinical
labor direct costs in these situations, since the same 3 minutes of
clinical labor time is still being furnished.
We are proposing to remove the clinical labor time for the ``Scan
exam documents into PACS. Complete exam in RIS system to populate
images into work queue'' (CA032) activity. CPT code 27X69 does not
include a PACS workstation among the recommended equipment, and the
predecessor code 27370 did not previously include time for this
clinical labor activity. We believe that data entry activities such as
this task would be classified as indirect PE, as they are considered
administrative activities and are not individually allocable to a
particular patient for a particular service. We are also proposing to
refine the equipment times in accordance with our standard equipment
time formulas.
(7) Application of Long Arm Splint (CPT Code 29105)
CPT code 29105 (Application of long arm splint (shoulder to hand))
was identified as potentially misvalued on a screen of 0-day global
services reported with an E/M visit 50 percent of the time or more, on
the same day of service by the same patient and the same practitioner,
that have not been reviewed in the last 5 years with Medicare
utilization greater than 20,000. For CY 2019, we are proposing the RUC-
recommended work RVU of 0.80 for CPT code 29105.
For the direct PE inputs, we are proposing to refine the equipment
times in accordance with our standard equipment time formulas.
(8) Strapping Lower Extremity (CPT Codes 29540 and 29550)
CPT codes 29540 (Strapping; ankle and/or foot) and 29550
(Strapping; toes) were identified as potentially misvalued
[[Page 35750]]
on a screen of 0-day global services reported with an E/M visit 50
percent of the time or more, on the same day of service by the same
patient and the same practitioner, that have not been reviewed in the
last 5 years with Medicare utilization greater than 20,000. For CY
2019, we are proposing the HCPAC-recommended work RVU of 0.39 for CPT
code 29540 and the HCPAC-recommended work RVU of 0.25 for CPT code
29550.
For the direct PE inputs, we are proposing to refine the clinical
labor time for the ``Provide education/obtain consent'' (CA011)
activity from 3 minutes to 2 minutes for both codes, as this is the
standard clinical labor time assigned for patient education and
consent. We are also proposing to remove the 2 minutes of clinical
labor time for the ``Review home care instructions, coordinate visits/
prescriptions'' (CA035) activity for both codes. CPT codes 29540 and
29550 are both typically billed with a same day E/M service, and we
believe that it would be duplicative to assign clinical labor time for
reviewing home care instructions given that this task would typically
be done during the same day E/M service. We are also proposing to
refine the equipment times in accordance with our standard equipment
time formulas.
(9) Bronchoscopy (CPT Codes 31623 and 31624)
CPT code 31623 (Bronchoscopy, rigid or flexible, including
fluoroscopic guidance, when performed; with brushing or protected
brushings) was identified on a high growth screen of services with
total Medicare utilization of 10,000 or more that have increased by at
least 100 percent from 2009 through 2014. CPT code 31624 (Bronchoscopy,
rigid or flexible, including fluoroscopic guidance, when performed;
with bronchial alveolar lavage) was also included for review as part of
the same family of codes. For CY 2019, we are proposing the RUC-
recommended work RVU of 2.63 for CPT codes 31623 and 31624.
For the direct PE inputs, we are proposing to refine the clinical
labor time for the ``Complete post-procedure diagnostic forms, lab and
x-ray requisitions'' (CA027) activity from 4 minutes to 2 minutes for
CPT codes 31623 and 31624. Two minutes is the standard time, as well as
the current time for this clinical labor activity, and we have no
reason to believe that the time to perform this task has increased
since the codes were last reviewed. We did not receive any explanation
in the recommendations as to why the time for this activity would be
doubling over the current values. We are also proposing to refine the
equipment times in accordance with our standard equipment time
formulas.
(10) Pulmonary Wireless Pressure Sensor Services (CPT Codes 332X0 and
93XX1)
In September 2017, the CPT Editorial Panel created a code to
describe pulmonary wireless sensor implantation and another code for
remote care management of patients with an implantable, wireless
pulmonary artery pressure sensor monitor. For CY 2019, we are proposing
the RUC-recommended work RVU of 6.00 for CPT code 332X0 (Transcatheter
implantation of wireless pulmonary artery pressure sensor for long term
hemodynamic monitoring, including deployment and calibration of the
sensor, right heart catheterization, selective pulmonary
catheterization, radiological supervision and interpretation, and
pulmonary artery angiography, when performed), and the RUC-recommended
work RVU of 0.70 for CPT code 93XX1 (Remote monitoring of a wireless
pulmonary artery pressure sensor for up to 30 days including at least
weekly downloads of pulmonary artery pressure recordings,
interpretation(s), trend analysis, and report(s) by a physician or
other qualified health care professional).
We are not proposing any direct PE refinements for this code
family.
(11) Cardiac Event Recorder Procedures (CPT Codes 332X5 and 332X6)
In February 2017, the CPT Editorial Panel created two new codes
replacing cardiac event recorder codes to reflect new technology. For
CY 2019, we are proposing the RUC-recommended work RVU of 1.53 for CPT
code 332X5 (Insertion, subcutaneous cardiac rhythm monitor, including
programming) and the RUC-recommended work RVU of 1.50 for CPT code
332X6 (Removal, subcutaneous cardiac rhythm monitor).
We are not proposing any direct PE refinements for this code
family.
(12) Aortoventriculoplasty With Pulmonary Autograft (CPT Code 335X1)
In September 2017, the CPT Editorial Panel created one new code to
combine the efforts of aortic valve and root replacement with
subvalvular left ventricular outflow tract enlargement to allow for an
unobstructed left ventricular outflow tract.
For CY 2019, we are proposing the RUC-recommended work RVU of 64.00
for CPT code 335X1 (Replacement, aortic valve; by translocation of
autologous pulmonary valve and transventricular aortic annulus
enlargement of the left ventricular outflow tract with valved conduit
replacement of pulmonary valve (Ross-Konno procedure)). When this code
is re-reviewed in a few years as part of the new technology screen, we
look forward to receiving new recommendations on the whole family,
including the related Ross and Konno procedures (CPT codes 33413 and
33412 respectively) that were used as references for CPT code 335X1.
For the direct PE inputs, we are proposing to refine the preservice
clinical labor times to match our standards for 90-day global
procedures. We are proposing to refine the clinical labor time for the
``Coordinate pre-surgery services (including test results)'' (CA002)
activity from 25 minutes to 20 minutes, to refine the clinical labor
time for the ``Schedule space and equipment in facility'' (CA003)
activity from 12 minutes to 8 minutes, and to refine the clinical labor
time for the ``Provide pre-service education/obtain consent'' (CA004)
activity from 26 minutes to 20 minutes. We are also proposing to add 15
minutes of clinical labor time for the ``Perform regulatory mandated
quality assurance activity (pre-service)'' (CA008) activity. We agree
with the recommendation that the total preservice clinical labor time
for CPT code 335X1 is unchanged from the two reference codes at 75
minutes. However, we believe that the clinical labor associated with
additional coordination between multiple specialties prior to patient
arrival is more accurately described through the use of the CA008
activity code than by distributing this 15 minutes amongst the other
preservice clinical labor activities. We previously established
standard preservice times for 90-day global procedures, and did not
want to propose clinical labor times above those standards for CPT code
335X1. We also note that there is no effect on the total clinical labor
direct costs in this situation, since the same 15 minutes of preservice
clinical labor time is still being furnished.
(13) Hemi-Aortic Arch Replacement (CPT Code 33X01)
At the September 2017 CPT Editorial Panel meeting, the Panel
created one new add-on code to report hemi-aortic arch graft
replacement. For CY 2019, we are proposing the RUC-recommended work RVU
of 19.74 for CPT code 33X01 (Aortic hemiarch graft including isolation
and control of the arch vessels, beveled open distal aortic anastomosis
extending under one or more of the arch vessels, and total circulatory
arrest or isolated cerebral perfusion). CPT code
[[Page 35751]]
33X01 is a facility-only procedure with no recommended direct PE
inputs.
(14) Leadless Pacemaker Procedures (CPT Codes 33X05 and 33X06)
At the September 2017 CPT Editorial Panel meeting, the Panel
replaced the five leadless pacemaker services Category III codes with
the addition of two new CPT codes to report transcatheter leadless
pacemaker procedures and revised five codes to include evaluation and
interrogation services of leadless pacemaker systems.
For CPT code 33X05 (Transcatheter insertion or replacement of
permanent leadless pacemaker, right ventricular, including imaging
guidance (e.g., fluoroscopy, venous ultrasound, ventriculography,
femoral venography) and device evaluation (e.g., interrogation or
programming), when performed), we disagree with the recommended work
RVU of 8.77 and we are proposing a work RVU of 7.80 based on a direct
crosswalk to one of the top reference codes selected by the RUC survey
participants, CPT code 33207 (Insertion of new or replacement of
permanent pacemaker with transvenous electrode(s); ventricular). This
code has the same 60 minutes of intraservice time as CPT code 33X05 and
an additional 61 minutes of total time at a work RVU of 7.80. In our
review of CPT code 33X05, we noted that this reference code had an
additional inpatient hospital visit of CPT code 99232 (Subsequent
hospital care, per day, for the evaluation and management of a patient,
which requires at least 2 of 3 key components) and a full instead of a
half discharge visit of CPT code 99238 (Hospital discharge day
management; 30 minutes or less) included in its 90-day global period.
The combined work RVU of these two visits would be equal to 2.03.
However, the recommended work RVU for CPT code 33X05 was 0.97 work RVUs
higher than CPT code 33207, despite having fewer of these visits and
significantly less surveyed total time. While we acknowledge that CPT
code 33X05 is a more intense procedure than CPT code 33207, we do not
believe that it should be valued almost a full RVU higher than the
reference code given the fewer visits in the global period and the
lower surveyed work time.
Therefore, we are proposing to crosswalk CPT code 33X05 to CPT code
33207 at the same work RVU of 7.80. The proposed work RVU is also
supported through a reference crosswalk to CPT code 38542 (Dissection,
deep jugular node(s)), which has 60 minutes of intraservice time, 198
minutes of total time, and a work RVU of 7.95. We believe that our
proposed work RVU of 7.80 is a more accurate valuation for CPT code
33X05, while still recognizing the greater intensity of this procedure
in comparison to its reference code.
For CPT code 33X06 (Transcatheter removal of permanent leadless
pacemaker, right ventricular), we disagree with the RUC-recommended
work RVU of 9.56 and we are proposing a work RVU of 8.59. Although we
disagree with the RUC-recommended work RVU, we concur that the relative
difference in work between CPT codes 33X05 and 33X06 is equivalent to
the recommended interval of 0.79 RVUs. Therefore, we are proposing a
work RVU of 8.59 for CPT code 33X06, based on the recommended interval
of 0.79 additional RVUs above our proposed work RVU of 7.80 for CPT
code 33X05. We also note that our proposed work RVU for CPT code 33X06
situates it approximately halfway between the two reference codes from
the survey, with CPT code 33270 (Insertion or replacement of permanent
subcutaneous implantable defibrillator system, with subcutaneous
electrode, including defibrillation threshold evaluation, induction of
arrhythmia, evaluation of sensing for arrhythmia termination, and
programming or reprogramming of sensing or therapeutic parameters, when
performed) having an intraservice time of 90 minutes and a work RVU of
9.10, and CPT code 33207 having an intraservice time of 60 minutes and
a work RVU of 7.80. CPT code 33X06 has a surveyed intraservice time of
75 minutes and nearly splits the difference between them at our
proposed work RVU of 8.59.
We are not proposing any direct PE refinements for this code
family.
(15) PICC Line Procedures (CPT Codes 36568, 36569, 36X72, 36X73, and
36584)
In CY 2016, CPT code 36569 (Insertion of peripherally inserted
central venous catheter (PICC), without subcutaneous port or pump,
without imaging guidance; age 5 years or older) was identified as
potentially misvalued using a high expenditure services screen across
specialties with Medicare allowed charges of $10 million or more. CPT
code 36569 is typically reported with CPT codes 76937 (Ultrasound
guidance for vascular access requiring ultrasound evaluation of
potential access sites, documentation of selected vessel patency,
concurrent realtime ultrasound visualization of vascular needle entry,
with permanent recording and reporting) and 77001 (Fluoroscopic
guidance for central venous access device placement, replacement
(catheter only or complete), or removal) and was referred to the CPT
Editorial Panel to have the two common imaging codes bundled into the
code. In September 2017, the CPT Editorial Panel revised CPT codes
36568 (Insertion of peripherally inserted central venous catheter
(PICC), without subcutaneous port or pump; younger than 5 years of
age), 36569 and 36584 (Replacement, complete, of a peripherally
inserted central venous catheter (PICC), without subcutaneous port or
pump, through same venous access, including all imaging guidance, image
documentation, and all associated radiological supervision and
interpretation required to perform the replacement) and created two new
CPT codes to specify the insertion of peripherally inserted central
venous catheter (PICC), without subcutaneous port or pump, including
all imaging guidance, image documentation, and all associated
radiological supervision and interpretation required to perform the
insertion.
For CY 2019, we are proposing the RUC-recommended work RVU for two
of the CPT codes in the family. We are proposing the RUC-recommended
work RVU of 2.11 for CPT code 36568 and the RUC-recommended work RVU of
1.90 for CPT code 36569.
For CPT code 36X72 (Insertion of peripherally inserted central
venous catheter (PICC), without subcutaneous port or pump, including
all imaging guidance, image documentation, and all associated
radiological supervision and interpretation required to perform the
insertion; younger than 5 years of age), we disagree with the RUC-
recommended work RVU of 2.00 and are proposing a work RVU of 1.82 based
on a direct crosswalk to CPT code 50435 (Exchange nephrostomy catheter,
percutaneous, including diagnostic nephrostogram and/or ureterogram
when performed, imaging guidance (e.g., ultrasound and/or fluoroscopy)
and all associated radiological supervision and interpretation). CPT
code 50435 is a recently reviewed code that also includes radiological
supervision and interpretation with similar intraservice and total time
values. In our review of CPT code 36X72, we were concerned about the
possibility that the recommended work RVU of 2.00 could create a rank
order anomaly in terms of intensity with the other codes in the family.
We noted that the recommended intraservice time for CPT code 36X72 as
compared to CPT code 36568, the most similar code in the family, is
decreasing from 38 minutes to 22 minutes (42 percent), and the
recommended total time is decreasing from 71 minutes to 51 minutes (38
[[Page 35752]]
percent); however, the recommended work RVU is only decreasing from
2.11 to 2.00, which is a reduction of just over 5 percent. We also
noted that CPT code 36X72 has a lower recommended intraservice time and
total time as compared to CPT code 36569, yet has a higher recommended
work RVU. Although we do not imply that the decreases in time as
reflected in survey values must equate to a one-to-one or linear
decrease in the valuation of work RVUs, we believe that since the two
components of work are time and intensity, significant decreases in
time should be reflected in decreases to work RVUs.
In the case of CPT code 36X72, we believe that it would be more
accurate to propose a work RVU of 1.82 based on a crosswalk to CPT code
50435 to better fit with the recommended work RVUs for CPT codes 36568
and 36569. The proposed work valuation is also based on the use of
three additional crosswalk codes: CPT code 32554 (Thoracentesis, needle
or catheter, aspiration of the pleural space; without imaging
guidance), CPT code 43198 (Esophagoscopy, flexible, transnasal; with
biopsy, single or multiple), and CPT code 64644 (Chemodenervation of
one extremity; 5 or more muscles). All of these codes were recently
reviewed with similar intensity, intraservice time, and total time
values, and all three of them also share a work RVU of 1.82.
For CPT code 36X73 (Insertion of peripherally inserted central
venous catheter (PICC), without subcutaneous port or pump, including
all imaging guidance, image documentation, and all associated
radiological supervision and interpretation required to perform the
insertion; age 5 years or older), we disagree with the RUC-recommended
work RVU of 1.90 and are proposing a work RVU of 1.70 based on
maintaining the current work RVU of CPT code 36569. In our review of
CPT code 36X73, we were again concerned about the possibility that the
recommended work RVU of 1.90 could create a rank order anomaly in terms
of intensity with the other codes in the family. We noted that the
recommended intraservice time for CPT code 36X73 as compared to CPT
code 36569, the most similar code in the family, is decreasing from 27
minutes to 15 minutes (45 percent), and the recommended total time is
decreasing from 60 minutes to 40 minutes (33 percent); however, the
RUC-recommended work RVU is exactly the same for these two codes at
1.90. Although we do not imply that the decreases in time as reflected
in survey values must equate to a one-to-one or linear decrease in the
valuation of work RVUs, we believe that since the two components of
work are time and intensity, significant decreases in time should be
reflected in decreases to work RVUs.
In the case of CPT code 36X73, we believe that it would be more
accurate to propose a work RVU of 1.70 based on maintaining the current
work RVU of CPT code 36569. These two CPT codes describe the same
procedure done with (CPT code 36X73) and without (CPT code 35659)
imaging guidance and radiological supervision and interpretation.
Because the inclusion of the imaging described by CPT code 36X73 has
now become the typical case for this service, we believe that it is
more accurate to maintain the current work RVU of 1.70 as opposed to
increasing the work RVU to 1.90, especially considering that the new
surveyed work time for CPT code 36X73 is lower than the current work
time for CPT code 36569. The proposed work RVU of 1.70 is also based on
a crosswalk to CPT code 36556 (Insertion of non-tunneled centrally
inserted central venous catheter; age 5 years or older). This is a
recently reviewed code with the same 15 minutes of intraservice time
and the same 40 minutes of total time with a work RVU of 1.75.
For CPT code 36584, we disagree with the RUC-recommended work RVU
of 1.47 and are proposing a work RVU of 1.20 based on maintaining the
current work RVU. We note that the recommended intraservice time for
CPT code 36584 is decreasing from 15 minutes to 12 minutes (20 percent
reduction), and the recommended total time is decreasing from 45
minutes to 34 minutes (25 percent reduction); however, the recommended
work RVU is increasing from 1.20 to 1.47, an increase of approximately
23 percent. Although we do not imply that the decreases in time as
reflected in survey values must equate to a one-to-one or linear
decrease in the valuation of work RVUs, we believe that since the two
components of work are time and intensity, significant decreases in
time should be reflected in decreases to work RVUs. We are especially
concerned when the recommended work RVU is increasing despite survey
results indicating that the work time is decreasing due to a
combination of improving technology and greater efficiencies in
practice patterns.
In the case of CPT code 36584, we believe that it would be more
accurate to propose a work RVU of 1.20 based on maintaining the current
work RVU for the code. Because the inclusion of the imaging has now
become the typical case for this service, we believe that it is more
accurate to maintain the current work RVU of 1.20 as opposed to
increasing the work RVU to 1.47, especially considering that the new
surveyed work time for CPT code 36584 is decreasing from the current
work time. The proposed work RVU of 1.20 is also based on a crosswalk
to CPT code 40490 (Biopsy of lip), which has the same total time of 34
minutes and slightly higher intraservice time at a work RVU of 1.22.
We note that the RUC-recommended work pool is increasing by
approximately 68 percent for the PICC Line Procedures family as a
whole, while the RUC-recommended work time pool for the same codes is
only increasing by about 22 percent. Since time is defined as one of
the two components of work, we believe that this indicates a
discrepancy in the recommended work values. We do not believe that the
recoding of the services in this family has resulted in an increase in
their intensity, only a change in the way in which they will be
reported, and therefore, we do not believe that it would serve the
interests of relativity to propose the RUC-recommended work values for
all of the codes in this family. We believe that, generally speaking,
the recoding of a family of services should maintain the same total
work pool, as the services themselves are not changing, only the coding
structure under which they are being reported. We also note that,
through the bundling of some of these frequently reported services, it
is reasonable to expect that the new coding system will achieve savings
via elimination of duplicative assumptions of the resources involved in
furnishing particular servicers. For example, a practitioner would not
be carrying out the full preservice work three times for CPT codes
36568, 76937, and 77001, but preservice times were assigned to all of
the codes under the old coding. We believe the new coding assigns more
accurate work times and thus reflects efficiencies in resource costs
that existed but were not reflected in the services as they were
previously reported.
For the direct PE inputs, we are proposing to refine the clinical
labor time for the ``Prepare, set-up and start IV, initial positioning
and monitoring of patient'' (CA016) activity from 4 minutes to 2
minutes for CPT codes 36X72 and 36X73. We note that the two reference
codes for the two new codes, CPT codes 36568 and 36569, currently have
2 minutes assigned for this activity, and CPT code 36584 also has a
recommended 2 minutes assigned to this same activity. We do not agree
that the patient positioning would take twice
[[Page 35753]]
as long for CPT codes 36X72 and 36X73 as compared to the rest of the
family, and are therefore refining both of them to the same 2 minutes
of clinical labor time. We are also proposing to refine the equipment
times in accordance with our standard equipment time formulas.
(16) Biopsy or Excision of Inguinofemoral Node(s) (CPT Code 3853X)
In September 2017, the CPT Editorial Panel created a new code to
describe biopsy or excision of inguinofemoral node(s). A parenthetical
was added to CPT codes 56630 (Vulvectomy, radical, partial) and 56633
(Vulvectomy, radical, complete) to instruct separate reporting of code
3853X with radical vulvectomy. This service was previously reported
with unlisted codes.
CPT code 3853X (Biopsy or excision of lymph node(s); open,
inguinofemoral node(s)) is a new CPT code describing a lymph node
biopsy without complete lymphadenectomy. The RUC recommended a work RVU
of 6.74 for CPT code 3853X, with 223 minutes of total time and 65
minutes of intraservice time. We propose the RUC-recommended work RVU
of 6.74 for CPT code 3853X. However, we are concerned that this CPT
code is described as having a 10-day global period. The two CPT codes
that are often reported together with this code, CPT code 56630
(Vulvectomy, radical, partial) and CPT code 56633 (Vulvectomy, radical,
complete), are both 90-day global codes. In addition, CPT code 3853X
has a discharge visit and two follow up visits in the global period.
This is consistent with the number of postoperative visits typically
associated with 90-day global codes. Therefore, we propose to assign a
90-day global indicator for CPT code 3853X rather than the 10-day
global time period reflected in the RUC recommendation.
We are not proposing any direct PE refinements for this code
family.
(17) Radioactive Tracer (CPT Code 38792)
CPT code 38792 (Injection procedure; radioactive tracer for
identification of sentinel node) was identified as potentially
misvalued on a screen of codes with a negative intraservice work per
unit of time (IWPUT), with 2016 estimated Medicare utilization over
10,000 for RUC reviewed codes and over 1,000 for Harvard valued and
CMS/Other source codes. For CY 2019, we are proposing the RUC-
recommended work RVU of 0.65 for CPT code 38792.
For the direct PE inputs, we are proposing to refine the clinical
labor time for the ``Prepare room, equipment and supplies'' (CA013)
activity to 3 minutes and to refine the clinical labor time for the
``Confirm order, protocol exam'' (CA014) activity to 0 minutes. CPT
code 38792, as well as its alternate reference code 78300 (Bone and/or
joint imaging; limited area), both did not previously have clinical
labor time assigned for the ``Confirm order, protocol exam'' clinical
labor task, and we do not have any reason to believe that the services
being furnished by the clinical staff have changed, only the way in
which this clinical labor time has been presented on the PE worksheets.
We also note that there is no effect on the total clinical labor direct
costs in these situations, since the same 3 minutes of clinical labor
time is still being furnished. We are also proposing to refine the
equipment times in accordance with our standard equipment time
formulas.
(18) Percutaneous Change of G-Tube (CPT Code 43760)
CPT code 43760 (Change of gastrostomy tube, percutaneous, without
imaging or endoscopic guidance) was identified as potentially misvalued
on a screen of 0-day global services reported with an E/M visit 50
percent of the time or more, on the same day of service by the same
patient and the same practitioner, that have not been reviewed in the
last 5 years with Medicare utilization greater than 20,000. It was
surveyed for the April 2017 RUC meeting and recommendations for work
and direct PE inputs were submitted to CMS. However, the RUC also noted
that because the data for CPT code 43760 were bimodal, it might be
appropriate to consider changes in the CPT descriptors to better
differentiate physician work. In September 2017, the CPT Editorial
Panel deleted CPT code 43760 and will use two new codes (43X63 and
43X64) that describe replacement of gastrostomy tube, with and without
revision of gastrostomy tract, respectively. (See below.) Therefore, we
are not proposing work or direct PE values for CPT code 43760.
(19) Gastrostomy Tube Replacement (CPT Codes 43X63 and 43X64)
In September 2017, the CPT Editorial Panel created two new codes
that describe replacement of gastrostomy tube, with and without
revision of gastrostomy tract, respectively. These two new codes were
surveyed for the January 2018 RUC meeting and recommendations for work
and direct PE inputs were submitted to CMS.
We are proposing a work RVU of 0.75 for CPT code 43X63 (Replacement
of gastrostomy tube, percutaneous, includes removal, when performed,
without imaging or endoscopic guidance; not requiring revision of
gastrostomy tract.) and a work RVU of 1.41 for CPT code 43X64
(Replacement of gastrostomy tube, percutaneous, includes removal, when
performed, without imaging or endoscopic guidance; requiring revision
of gastrostomy tract.), consistent with the RUC's recommendations for
these new CPT codes.
For the direct PE inputs, we are proposing to refine the equipment
times in accordance with our standard equipment time formulas.
(20) Diagnostic Proctosigmoidoscopy--Rigid (CPT Code 45300)
CPT code 45300 (Proctosigmoidoscopy, rigid; diagnostic, with or
without collection of specimen(s) by brushing or washing (separate
procedure)) was identified as potentially misvalued on a screen of 0-
day global services reported with an E/M visit 50 percent of the time
or more, on the same day of service by the same patient and the same
practitioner, that have not been reviewed in the last 5 years with
Medicare utilization greater than 20,000. For CY 2019, we are proposing
the RUC-recommended work RVU of 0.80 for CPT code 45300.
For the direct PE inputs, we are proposing to refine the equipment
times in accordance with our standard equipment time formulas.
(21) Hemorrhoid Injection (CPT Code 46500)
CPT code 46500 (Injection of sclerosing solution, hemorrhoids) was
identified as potentially misvalued on a screen of codes with a
negative intraservice work per unit of time (IWPUT), with 2016
estimated Medicare utilization over 10,000 for RUC reviewed codes and
over 1,000 for Harvard valued and CMS/Other source codes.
For CPT code 46500, we disagree with the RUC-recommended work RVU
of 2.00 and we are proposing a work RVU of 1.74 based on a direct
crosswalk to CPT code 68811 (Probing of nasolacrimal duct, with or
without irrigation; requiring general anesthesia). This is another
recently-reviewed 10-day global code with the same 10 minutes of
intraservice time and slightly higher total time. When CPT code 46500
was previously reviewed as described in the CY 2016 PFS final rule with
comment period (80 FR 70963), we finalized a proposal to reduce the
work RVU from 1.69 to 1.42, which reduced the work RVU by the same
ratio as the
[[Page 35754]]
reduction in the total work time. In light of the additional evidence
provided by this new survey, we agree that the work RVU should be
increased from the current value of 1.42. However, we believe that our
proposed work RVU of 1.74 based on a crosswalk to CPT code 68811 is
more accurate than the RUC-recommended work RVU of 2.00.
In the most recent survey of CPT code 46500, the intraservice work
time remained unchanged at 10 minutes while the total time increased by
only 2 minutes, increasing from 59 minutes to 61 minutes (3 percent).
However, the RUC-recommended work RVU is increasing from 1.42 to 2.00,
an increase of 41 percent, and also an increase of 19 percent over the
historic value of 1.69 for CPT code 46500. Although we do not imply
that the increase in time as reflected in survey values must equate to
a one-to-one or linear increase in the valuation of work RVUs, we
believe that since the two components of work are time and intensity,
minimal increases in surveyed work time typically should not be
reflected in disproportionately large increases to work RVUs. In the
case of CPT code 46500, we believe that our crosswalk to CPT code 68811
at a work RVU of 1.74 more accurately maintains relativity with other
10-day global codes on the PFS. We also note that the 3 percent
increase in surveyed work time for CPT code 46500 matches a 3 percent
increase in the historic work RVU of the code, from 1.69 to 1.74.
Therefore, we are proposing a work RVU of 1.74 for CPT code 46500 based
on the aforementioned crosswalk.
For the direct PE inputs, we are proposing to remove 10 minutes of
clinical labor time for the ``Assist physician or other qualified
healthcare professional--directly related to physician work time
(100%)'' (CA018) activity. This clinical labor time is listed twice in
the recommendations along with a statement that although the clinical
labor has not changed from prior reviews, time for both clinical staff
members was inadvertently not included in the previous spreadsheets. We
appreciate this notification in the recommendations, and therefore, we
are asking for more information about why the clinical labor associated
with this additional staff member was left out for previous reviews. We
are particularly interested in knowing what activities the additional
staff member would be undertaking during the procedure. We are
proposing to remove the clinical labor associated with this additional
clinical staff member pending the receipt of additional information. We
are also proposing to remove 1 impervious staff gown (SB027), 1
surgical mask with face shield (SB034), and 1 pair of shoe covers
(SB039) pending more information about the additional clinical staff
member.
We are proposing to remove the clinical labor time for the ``Review
home care instructions, coordinate visits/prescriptions'' (CA035)
activity. CPT code 46500 is typically billed with a same day E/M
service, and we believe that it would be duplicative to assign clinical
labor time for reviewing home care instructions given that this task
would typically be done during the same day E/M service. We are also
proposing to refine the equipment times in accordance with our standard
equipment time formulas.
(22) Removal of Intraperitoneal Catheter (CPT Code 49422)
In October 2016, CPT code 49422 (Removal of tunneled
intraperitoneal catheter) was identified as a site of service anomaly
because Medicare data from 2012-2014 indicated that it was performed
less than 50 percent of the time in the inpatient setting, yet included
inpatient hospital E/M services within the 10-day global period. The
code was resurveyed using a 0-day global period for the April 2017 RUC
meeting. For CY 2019, we are proposing the RUC-recommended work RVU of
4.00 for CPT code 49422.
We are not proposing any direct PE refinements for this code
family.
(23) Dilation of Urinary Tract (CPT Codes 50X39, 50X40, 52334, and
74485)
In October 2014, the CPT Editorial Panel deleted six codes and
created twelve new codes to describe genitourinary catheter procedures
and bundle inherent imaging services. In January 2015, the specialty
societies indicated that CPT code 50395 (Introduction of guide into
renal pelvis and/or ureter with dilation to establish nephrostomy
tract, percutaneous), which was identified as part of the family, would
be referred to the CPT Editorial Panel to clear up any confusion with
overlap in physician work with CPT code 50432 (Placement of nephrostomy
catheter, percutaneous, including diagnostic nephrostogram and/or
ureterogram when performed, imaging guidance (e.g., ultrasound and/or
fluoroscopy) and all associated radiological supervision and
interpretation). In September 2017, the CPT Editorial Panel deleted CPT
code 50395 and created two new codes to report dilation of existing
tract, and establishment of new access to the collecting system,
including percutaneous, for an endourologic procedure including imaging
guidance (e.g., ultrasound and/or fluoroscopy), all associated
radiological supervision and interpretation, as well as post procedure
tube placement when performed.
The specialty society surveyed the new CPT code 50X39 (Dilation of
existing tract, percutaneous, for an endourologic procedure including
imaging guidance (e.g., ultrasound and/or fluoroscopy) and all
associated radiological supervision and interpretation, as well as post
procedure tube placement, when performed), and the RUC recommended a
total time of 70 minutes, intraservice time of 30 minutes, and a work
RVU of 3.37. The RUC indicated that its recommended work RVU for this
CPT code is identical to the work RVU of the CPT code being deleted,
even though imaging guidance CPT code 74485 has now been bundled into
the valuation of the CPT code. The RUC provided two key reference CPT
codes to support its recommendation: CPT code 50694 (Placement of
ureteral stent, percutaneous, including diagnostic nephrostogram and/or
ureterogram when performed, imaging guidance (e.g., ultrasound and/or
fluoroscopy), and all associated radiological supervision and
interpretation; new access, without separate nephrostomy catheter) with
total time of 111 minutes, intraservice time of 62 minutes, and a work
RVU of 5.25; and CPT code 50695 (Placement of ureteral stent,
percutaneous, including diagnostic nephrostogram and/or ureterogram
when performed, imaging guidance (e.g., ultrasound and/or fluoroscopy),
and all associated radiological supervision and interpretation; new
access, with separate nephrostomy catheter), with total time of 124
minutes and intraservice time of 75 minutes, and a work RVU of 6.80. To
further support its recommendation, the RUC also referenced CPT code
52287 (Cystourethroscopy, with injection(s) for chemodenervation of the
bladder) with total time of 58 minutes, intraservice time of 21
minutes, and a work RVU of 3.37. We disagree with the RUC that the work
RVU for this CPT code should be the same as the CPT code being deleted.
Survey respondents indicated that the total time for completing the
service described by the new CPT code is nearly 30 minutes less than
the existing CPT code, even though imaging guidance was described as
part of the procedure. We also note that the reference CPT codes both
have substantially higher total and intraservice times than CPT code
50X39. We considered a number of parameters to arrive at our proposed
work RVU of 2.78, supported by a
[[Page 35755]]
crosswalk to CPT code 31646 (Bronchoscopy, rigid or flexible, including
fluoroscopic guidance, when performed; with therapeutic aspiration of
tracheobronchial tree, subsequent, same hospital stay). We examined the
intraservice time ratio for the new CPT code in relation to the
combination of CPT codes that the service represents and found that
this would support a work RVU of 2.55. We also calculated the
intraservice time ratio for the new CPT code in relation to each of the
two reference CPT codes. For the comparison with CPT code 50694, the
intraservice time ratio is 2.54, while the comparison with the second
reference CPT code 50695 yields an intraservice time ratio of 2.72. We
took the highest of these three values, 2.72, and found a corresponding
crosswalk that we believe appropriately values the service described by
the new CPT code. Therefore, we are proposing a work RVU of 2.78 for
CPT code 50X39.
The specialty society also surveyed the new CPT code 50X40
(Dilation of existing tract, percutaneous, for an endourologic
procedure including imaging guidance (e.g., ultrasound and/or
fluoroscopy) and all associated radiological supervision and
interpretation, as well as post procedure tube placement, when
performed; including new access into the renal collecting system) and
the RUC recommended a total time of 100 minutes, an intraservice time
of 60 minutes, and a work RVU of 5.44. The recommended intraservice
time of 60 minutes reflects the 75th percentile of survey results,
rather than the median survey time, which is typically used for
determining the intraservice time for new CPT codes. The RUC justified
the use of the higher intraservice time because they believe the time
better represents the additional time needed to introduce the guidewire
into the renal pelvis and/or ureter, above and beyond the work involved
in performing CPT code 50X39. The RUC compared this CPT code to CPT
code 52235 (Cystourethroscopy, with fulguration (including cryosurgery
or laser surgery) and/or resection of; MEDIUM bladder tumor(s) (2.0 to
5.0 cm)), with total time of 94 minutes, intraservice time of 45
minutes, and a work RVU of 5.44. The RUC also cited, as support, the
second key reference CPT code 50694 (Placement of ureteral stent,
percutaneous, including diagnostic nephrostogram and/or ureterogram
when performed, imaging guidance (e.g., ultrasound and/or fluoroscopy),
and all associated radiological supervision and interpretation; new
access, without separate nephrostomy catheter) with total time 111
minutes, intraservice time 62 minutes, and a work RVU of 5.25. We do
not agree with the RUC's recommended work RVU because we believe that
the intraservice time for this CPT code should reflect the survey
median rather than the 75th percentile. There is no indication that the
additional work of imaging guidance was systematically excluded by
survey respondents when estimating the time needed to furnish the
service. Therefore, we are proposing to reduce the intraservice time
for CPT code 50X40 from the RUC-recommended 60 minutes to the survey
median time of 45 minutes. We note that this is still 15 minutes more
than the intraservice time for CPT code 50X39, primarily for the
provider to introduce the guidewire into the renal pelvis and/or
ureter. We welcome comments about the amount of time needed to furnish
this procedure. With the revised intraservice time of 45 minutes and a
total time of 85 minutes, we believe that the RUC-recommended work RVU
for this CPT code is overstated. When we apply the increment between
the RUC-recommended values for between CPT codes 50X39 and 50X40 (2.07
work RVUs) in addition to our proposed work RVU for CPT code 50X39, we
estimate that this CPT code is more accurately represented by a work
RVU of 4.83. This value is supported by a crosswalk to CPT code 36902
(Introduction of needle(s) and/or catheter(s), dialysis circuit, with
diagnostic angiography of the dialysis circuit, including all direct
puncture(s) and catheter placement(s), injection(s) of contrast, all
necessary imaging from the arterial anastomosis and adjacent artery
through entire venous outflow including the inferior or superior vena
cava, fluoroscopic guidance, radiological supervision and
interpretation and image documentation and report; with transluminal
balloon angioplasty, peripheral dialysis segment, including all imaging
and radiological supervision and interpretation necessary to perform
the angioplasty), which has intraservice time of 40 minutes and total
time of 86 minutes. We believe that CPT code 36902 describes a service
that is similar to the new CPT code 50X40) and therefore provides a
reasonable crosswalk. We are proposing a work RVU of 4.83 for CPT code
50X40.
We are proposing the RUC-recommended work RVU of 3.37 for CPT code
52334 (Cystourethroscopy with insertion of ureteral guide wire through
kidney to establish a percutaneous nephrostomy, retrograde) and the
RUC-recommended work RVU of 0.83 for CPT code 74485 (Dilation of
ureter(s) or urethra, radiological supervision and interpretation).
For the direct PE inputs, we are proposing to remove the clinical
labor time for the ``Confirm availability of prior images/studies''
(CA006) activity for CPT code 52334. This code does not currently
include this clinical labor time, and unlike the two new codes in the
family (CPT codes 50X39 and 50X40), CPT code 52234 does not include
imaging guidance in its code descriptor. When CPT code 52234 is
performed with imaging guidance, it would be billed together with a
separate imaging code that already includes clinical labor time for
confirming the availability of prior images. As a result, we believe
that it would be duplicative to include this clinical labor time in CPT
code 52234.
(24) Transurethral Destruction of Prostate Tissue (CPT Codes 53850,
53852, and 538X3)
In September 2017, the CPT Editorial Panel created a new code (CPT
code 538X3) to report transurethral destruction of prostate tissue by
radiofrequency-generated water vapor thermotherapy. CPT codes 53850
(Transurethral destruction of prostate tissue; by microwave
thermotherapy) and 53852 (Transurethral destruction of prostate tissue;
by radiofrequency thermotherapy) were also included for review as part
of the same family of codes.
For CPT code 53850 (Transurethral destruction of prostate tissue;
by microwave thermotherapy), the RUC- recommended a work RVU of 5.42,
supported by a direct crosswalk to CPT code 33272 (Removal of
subcutaneous implantable defibrillator electrode) with a total time of
151 minutes, intraservice time of 45 minutes, and a work RVU of 5.42.
The RUC indicated that a work RVU of 5.42 accurately reflects the
lowest value of the three CPT codes in this family. We are proposing
the work RVU of 5.42 for CPT code 53850, as recommended by the RUC.
The RUC recommended a work RVU of 5.93 for CPT code 53852
(Transurethral destruction of prostate tissue; by radiofrequency
thermotherapy) and for CPT code 538X3 (Transurethral destruction of
prostate tissue; by radiofrequency generated water vapor
thermotherapy). We are proposing the RUC-recommended value of 5.93 for
CPT code 53852.
CPT code 538X3 (Transurethral destruction of prostate tissue; by
radiofrequency generated water vapor thermotherapy) is a service
reflecting
[[Page 35756]]
the use of a new technology, ``radiofrequency generated water vapor
thermotherapy,'' as distinct from CPT code 53852, which describes
destruction of tissue by ``radiofrequency thermotherapy.'' The RUC
indicated that this CPT code is the most intense of the three CPT codes
in this family, thereby justifying a work RVU identical to that of CPT
code 53852 despite lower intraservice and total times. The RUC stated
that 15 minutes of post service time is appropriate due to greater
occurrence of post-procedure hematuria necessitating a longer
monitoring time. However, the post-service monitoring time for this CPT
code, 15 minutes, is identical to that for CPT code 53852. We do not
agree with the explanation provided by the RUC for recommending a work
RVU identical to that of CPT code 53852, given that the total time is 5
minutes lower, and the post service times are identical. Both the
intraservice time ratio between this new CPT code and CPT code 53852
(4.94) and the total time ratio between the two CPT codes (5.72)
suggest that the RUC-recommended work RVU of 5.93 overestimates the
work involved in furnishing this service. We reviewed other 90-day
global CPT codes with similar times and identified CPT code 24071
(Excision, tumor, soft tissue of upper arm or elbow area, subcutaneous;
3 cm or greater) with a total time of 183 minutes, intraservice time of
45 minutes, and a work RVU of 5.70 as an appropriate crosswalk. We
believe that this is a better reflection of the work involved in
furnishing CPT code 538X3, and therefore, we are proposing a work RVU
of 5.70 for this CPT code. We welcome comments about the time and
intensity required to furnish this new service. Since this CPT code
reflects the use of a new technology, it will be reviewed again in 3
years.
For the direct PE inputs, we are proposing to add a new supply
(SA128: ``kit, Rezum delivery device''), a new equipment item (EQ389:
``generator, water thermotherapy procedure''), and updating the price
of two supplies (SA036: ``kit, transurethral microwave thermotherapy''
and SA037: ``kit, transurethral needle ablation (TUNA)'') in response
to the submission of invoices. We note that these invoices were
submitted along with additional information listing the vendor discount
for these supplies and equipment. We appreciate the inclusion of the
discounted prices on these invoices, and we encourage other invoice
submissions to provide the discounted price as well where available.
Based on the market research on supply and equipment pricing carried
out by our contractors, we have reason to believe that a vendor
discount of 10-15 percent is common on many supplies and equipment.
Since we are obligated by statute to establish RVUs for each service as
required based on the resource inputs required to furnish the typical
case of a service, we have concerns that relying on invoices for supply
and equipment pricing absent these vendor discounts may overestimate
the resource cost of some services. We encourage the submission of
additional invoices that include the discounted price of supplies and
equipment to more accurately assess the market cost of these resources.
Furthermore, we refer readers to our discussion of the market-based
supply and equipment pricing update detailed in section II.B. of this
proposed rule.
(25) Vaginal Treatments (CPT Codes 57150 and 57160)
CPT codes 57150 (Irrigation of vagina and/or application of
medicament for treatment of bacterial, parasitic, or fungoid disease)
and 57160 (Fitting and insertion of pessary or other intravaginal
support device) were identified as potentially misvalued on a screen of
0-day global services reported with an E/M visit 50 percent of the time
or more, on the same day of service by the same patient and the same
practitioner, that have not been reviewed in the last 5 years with
Medicare utilization greater than 20,000. For CY 2019, we are proposing
the RUC-recommended work RVU of 0.50 for CPT code 57150 and the RUC-
recommended work RVU of 0.89 for CPT code 57160.
We are not proposing any direct PE refinements for this code
family.
(26) Biopsy of Uterus Lining (CPT Codes 58100 and 58110)
CPT code 58100 (Endometrial sampling (biopsy) with or without
endocervical sampling (biopsy), without cervical dilation, any method)
was identified as potentially misvalued on a screen of 0-day global
services reported with an E/M visit 50 percent of the time or more, on
the same day of service by the same patient and the same practitioner,
that have not been reviewed in the last 5 years with Medicare
utilization greater than 20,000. CPT code 58110 (Endometrial sampling
(biopsy) performed in conjunction with colposcopy) was also included
for review as part of the same family of codes. For CY 2019, we are
proposing the RUC-recommended work RVU of 1.21 for CPT code 58100 and
the RUC-recommended work RVU of 0.77 for CPT code 58110.
For the direct PE inputs, we are proposing to remove the clinical
labor time for the ``Review/read post-procedure x-ray, lab and
pathology reports'' (CA028) activity for CPT code 58100. This code is
typically billed with a same day E/M service, and we believe that it
would be duplicative to assign clinical labor time for reviewing
reports given that this task would typically be done during the same
day E/M service. We are also proposing to refine the equipment times in
accordance with our standard equipment time formulas.
(27) Injection Greater Occipital Nerve (CPT Code 64405)
CPT code 64405 (Injection, anesthetic agent; greater occipital
nerve) was identified as potentially misvalued on a screen of 0-day
global services reported with an E/M visit 50 percent of the time or
more, on the same day of service by the same patient and the same
practitioner, that have not been reviewed in the last 5 years with
Medicare utilization greater than 20,000. For CY 2019, we are proposing
the RUC-recommended work RVU of 0.94 for CPT code 64405.
For the direct PE inputs, we are proposing to refine the equipment
time for the exam table (EF023) in accordance with our standard
equipment time formulas.
(28) Injection Digital Nerves (CPT Code 64455)
CPT code 64455 (Injection(s), anesthetic agent and/or steroid,
plantar common digital nerve(s) (e.g., Morton's neuroma)) was
identified as potentially misvalued on a screen of 0-day global
services reported with an E/M visit 50 percent of the time or more, on
the same day of service by the same patient and the same practitioner,
that have not been reviewed in the last 5 years with Medicare
utilization greater than 20,000. For CY 2019, we are proposing the RUC-
recommended work RVU of 0.75 for CPT code 64455.
For the direct PE inputs, we are proposing to refine the equipment
time for the exam table (EF023) in accordance with our standard
equipment time formulas.
(29) Removal of Foreign Body--Eye (CPT Codes 65205 and 65210)
CPT codes 65205 (Removal of foreign body, external eye;
conjunctival superficial) and 65210 (Removal of foreign body, external
eye; conjunctival embedded (includes concretions), subconjunctival, or
scleral nonperforating) were identified as potentially misvalued on a
screen of 0-day global services reported with an
[[Page 35757]]
E/M visit 50 percent of the time or more, on the same day of service by
the same patient and the same practitioner, that have not been reviewed
in the last 5 years with Medicare utilization greater than 20,000.
For CY 2019, we are proposing the RUC-recommended work RVU of 0.49
for CPT code 65205. We note that the recommendations for this code
included a statement that the work required to perform CPT code 65205
and the procedure itself had not fundamentally changed since the time
of the last review. However, due to the fact that the surveyed
intraservice time had decreased from 5 minutes to 3 minutes, the work
RVU was lowered from the current value of 0.71 to the recommended work
RVU of 0.49, based on a direct crosswalk to CPT code 68200
(Subconjunctival injection). We note that this recommendation appears
to have been developed under a methodology similar to our ongoing use
of time ratios as one of several methods used to evaluate work. We used
time ratios to identify potential work RVUs and considered these work
RVUs as potential options relative to the values developed through
other options. As we have stated in past rulemaking (such as 82 FR
53032-53033), we do not imply that the decrease in time as reflected in
survey values must equate to a one-to-one or linear decrease in newly
valued work RVUs, as indeed it does not in the case of CPT code 65205
here. Instead, we believed that, since the two components of work are
time and intensity, significant decreases in time should be reflected
in decreases to work RVUs. We appreciate that the RUC-recommended work
RVU for CPT code 65205 has taken these changes in work time into
account, and we support the use of similar methodologies, where
appropriate, in future work valuations.
For CPT code 65210, we disagree with the RUC-recommended work RVU
of 0.75 and we are proposing a work RVU of 0.61 based on a direct
crosswalk to CPT code 92511 (Nasopharyngoscopy with endoscope). This
crosswalk code has the same intraservice time of 5 minutes and 4
additional minutes of total time as compared to CPT code 65210. We note
that the recommended intraservice time for CPT code 65210 is decreasing
from 13 minutes to 5 minutes (62 percent reduction), and the
recommended total time for CPT code 65210 is decreasing from 25 minutes
to 13 minutes (48 percent reduction); however, the RUC-recommended work
RVU is only decreasing from 0.84 to 0.75, which is a reduction of about
11 percent. As we noted earlier, we do not believe that the decrease in
time as reflected in survey values must equate to a one-to-one or
linear decrease in the valuation of work RVUs, and we are not proposing
a linear decrease in the work valuation based on these time ratios.
However, we believe that since the two components of work are time and
intensity, significant decreases in time should be reflected in
decreases to work RVUs, and we do not believe that the recommended work
RVU of 0.75 appropriately reflects these decreases in surveyed work
time.
Our proposed work RVU of 0.61 is also based on a crosswalk to CPT
code 51700 (Bladder irrigation, simple, lavage and/or instillation),
another recently reviewed code with higher time values and a work RVU
of 0.60. We also note that two injection codes (CPT codes 20551 and
64455) were reviewed at the same RUC meeting as CPT code 65210, each of
which shared the same intraservice time of 5 minutes and had a higher
total time of 21 minutes. Both of these codes had a RUC-recommended
work RVU of 0.75, which we are proposing without refinement for CY
2019. Due to the fact that CPT code 65210 has a lower total time and a
lower intensity than both of these injection procedures, we did not
agree that CPT code 65210 should be valued at the same work RVU of
0.75. We believe that our proposed work RVU of 0.61 based on a
crosswalk to CPT code 92511 is a more accurate value for this code.
For the direct PE inputs, we noted that the RUC-recommended
equipment time for the screening lane (EL006) equipment in CPT codes
65205 and 65210 was equal to the total work time in addition to the
clinical labor time needed to set up and clean the equipment. We
disagree that the screening lane would typically be in use for the
total work time, given that this includes the preservice evaluation
time and the immediate postservice time. Although we are not currently
proposing to refine the equipment time for the screening lane in these
two codes, we are soliciting comments on whether the use of the
intraservice work time would be more typical than the total work time
for CPT codes 65205 and 65210.
(30) Injection--Eye (CPT Codes 67500, 67505, and 67515)
CPT code 67515 (Injection of medication or other substance into
Tenon's capsule) was identified as potentially misvalued on a screen of
0-day global services reported with an E/M visit 50 percent of the time
or more, on the same day of service by the same patient and the same
practitioner, that have not been reviewed in the last 5 years with
Medicare utilization greater than 20,000. CPT codes 67500 (Retrobulbar
injection; medication (separate procedure, does not include supply of
medication)) and 67505 (Retrobulbar injection; alcohol) were also
included for review as part of the same family of codes. For CY 2019,
we are proposing the RUC-recommended work RVU of 1.18 for CPT code
67500.
For CPT code 67505, we disagree with the RUC-recommended work RVU
of 1.18 and we are proposing a work RVU of 0.94 based on a direct
crosswalk to CPT code 31575 (Laryngoscopy, flexible; diagnostic). This
is a recently reviewed code with the same intraservice time of 5
minutes and 2 fewer minutes of total time as compared to CPT code
67505. We disagreed with the recommendation to propose the same work
RVU of 1.18 for both CPT code 67500 and 67505 for several reasons. We
noted that the current work RVU of 1.44 for CPT code 67500 is higher
than the current work RVU of 1.27 for CPT code 67505, while the current
work time of CPT code 67500 is less than the current work time for CPT
code 67505. This supported the view that CPT code 67500 should be
valued higher than CPT code 67505 due to its greater intensity, which
we also found to be supportable on clinical grounds. The typical
patient for CPT code 67505 has already lost their sight, and there is
less of a concern about accidental blindness as compared to CPT code
67500. At the recommended identical work RVUs, CPT code 67500 has
almost triple the intensity of CPT code 67505. Similarly, the intensity
does not match our clinical understanding of the complexity and
difficulty of the two procedures.
We also noted that the surveyed total time for CPT code 67505 was 7
minutes less than the surveyed time for CPT code 67500, approximately
21 percent lower. If we were to take the total time ratio between the
two codes, it would produce a suggested work RVU of 0.93 (26 minutes
divided by 33 minutes times a work RVU of 1.18). This time ratio
suggested a work RVU almost identical to the 0.94 value that we
determined via a crosswalk to CPT code 31575. Based on the preceding
rationale, we are proposing a work RVU of 0.94 for CPT code 67505.
For CPT code 67515, we disagree with the RUC-recommended work RVU
of 0.84 and we are proposing a work RVU of 0.75 based on a crosswalk to
CPT code 64450 (Injection, anesthetic agent; other peripheral nerve or
branch). The recommended work RVU is based on a direct crosswalk to CPT
code 65222 (Removal of foreign body, external eye;
[[Page 35758]]
corneal, with slit lamp) at a work RVU of 0.84. However, the
recommended crosswalk code has more than double the intraservice time
of CPT code 67515 at 7 minutes, and we believe that it would be more
accurate to use a crosswalk to a code with a more similar intraservice
time such as CPT code 64450, which is another type of injection
procedure. The proposed work RVU of 0.75 is also based on the use of
the intraservice time ratio with the first code in the family, CPT code
67500. The intraservice time ratio between these codes is 0.60 (3
minutes divided by 5 minutes), which yields a suggested work RVU of
0.71 when multiplied by the recommended work RVU of 1.18 for CPT code
67500. We believe that this provides further rationale for our proposed
work RVU of 0.75 for CPT code 67515.
We are not proposing any direct PE refinements for this code
family.
(31) X-Ray Spine (CPT Codes 72020, 72040, 72050, 72052, 72070, 72072,
72074, 72080, 72100, 72110, 72114, and 72120)
CPT codes 72020 (Radiologic examination, spine, single view,
specify level) and 72072 (Radiologic examination, spine; thoracic, 3
views) were identified on a screen of CMS or Other source codes with
Medicare utilization greater than 100,000 services annually. The code
family was expanded to include ten additional CPT codes to be reviewed
together as a group: CPT codes 72040 (Radiologic examination, spine,
cervical; 2 or 3 views), 72050 (Radiologic examination, spine,
cervical; 4 or 5 views), 72052 (Radiologic examination, spine,
cervical; 6 or more views), 72070 (Radiologic examination, spine;
thoracic, 2 views), 72074 (Radiologic examination, spine; thoracic,
minimum of 4 views), 72080 (Radiologic examination, spine;
thoracolumbar junction, minimum of 2 views), 72100 (Radiologic
examination, spine, lumbosacral; 2 or 3 views), 72110 (Radiologic
examination, spine, lumbosacral; minimum of 4 views), 72114 (Radiologic
examination, spine, lumbosacral; complete, including bending views,
minimum of 6 views), and 72120 (Radiologic examination, spine,
lumbosacral; bending views only, 2 or 3 views).
The radiologic examination procedures described by CPT codes 72020
(Radiologic examination, spine, single view, specify level), 72040
(Radiologic examination, spine, cervical; 2 or 3 views), 72050
(Radiologic examination, spine, cervical; 4 or 5 views), 72052
(Radiologic examination, spine, cervical; 6 or more views), 72070
(Radiologic examination, spine; thoracic, 2 views), 72072 (Radiologic
examination, spine; thoracic, 3 views), 72074 (Radiologic examination,
spine; thoracic, minimum of 4 views), 72080 (Radiologic examination,
spine; thoracolumbar junction, minimum of 2 views), 72100 (Radiologic
examination, spine, lumbosacral; 2 or 3 views), 72110 (Radiologic
examination, spine, lumbosacral; minimum of 4 views), 72114 (Radiologic
examination, spine, lumbosacral; complete, including bending views,
minimum of 6 views), 72120 (Radiologic examination, spine, lumbosacral;
bending views only, 2 or 3 views), 72200 (Radiologic examination,
sacroiliac joints; less than 3 views), 72202 (Radiologic examination,
sacroiliac joints; 3 or more views), 72220 (Radiologic examination,
sacrum and coccyx, minimum of 2 views), 73070 (Radiologic examination,
elbow; 2 views), 73080 (Radiologic examination, elbow; complete,
minimum of 3 views), 73090 (Radiologic examination; forearm, 2 views),
73650 (Radiologic examination; calcaneus, minimum of 2 views), and
73660 (Radiologic examination; toe(s), minimum of 2 views) were all
identified as potentially misvalued through a screen for CPT codes with
high utilization. With approval from the RUC Research Subcommittee, the
specialty societies responsible for reviewing these CPT codes did not
conduct surveys, but instead employed a ``crosswalk methodology,'' in
which they derived physician work and time components for CPT codes by
comparing them to similar CPT codes. We recognize that a substantial
amount of time and effort is involved in conducting surveys of
potentially misvalued CPT codes; however, we have concerns about the
quality of the underlying data used to value these CPT codes. The
descriptors and other information on which the recommendations are
based have themselves not been surveyed, in several instances, since
1995. There is no new information about any of these CPT codes that
would allow us to detect any potential improvements in efficiency of
furnishing the service or evaluate whether changes in practice patterns
have affected time and intensity. We are not categorically opposed to
changes in process or methodology that might reduce the burden of
conducting surveys, but without the benefit of any additional data,
through surveys or otherwise, we are not convinced that there is a
basis for evaluating the RUC's recommendations for work RVUs for each
of these CPT codes.
Since all 20 of the CPT codes in this group have very similar
intraservice (from 3-5 minutes) and total (ranging from 5-8 minutes)
times, we are proposing to use an alternative approach to the valuation
of work RVUs for these CPT codes. We calculated the utilization-
weighted average RUC-recommended work RVU for the 20 CPT codes. The
result of this calculation is a work RVU of 0.23, which we propose to
apply uniformly to each CPT code: 72020, 72040, 72050, 72052, 72070,
72072, 72074, 72080, 72100, 72110, 72114, 72120, 72200, 72202, 72220,
73070, 73080, 73090, 73650, and 73660. We recognize that the proposed
work RVU for some of these CPT codes may be somewhat lower at the code
level than the RUC's recommendation, while the proposed work RVU for
other CPT codes may be slightly higher than the RUC's recommended
value. We nevertheless believe that the alternative, accepting the
RUC's recommendation for each separate CPT code implies a level of
precision about the time and intensity of the CPT codes that we have no
way to validate.
For the direct PE inputs, we are proposing to add a patient gown
(SB026) supply to CPT code 72120. We noted that all of the other codes
in the family that included clinical labor time for the ``Greet
patient, provide gowning, ensure appropriate medical records are
available'' (CA009) task included a patient gown, and we are proposing
to add the patient gown to match the other codes in the family. We
believe that the exclusion of the patient gown for CPT code 72120 was
most likely due to a clerical error in the recommendations. We are also
proposing to refine the equipment time for the basic radiology room
(EL012) in accordance with our standard equipment time formulas.
In our review of the clinical labor time recommended for the
``Perform procedure/service--NOT directly related to physician work
time'' (CA021) task, we noted that the standard convention for this
family of codes seemed to be 3 minutes of clinical labor time per view
being conducted. For example, CPT code 72020 with a single view had 3
minutes of recommended clinical labor time for this activity, while CPT
code 72070 with two views had 6 minutes. However, we also noted that
for the codes with 2-3 views such as CPT codes 72040 and 72100, the
recommended clinical labor time of 9 minutes appears to assume that 3
views would always be typical for the procedure. The same pattern
occurred for codes with 4-5 views, which have a
[[Page 35759]]
recommended clinical labor time of 15 minutes (assuming 5 views is
typical), and for codes with 6 or more views, which have a recommended
clinical labor time of 21 minutes (assuming 7 views is typical).
We are not proposing to refine the clinical labor times for this
task as we do not have data available to know how many views would be
typical for these CPT codes. However, we note that the intraservice
clinical labor time has not changed in roughly 2 decades for these X-
ray services, including during this most recent review, and we believe
that improving technology during this span of time may have resulted in
greater efficiencies in the procedures. We continue to be interested in
data sources regarding the intraservice clinical labor times for
services such as these that do not match the physician intraservice
time, and we welcome any comments that may be able to provide
additional details for the twelve codes under review in this family.
(32) X-Ray Sacrum (CPT Codes 72200, 72202, and 72220)
CPT code 72220 (Radiologic examination, sacrum and coccyx, minimum
of 2 views) was identified on a screen of CMS or Other source codes
with Medicare utilization greater than 100,000 services annually. CPT
codes 72200 (Radiologic examination, sacroiliac joints; less than 3
views) and 72202 (Radiologic examination, sacroiliac joints; 3 or more
views) were also included for review as part of the same family of
codes. See (31) X-Ray Spine (CPT codes 72020, 72040, 72050, 72052,
72070, 72072, 72074, 72080, 72100, 72110, 72114, and 72120) for a
discussion of proposed work RVUs for these codes.
For the direct PE inputs, we are proposing to refine the equipment
time for the basic radiology room (EL012) in accordance with our
standard equipment time formulas.
(33) X-Ray Elbow-Forearm (CPT Codes 73070, 73080, and 73090)
CPT codes 73070 (Radiologic examination, elbow; 2 views) and 73090
(Radiologic examination; forearm, 2 views) were identified on a screen
of CMS or Other source codes with Medicare utilization greater than
100,000 services annually. CPT code 73080 (Radiologic examination,
elbow; complete, minimum of 3 views) was also included for review as
part of the same family of codes. See (31) X-Ray Spine (CPT codes
72020, 72040, 72050, 72052, 72070, 72072, 72074, 72080, 72100, 72110,
72114, and 72120) above for a discussion of proposed work RVUs for
these codes.
For the direct PE inputs, we are proposing to refine the equipment
time for the basic radiology room (EL012) in accordance with our
standard equipment time formulas.
(34) X-Ray Heel (CPT Code 73650)
CPT code 73650 (Radiologic examination; calcaneus, minimum of 2
views) was identified on a screen of CMS or Other source codes with
Medicare utilization greater than 100,000 services annually. See (31)
X-Ray Spine above for a discussion of proposed work RVUs for these
codes.
For the direct PE inputs, we are proposing to refine the equipment
time for the basic radiology room (EL012) in accordance with our
standard equipment time formulas.
(35) X-Ray Toe (CPT Code 73660)
CPT code 73660 (Radiologic examination; toe(s), minimum of 2 views)
was identified on a screen of CMS or Other source codes with Medicare
utilization greater than 100,000 services annually. See (31) X-Ray
Spine above for a discussion of proposed work RVUs for these codes.
For the direct PE inputs, we are proposing to add a patient gown
(SB026) supply to CPT code 73660. We noted that the other codes in
related X-ray code families that included clinical labor time for the
``Greet patient, provide gowning, ensure appropriate medical records
are available'' (CA009) task included a patient gown, and we are
proposing to add the patient gown to match the other codes in these
families. We are also proposing to refine the equipment time for the
basic radiology room (EL012) in accordance with our standard equipment
time formulas.
(36) X-Ray Esophagus (CPT Codes 74210, 74220, and 74230)
CPT code 74220 (Radiologic examination; esophagus) was identified
on a screen of CMS or Other source codes with Medicare utilization
greater than 100,000 services annually. CPT codes 74210 (Radiologic
examination; pharynx and/or cervical esophagus) and 74230 (Swallowing
function, with cineradiography/videoradiography) were also included for
review as part of the same family of codes.
We are proposing the work RVUs recommended by the RUC for the CPT
codes in this family as follows: A work RVU 0.59 for CPT code 74210
(Radiologic examination; pharynx and/or cervical esophagus), a work RVU
of 0.67 for CPT code 74220 (Radiologic examination; esophagus), and a
work RVU of 0.53 for CPT code 74230 (Swallowing function, with
cineradiography/videoradiography).
For the direct PE inputs, we noted that the recommended quantity of
the Polibar barium suspension (SH016) supply is increasing from 1 ml to
150 ml for CPT code 74210 and 100 ml are being added to CPT code 74220,
which did not previously include this supply. The RUC recommendation
states that this supply quantity increase is due to clinical necessity,
but does not go into further details about the typical use of the
supply. Although we are not proposing to refine the quantity of the
Polibar barium suspension at this time, we are seeking additional
comment about the typical use of the supply in these procedures. We are
also proposing to refine the equipment times for all three codes in
accordance with our standard equipment time formulas.
(37) X-Ray Urinary Tract (CPT Code 74420)
CPT code 74420 (Urography, retrograde, with or without KUB) was
identified on a screen of CMS or Other source codes with Medicare
utilization greater than 100,000 services annually.
We are proposing the RUC-recommended work RVU of 0.52 for CPT code
74420 (Urography, retrograde, with or without KUB).
For the direct PE inputs, we are proposing to remove the 1 minute
of clinical labor time for the ``Confirm order, protocol exam'' (CA014)
activity. The clinical labor time recommended for this activity is not
included in the reference code, nor is it included in any of the two
dozen other X-ray codes that were reviewed at the same RUC meeting.
There is also no explanation in the recommended materials as to why
this clinical labor time would need to be added. We do not believe that
this clinical labor would be typical for CPT code 74420, and we are
proposing to remove it to match the rest of the X-ray codes. We are
also proposing to refine the equipment times in accordance with our
standard equipment time formulas.
(38) Fluoroscopy (CPT Code 76000)
CPT code 76000 (Fluoroscopy (separate procedure), up to 1 hour
physician or other qualified health care professional time) was
identified on a screen of CMS or Other source codes with Medicare
utilization greater than 100,000 services annually. CPT code 76001
(Fluoroscopy, physician or other qualified health care professional
time more than 1 hour, assisting a nonradiologic physician or other
qualified health care professional) was
[[Page 35760]]
also included for review as part of the same family of codes. However,
due to the fact that supervision and interpretation services have been
increasingly bundled into the underlying procedure codes, the RUC
concluded that this practice is rare, if not obsolete, and CPT code
76001 was recommended for deletion by the CPT Editorial Panel for CY
2019.
We are proposing the RUC-recommended work RVU of 0.30 for CPT code
76000 (Fluoroscopy (separate procedure), up to 1 hour physician or
other qualified health care professional time, other than 71023 or
71034 (e.g., cardiac fluoroscopy)).
For the direct PE inputs, we are proposing to refine the equipment
times in accordance with our standard equipment time formulas.
(39) Echo Exam of Eye Thickness (CPT Code 76514)
CPT code 76514 (Ophthalmic ultrasound, diagnostic; corneal
pachymetry, unilateral or bilateral (determination of corneal
thickness)) was identified as potentially misvalued on a screen of
codes with a negative intraservice work per unit of time (IWPUT), with
2016 estimated Medicare utilization over 10,000 for RUC reviewed codes
and over 1,000 for Harvard-valued and CMS/Other source codes.
For CPT code 76514, we disagree with the RUC-recommended work RVU
of 0.17 and we are proposing a work RVU of 0.14. We note that the
recommended intraservice time for CPT code 76514 is decreasing from 5
minutes to 3 minutes (40 percent reduction), and the recommended total
time for CPT code 76514 is decreasing from 15 minutes to 5 minutes (67
percent reduction); however, the RUC-recommended work RVU is not
decreasing at all and remains at 0.17. Although we do not imply that
the decrease in time as reflected in survey values must equate to a
one-to-one or linear decrease in the valuation of work RVUs, we believe
that since the two components of work are time and intensity,
significant decreases in time should be reflected in decreases to work
RVUs.
We also note that the RUC recommendations for CPT code 76514 stated
that, although the steps in the procedure are unchanged since it was
first valued, the workflow has changed. With the advent of smaller and
easier to use pachymeters, the technician now typically takes the
measurements that used to be taken by the practitioner for CPT code
76514, and the intraservice time was reduced by two minutes to account
for the technician performing this service. We believe that this change
in workflow indicates that the work RVU for the code should be reduced
in some fashion, since some of the work that was previously done by the
practitioner is now typically performed by the technician. We have no
reason to believe that there is more intensive cognitive work being
performed by the practitioner after these measurements are taken since
the recommendations indicated that the steps in the procedure are
unchanged since this code was first valued.
Therefore, we are proposing a work RVU of 0.14 for CPT code 76514,
which is based on taking half of the intraservice time ratio. We
considered applying the intraservice time ratio to CPT code 76514,
which would reduce the work RVU to 0.10 based on taking the change in
intraservice time (from 5 minutes to 3 minutes) and multiplying this
ratio of 0.60 times the current work RVU of 0.17. However, we recognize
that the minutes shifted to the clinical staff were less intense than
the minutes that remained in CPT code 76514, and therefore, we applied
half of the intraservice time ratio for a reduction of 0.03 RVUs to
arrive at a proposed work RVU of 0.14. We believe that this proposed
value more accurately takes into account the changes in workflow that
have caused substantial reductions in the surveyed work time for the
procedure.
We are not proposing any direct PE refinements for this code
family.
(40) Ultrasound Elastography (CPT Codes 767X1, 767X2, and 767X3)
In September 2017, the CPT Editorial Panel created three new codes
describing the use of ultrasound elastography to assess organ
parenchyma and focal lesions: CPT codes 767X1 (Ultrasound,
elastography; parenchyma), 767X2 (Ultrasound, elastography; first
target lesion) and 767X3 (Ultrasound, elastography; each additional
target lesion). The most common use of this code set will be for
preparing patients with disease of solid organs, like the liver, or
lesions within solid organs.
The RUC recommended a work RVU of 0.59 for CPT code 767X1
(Ultrasound, elastography; parenchyma (e.g., organ)), a work RVU of
0.59 for CPT code 767X2 (Ultrasound, elastography; first target
lesion), and a work RVU of 0.50 for add-on CPT code 767X3 (Ultrasound,
elastography; each additional target lesion). We are proposing the RUC-
recommended work RVUs for each of these new CPT codes.
For the direct PE inputs, we are proposing to refine the clinical
labor time for the ``Prepare room, equipment and supplies'' (CA013)
activity to 3 minutes and to refine the clinical labor time for the
``Confirm order, protocol exam'' (CA014) activity to 0 minutes for CPT
codes 767X1 and 767X2. CPT code 76700 (Ultrasound, abdominal, real time
with image documentation; complete), the reference code for these two
new codes, did not previously have clinical labor time assigned for the
``Confirm order, protocol exam'' clinical labor task, and we do not
have any reason to believe that these particular services being
furnished by the clinical staff have changed in the new codes, only the
way in which this clinical labor time has been presented on the PE
worksheets. We also note that there is no effect on the total clinical
labor direct costs in these situations, since the same 3 minutes of
clinical labor time is still being furnished in CPT codes 767X1 and
767X2. We are also proposing to refine the equipment times in
accordance with our standard equipment time formulas.
(41) Ultrasound Exam--Scrotum (CPT Code 76870)
CPT code 76870 (Ultrasound, scrotum and contents) was identified on
a screen of CMS or Other source codes with Medicare utilization greater
than 100,000 services annually. We are proposing a work RVU of 0.64 for
CPT code 76870 (Ultrasound, scrotum and contents), as recommended by
the RUC.
For the direct PE inputs, we are proposing to refine the clinical
labor time for the ``Prepare room, equipment and supplies'' (CA013)
activity to 3 minutes and to refine the clinical labor time for the
``Confirm order, protocol exam'' (CA014) activity to 0 minutes. CPT
code 76870 did not previously have clinical labor time assigned for the
``Confirm order, protocol exam'' clinical labor task, and we do not
have any reason to believe that the services being furnished by the
clinical staff have changed, only the way in which this clinical labor
time has been presented on the PE worksheets. We also note that there
is no effect on the total clinical labor direct costs in these
situations since the same 3 minutes of clinical labor time is still
being furnished under the CA013 room preparation activity. We are also
proposing to refine the equipment times in accordance with our standard
equipment time formulas.
(42) Contrast-Enhanced Ultrasound (CPT Codes 76X0X and 76X1X)
In September 2017, the CPT Editorial Panel created two new CPT
codes describing the use of intravenous microbubble agents to evaluate
[[Page 35761]]
suspicious lesions by ultrasound. CPT code 76X0X (Ultrasound, targeted
dynamic microbubble sonographic contrast characterization (non-
cardiac); initial lesion) is a stand-alone procedure for the evaluation
of a single target lesion. CPT code 76X1X (Ultrasound, targeted dynamic
microbubble sonographic contrast characterization (non-cardiac); each
additional lesion with separate injection) is an add-on code for the
evaluation of each additional lesion.
The two new CPT codes in this family represent a new technology
that involves the use of intravenous microbubble agents to evaluate
suspicious lesions by ultrasound. The first new CPT code, 76X0X
(Ultrasound, targeted dynamic microbubble sonographic contrast
characterization (non-cardiac); initial lesion), is the base code for
the new add-on CPT code 76X1X (Ultrasound, targeted dynamic microbubble
sonographic contrast characterization (non-cardiac); each additional
lesion with separate injection). The RUC reviewed the survey results
for CPT code 76X0X and recommended total time of 30 minutes and
intraservice time of 20 minutes. Their recommendation for a work RVU of
1.62 is based neither on the median of the survey results (1.82) nor
the 25th percentile of the survey results (1.27). Instead, the RUC-
recommended work RVU is based on a crosswalk to CPT code 73719
(Magnetic resonance (e.g., proton) imaging, lower extremity other than
joint; with contrast material(s)), which has identical intraservice and
total times as the survey CPT code. The RUC also identified a
comparison CPT code (CPT code 73222 (Magnetic resonance (e.g., proton)
imaging, any joint of upper extremity; with contrast material(s)) with
work RVU 1.62 and similar times. For add-on CPT code 76X1X, the RUC
recommended a work RVU of 0.85, which is the 25th percentile of survey
results, with total and intraservice times of 15 minutes.
While we generally agree that, particularly in instances where a
CPT code represents a new technology or procedure, there may be reason
to deviate from survey metrics, we are confused by the logic behind the
RUC's recommendation of a work RVU of 1.62 for CPT code 76X0X. When we
consider the range of existing CPT codes with 30 minutes total time and
20 minutes intraservice time, we note that a work RVU of 1.62 is among
the highest potential crosswalks. We also note that the RUC agreed with
the 25th percentile of survey results for the new add-on CPT code,
76X1X, and we do not see why the 25th percentile wouldn't also be
appropriate for the base CPT code, 76X0X. Therefore, we are proposing a
work RVU of 1.27 for CPT code 76X0X. We identified two CPT codes with
total time of 30 minutes and intraservice time of 20 minutes that
bracket the proposed work RVU of 1.27: CPT code 93975 (Duplex scan of
arterial inflow and venous outflow of abdominal, pelvic, scrotal
contents and/or retroperitoneal organs; complete study) has a work RVU
of 1.16, and CPT code 72270 (Myelography, 2 or more regions (e.g.,
lumbar/thoracic, cervical/thoracic, lumbar/cervical, lumbar/thoracic/
cervical), radiological supervision and interpretation) has a work RVU
of 1.33. We are proposing the RUC-recommended work RVU of 0.85 for add-
on CPT code 76X1X.
For the direct PE inputs, we are proposing to refine the clinical
labor time for the ``Prepare room, equipment and supplies'' (CA013)
activity to 3 minutes and to refine the clinical labor time for the
``Confirm order, protocol exam'' (CA014) activity to 0 minutes for CPT
code 76X0X. CPT codes 76700 (Ultrasound, abdominal, real time with
image documentation; complete) and 76705 (Ultrasound, abdominal, real
time with image documentation; limited), the reference codes for this
new code, did not previously have clinical labor time assigned for the
``Confirm order, protocol exam'' clinical labor task, and we do not
have any reason to believe that these particular services being
furnished by the clinical staff have changed in the new code, only the
way in which this clinical labor time has been presented on the PE
worksheets. We also note that there is no effect on the total clinical
labor direct costs in these situations, since the same 3 minutes of
clinical labor time is still being furnished in CPT code 76X0X.
We are proposing to remove the 50 ml of the phosphate buffered
saline (SL180) for CPT codes 76X0X and 76X1X. When these codes were
reviewed by the RUC, the conclusion that was reached was to remove this
supply and replace it with normal saline. Since the phosphate buffered
saline remained in the recommended direct PE inputs, we believe its
inclusion may have been a clerical error. We are proposing to remove
the supply and soliciting comments on the phosphate buffered saline or
a replacement saline solution. We are also proposing to refine the
equipment times in accordance with our standard equipment time
formulas.
(43) Magnetic Resonance Elastography (CPT Code 76X01)
The CPT Editorial Panel created a new stand-alone code (76X01)
describing the use of magnetic resonance elastography for the
evaluation of organ parenchymal pathology. This code will most often be
used to evaluate patients with disease of solid organs (for example,
cirrhosis of the liver) or pathology within solid organs that manifest
with increasing fibrosis or scarring. The goal with magnetic resonance
elastography is to evaluate the degree of fibrosis/scarring (that is,
stiffness) without having to perform more invasive procedures (for
example, biopsy). This technique can be used to characterize the
severity of parenchymal disease, follow disease progression, or
response to therapy.
The RUC recommended a work RVU for new CPT code 76X01 (Magnetic
resonance (e.g., vibration) elastography) of 1.29, with 15 minutes of
intraservice time and 25 minutes of total time. The recommendation is
based on a comparison with two reference CPT codes, CPT code 74183
(Magnetic resonance (e.g., proton) imaging, abdomen; without contrast
material(s), followed by with contrast material(s) and further
sequences) with total time of 40 minutes, intraservice time of 30
minutes, and a work RVU of 2.20; and CPT code 74181 (Magnetic resonance
(e.g., proton) imaging, abdomen; without contrast material(s)), which
has a total time of 30 minutes, intraservice time of 20 minutes, and a
work RVU of 1.46. The RUC stated that both reference CPT codes have
higher work values than the new CPT code, which is justified in both
cases by higher intra-service times. They note that, despite shorter
intraservice and total time, CPT code 76X01 is slightly more intense to
perform due to the evaluation of wave propagation images and
quantitative stiffness measures. We do not agree with the RUC's
recommended work RVU for this CPT code. Using the RUC's two top
reference CPT codes as a point of comparison, the intraservice time
ratio in both instances suggests that a work RVU closer to 1.10 would
be more appropriate. We recognize that the RUC believes the new CPT
code is slightly more intense to furnish, but we are concerned about
the relativity of this code in comparison with other imaging procedures
that have similar intraservice and total times. Instead of the RUC-
recommended work RVU of 1.29 for CPT code 76X01, we are proposing a
work RVU of 1.10, which is based on a direct crosswalk to CPT code
71250 (Computed tomography, thorax; without contrast material). CPT
code 71250 has identical intraservice time (15 minutes) and total time
(25 minutes) compared to CPT code 76X01, and we
[[Page 35762]]
believe that the work involved in furnishing both services is similar.
We note that CPT code 76X01 describes a new technology and will be
reviewed again by the RUC in 3 years.
For the direct PE inputs, we are proposing to refine the clinical
labor time for the ``Prepare room, equipment and supplies'' (CA013)
activity from 6 minutes to 5 minutes, and for the ``Prepare, set-up and
start IV, initial positioning and monitoring of patient'' (CA016)
activity from 4 minutes to 3 minutes. We disagree that this additional
clinical labor time would be typical for these activities, which are
already above the standard times for these tasks. In both cases, we
propose to maintain the current time from the reference CPT code 72195
(Magnetic resonance (e.g., proton) imaging, pelvis; without contrast
material(s)) for these clinical labor activities. We are also proposing
to refine the equipment times in accordance with our standard equipment
time formulas.
(44) Computed Tomography (CT) Scan for Needle Biopsy (CPT Code 77012)
CPT code 77012 (Computed tomography guidance for needle placement
(e.g., biopsy, aspiration, injection, localization device),
radiological supervision and interpretation) was identified on a screen
of CMS or Other source codes with Medicare utilization greater than
100,000 services annually.
We are proposing the RUC-recommended work RVU of 1.50 for CPT code
77012 (Computed tomography guidance for needle placement (e.g., biopsy,
aspiration, injection, localization device), radiological supervision
and interpretation).
For the direct PE inputs, we are proposing to refine the clinical
labor time for the ``Prepare room, equipment and supplies'' (CA013)
activity to 3 minutes and to refine the clinical labor time for the
``Confirm order, protocol exam'' (CA014) activity to 0 minutes. CPT
code 77012 did not previously have clinical labor time assigned for the
``Confirm order, protocol exam'' clinical labor task, and we do not
have any reason to believe that the services being furnished by the
clinical staff have changed, only the way in which this clinical labor
time has been presented on the PE worksheets. We also note that there
is no effect on the total clinical labor direct costs in these
situations since the same 3 minutes of clinical labor time is still
being furnished under the CA013 room preparation activity.
We are proposing to refine the equipment time for the CT room
(EL007) to maintain the current time of 9 minutes. CPT code 77012 is a
radiological supervision and interpretation procedure and there has
been a longstanding convention in the direct PE inputs, shared by 38
other codes, to assign an equipment time of 9 minutes for the equipment
room in these procedures. We do not believe that it would serve the
interests of relativity to increase the equipment time for the CT room
in CPT code 77012 without also addressing the equipment room time for
the other radiological supervision and interpretation procedures.
Therefore, we are proposing to maintain the current equipment room time
of 9 minutes until this group of procedures can be subject to a more
comprehensive review. We are also proposing to refine the equipment
time for the Technologist PACS workstation (ED050) in accordance with
our standard equipment time formulas.
(45) Dual-Energy X-Ray Absorptiometry (CPT Code 77081)
CPT code 77081 (Dual-energy X-ray absorptiometry (DXA), bone
density study, 1 or more sites; appendicular skeleton (peripheral)
(e.g., radius, wrist, heel)) was identified as potentially misvalued on
a screen of codes with a negative intraservice work per unit of time
(IWPUT), with 2016 estimated Medicare utilization over 10,000 for RUC
reviewed codes and over 1,000 for Harvard valued and CMS/Other source
codes. For CY 2019, we are proposing the RUC-recommended work RVU of
0.20 for CPT code 77081.
We are not proposing any direct PE refinements for this code
family.
(46) Breast MRI With Computer-Aided Detection (CPT Codes 77X49, 77X50,
77X51, and 77X52)
CPT codes 77058 (Magnetic resonance imaging, breast, without and/or
with contrast material(s); unilateral) and 77059 (Magnetic resonance
imaging, breast, without and/or with contrast material(s); bilateral)
were identified in 2016 on a high expenditure services screen across
specialties with Medicare allowed charges of $10 million or more. When
preparing to survey these codes, the specialties noted that the
clinical indications had changed for these exams. The technology had
advanced to make computer-aided detection (CAD) typical and these codes
did not parallel the structure of other magnetic resonance imaging
(MRI) codes. In June 2017 the CPT Editorial Panel deleted CPT codes
0159T, 77058, and 77059 and created four new CPT codes to report breast
MRI with and without contrast (including computer-aided detection).
The RUC recommended a work RVU of 1.45 for CPT code 77X49 (Magnetic
resonance imaging, breast, without contrast material; unilateral). This
recommendation is based on a comparison with CPT codes 74176 (Computed
tomography, abdomen and pelvis; without contrast material) and 74177
(Computed tomography, abdomen and pelvis; with contrast material(s)),
which both have similar intraservice and total times in relation to CPT
code 77X49. We disagree with the RUC's recommended work RVU because we
do not believe that the reduction in total time of 15 minutes between
the new CPT code 77X49 and the deleted CPT code 74177 is adequately
reflected in its recommendation. While total time has decreased by 15
minutes, the only other difference between the two CPT codes is the
change in the descriptor from the phrase `without and/or with contrast
material(s)' to `without contrast material,' suggesting that there is
less work involved in the new CPT code than in the deleted CPT code.
Instead, we are proposing a work RVU of 1.15 for CPT code 77X49, which
is similar to the total time ratio between the new CPT code and the
deleted CPT code. It is also supported by a crosswalk to CPT code 77334
(Treatment devices, design and construction; complex (irregular blocks,
special shields, compensators, wedges, molds or casts)). CPT code 77334
has total time of 35 minutes, intraservice time of 30 minutes, and a
work RVU of 1.15.
CPT code 77X50 (Magnetic resonance imaging, breast, without
contrast material; bilateral) describes the same work as CPT code
77X49, but reflects a bilateral rather than the unilateral procedure.
The RUC recommended a work RVU of 1.60 for CPT code 77X50. Since we are
proposing a different work RVU for the unilateral procedure than the
value proposed by the RUC, we believe it is appropriate to recalibrate
the work RVU for CPT code 77X50 relative to the RUC's recommended
difference in work between the two CPT codes. The RUC's recommendation
for the bilateral procedure is 0.15 work RVUs larger than for the
unilateral procedure. Therefore, we are proposing a work RVU of 1.30
for CPT code 77X50.
The RUC recommended a work RVU of 2.10 for CPT code 77X51 (Magnetic
resonance imaging, breast, without and with contrast material(s),
including computer-aided detection (CAD-real time lesion detection,
characterization and pharmacokinetic analysis) when performed;
unilateral). CPT code 77X51 is a new CPT code that bundles the deleted
CPT code for unilateral breast
[[Page 35763]]
MRI without and/or with contrast material(s) with CAD, which was
previously reported, in addition to the primary procedure CPT code, as
CPT code 0159T (computer aided detection, including computer algorithm
analysis of MRI image data for lesion detection/characterization,
pharmacokinetic analysis, with further physician review for
interpretation, breast MRI). Consistent with our belief that the
proposed value for the base CPT code in this series of new CPT codes
(CPT code 77X49) should be a work RVU of 1.15, we are proposing a work
RVU for CPT code 77X51 that adds the RUC-recommended difference in RUC-
recommended work RVUs between CPT codes 77X49 and 77X51 (0.65 work
RVUs) to the proposed work RVU for CPT code 77X49. Therefore, we are
proposing a work RVU of 1.80 for CPT code 77X51.
The last new CPT code in this series, CPT code 77X52 (Magnetic
resonance imaging, breast, without and with contrast material(s),
including computer-aided detection (CAD-real time lesion detection,
characterization and pharmoacokinetic analysis) when performed;
bilateral) describes the same work as CPT code 77X51, but reflects a
bilateral rather than a unilateral procedure. The RUC recommended a
work RVU of 2.30 for this CPT code. Similar to the process for valuing
work RVUs for CPT code 77X50 and CPT code 77X51, we believe that a more
appropriate work RVU is calculated by adding the difference in the RUC
recommended work RVU for CPT codes 77X49 and 77X52, to the proposed
value for CPT code 77X49. Therefore, we are proposing a work RVU of
2.00 for CPT code 77X52.
For the direct PE inputs, we are proposing to refine the clinical
labor time for the ``Prepare, set-up and start IV, initial positioning
and monitoring of patient'' (CA016) activity from 7 minutes to 3
minutes for CPT codes 77X49 and 77X50, and from 9 minutes to 5 minutes
for CPT codes 77X51 and 77X52. We note that when the MRI of Lower
Extremity codes were reviewed during the previous rule cycle (CPT codes
73718-73720), these codes contained either 3 minutes or 5 minutes of
recommended time for this same clinical labor activity. We also note
that the current Breast MRI codes that are being deleted and replaced
with these four new codes, CPT codes 77058 and 77059, contain 5 minutes
of clinical labor time for this same activity. We have no reason to
believe that the new codes would require additional clinical labor time
for patient positioning, especially given that the recommended clinical
labor times are decreasing in comparison to the reference codes for
obtaining patient consent (CA011) and preparing the room (CA013).
Therefore, we are refining the clinical labor time for the CA016
activity as detailed above to maintain relativity with the current
clinical labor times in the reference codes, as well as with other
recently reviewed MRI procedures.
Included in the recommendations for this code family were five new
equipment items: CAD Server (ED057), CAD Software (ED058), CAD
Software--Additional User License (ED059), Breast coil (EQ388), and CAD
Workstation (CPU + Color Monitor) (ED056). We did not receive any
invoices for these five equipment items, and as such we do not have any
direct pricing information to use in their valuation. We are proposing
to use crosswalks to similar equipment items as proxies for three of
these new types of equipment until we do have pricing information:
CAD software (ED058) is crosswalked to flow cytometry
analytics software (EQ380).
Breast coil (EQ388) is crosswalked to Breast biopsy device
(coil) (EQ371).
CAD Workstation (CPU + Color Monitor) (ED056) is
crosswalked to Professional PACS workstation (ED053).
We welcome the submission of invoices with pricing information for
these three new equipment items for our consideration to replace the
use of these proxies. For the other two equipment items (CAD Server
(ED057) and CAD Software--Additional User License (ED059)), we are not
proposing to establish a price at this time as we believe both of them
would constitute forms of indirect PE under our methodology. We do not
believe that the CAD Server or Additional User License would be
allocated to the use of an individual patient for an individual
service, and can be better understood as forms of indirect costs
similar to office rent or administrative expenses. We understand that
as the PE data age, these issues involving the use of software and
other forms of digital tools become more complex. However, the use of
new technology does not change the statutory requirement under which
indirect PE is assigned on the basis of direct costs that must be
individually allocable to a particular patient for a particular
service. We look forward to continuing to seek out new data sources to
help in updating the PE methodology.
We are also proposing to refine the equipment times in accordance
with our standard equipment time formulas.
(47) Blood Smear Interpretation (CPT Code 85060)
CPT code 85060 (Blood smear, peripheral, interpretation by
physician with written report) was identified on a screen of CMS or
Other source codes with Medicare utilization greater than 100,000
services annually. For CY 2019, the RUC recommended a work RVU of 0.45
based on maintaining the current work RVU.
We disagree with the recommended value and are proposing a work RVU
of 0.36 for CPT code 85060 based on the total time ratio between the
current time of 15 minutes and the recommended time established by the
survey of 12 minutes. This ratio equals 80 percent, and 80 percent of
the current work RVU of 0.45 equals a work RVU of 0.36. When we
reviewed CPT code 85060, we found that the recommended work RVU was
higher than nearly all of the other global XXX codes with similar time
values, and we do not believe that this blood smear interpretation
procedure would have an anomalously high intensity. Although we do not
imply that the decrease in time as reflected in survey values must
equate to a one-to-one or linear decrease in the valuation of work
RVUs, we believe that since the two components of work are time and
intensity, significant decreases in time should be reflected in
decreases to work RVUs. In the case of CPT code 85060, we believe that
it would be more accurate to propose the total time ratio at a work RVU
of 0.36 to account for these decreases in the surveyed work time.
The proposed work RVU is also based on the use of three crosswalk
codes. We are directly supporting the proposed valuation through a
crosswalk to CPT code 95930 (Visual evoked potential (VEP) checkerboard
or flash testing, central nervous system except glaucoma, with
interpretation and report), which has a work RVU of 0.35 along with 10
minutes of intraservice time and 14 minutes of total time. We also
explain the proposed valuation by bracketing it between two other
crosswalks, with CPT code 99152 (Moderate sedation services provided by
the same physician or other qualified health care professional
performing the diagnostic or therapeutic service that the sedation
supports; initial 15 minutes of intraservice time, patient age 5 years
or older) on the lower end at a work RVU of 0.25 and CPT code 93923
(Complete bilateral noninvasive physiologic studies of upper or lower
extremity arteries, 3 or more levels, or single level study with
provocative
[[Page 35764]]
functional maneuvers) on the higher end at a work RVU of 0.45.
The RUC recommended no direct PE inputs for CPT code 85060 and we
are recommending none.
(48) Bone Marrow Interpretation (CPT Code 85097)
CPT code 85097 (Bone marrow, smear interpretation) was identified
on a screen of CMS or Other source codes with Medicare utilization
greater than 100,000 services annually. For CY 2019, the RUC
recommended a work RVU of 1.00 based on a direct crosswalk to CPT code
88121 (Cytopathology, in situ hybridization (e.g., FISH), urinary tract
specimen with morphometric analysis, 3-5 molecular probes, each
specimen; using computer-assisted technology).
We disagree with the RUC-recommended value and we are proposing a
work RVU of 0.94 for CPT code 85097 based on maintaining the current
work valuation. We noted that the survey indicated that CPT code 85097
typically takes 25 minutes of work time to perform, down from a
previous work time of 30 minutes, and, generally speaking, since the
two components of work are time and intensity, we believe that
significant decreases in time should be reflected in decreases to work
RVUs. For the specific case of CPT code 85097, we are supporting our
proposed work RVU of 0.94 through a crosswalk to CPT code 88361
(Morphometric analysis, tumor immunohistochemistry (e.g., Her-2/neu,
estrogen receptor/progesterone receptor), quantitative or
semiquantitative, per specimen, each single antibody stain procedure;
using computer-assisted technology), a recently reviewed code from CY
2018 with the identical time values and a work RVU of 0.95.
We also considered a work RVU of 0.90 based on double the
recommended work RVU of 0.45 for CPT code 85060 (Blood smear,
peripheral, interpretation by physician with written report). When both
of these CPT codes were under review, the explanation was offered that
in a peripheral blood smear, typically, the practitioner does not have
the approximately 12 precursor cells to review, whereas in an aspirate
from the bone marrow, the practitioner is examining all the precursor
cells. Additionally, for CPT code 85097, there are more cell types to
look at as well as more slides, usually four, whereas with CPT code
85060 the practitioner would typically only look at one slide. While we
do not propose to value CPT code 85097 at twice the work RVU of CPT
code 85060, we believe this analysis also supports maintaining the
current work RVU of 0.94 as opposed to raising it to 1.00.
For the direct PE inputs, we are proposing to remove the clinical
labor time for the ``Accession and enter information'' (PA001) and
``File specimen, supplies, and other materials'' (PA008) activities. As
we stated previously, information entry and specimen filing tasks are
not individually allocable to a particular patient for a particular
service and are considered to be forms of indirect PE. While we agree
that these are necessary tasks, under our established methodology we
believe that they are more appropriately classified as indirect PE.
(49) Fibrinolysins Screen (CPT Code 85390)
CPT code 85390 (Fibrinolysins or coagulopathy screen,
interpretation and report) was identified as potentially misvalued on a
screen of codes with a negative IWPUT, with 2016 estimated Medicare
utilization over 10,000 for RUC reviewed codes and over 1,000 for
Harvard valued and CMS/Other source codes. For CY 2019, we are
proposing the RUC-recommended work RVU of 0.75 for CPT code 85390.
Because this is a work only code, the RUC did not recommend, and we
are not proposing any direct PE inputs for CPT code 85390.
(50) Electroretinography (CPT Codes 92X71, 92X73, and 03X0T)
CPT code 92275 (Electroretinography with interpretation and report)
was identified in 2016 on a high expenditure services screen across
specialties with Medicare allowed charges of $10 million or more. In
January 2016, the specialty society noted that they became aware of
inappropriate use of CPT code 92275 for a less intensive version of
this test for diagnosis and indications that are not clinically proven
and for which less expensive and less intensive tests already exist.
CPT changes were necessary to ensure that the service for which CPT
code 92275 was intended was clearly described, as well as an accurate
vignette and work descriptor were developed. In September 2017, the CPT
Editorial Panel deleted CPT code 92275 and replaced it with two new
codes to describe electroretinography full field and multi focal. A
category III code was retained for pattern electroretinography.
For CPT code 92X71 (Electroretinography (ERG) with interpretation
and report; full field (e.g., ffERG, flash ERG, Ganzfeld ERG)), we
disagree with the recommended work RVU of 0.80 and we are instead
proposing a work RVU of 0.69 based on a direct crosswalk to CPT code
88172 (Cytopathology, evaluation of fine needle aspirate; immediate
cytohistologic study to determine adequacy for diagnosis, first
evaluation episode, each site). CPT code 88172 is another
interpretation procedure with the same 20 minutes of intraservice time,
which we believe is a more accurate comparison for CPT code 92X71 than
the two reference codes chosen by the survey participants due to their
significantly higher and lower intraservice times. We note that the
recommended intraservice time for CPT code 92X71 as compared to its
predecessor CPT code 92275 is decreasing from 45 minutes to 20 minutes
(56 percent reduction), and the recommended total time is decreasing
from 71 minutes to 22 minutes (69 percent reduction); however, the work
RVU is only decreasing from 1.01 to 0.80, which is a reduction of just
over 20 percent. Although we do not imply that the decreases in time as
reflected in survey values must equate to a one-to-one or linear
decrease in the valuation of work RVUs, we believe that since the two
components of work are time and intensity, significant decreases in
time should be reflected in decreases to work RVUs. In the case of CPT
code 92X71, we have reason to believe that the significant drops in
surveyed work time as compared to CPT code 92275 are a result of
improvements in technology since the predecessor code was reviewed. The
older machines used for electroretinography were slower and more
cumbersome, and now the same work for the service can be performed in
significantly less time. Therefore, we are proposing a work RVU of 0.69
based on the direct crosswalk to CPT code 88172, which we believe more
accurately accounts for these decreases in surveyed work time.
For CPT code 92X73 (Electroretinography (ERG) with interpretation
and report; multifocal (mfERG)), we disagree with the RUC-recommended
work RVU of 0.72 and are proposing a work RVU of 0.61. We concur that
the relative difference in work between CPT code 92X71 and 92X73 is
equivalent to the recommended interval of 0.08 RVUs. Therefore, we are
proposing a work RVU of 0.61 for CPT code 92X73, based on the
recommended interval of 0.08 fewer RVUs below our proposed work RVU of
0.69 for CPT code 92X71. The proposed work RVU is also based on the use
of two crosswalk codes: CPT code 88387 (Macroscopic examination,
dissection, and preparation of tissue for
[[Page 35765]]
non-microscopic analytical studies; each tissue preparation); and CPT
code 92100 (Serial tonometry (separate procedure) with multiple
measurements of intraocular pressure over an extended time period with
interpretation and report, same day). Both codes share the same 20
minutes of intraservice and 20 minutes of total time, with a work RVU
of 0.62 for CPT code 88387 and a work RVU of 0.61 for CPT code 92100.
The recommendations for this code family also include Category III
code 03X0T (Electroretinography (ERG) with interpretation and report,
pattern (PERG)). We typically assign contractor pricing for Category
III codes since they are temporary codes assigned to emerging
technology and services. However, in cases where there is an unusually
high volume of services that will be performed under a Category III
code, we have sometimes assigned an active status to the procedure and
developed RVUs before a formal CPT code is created. In the case of
Category III code 03X0T, the recommendations indicate that
approximately 80 percent of the services currently reported under CPT
code 92275 will be reported under the new Category III code. Since this
will involve an estimated 100,000 services for CY 2019, we believe that
the interests of relativity would be better served by assigning an
active status to Category III code 03X0T and creating RVUs through the
use of a proxy crosswalk to a similar existing service. Therefore, we
are proposing to assign an active status to Category III code 03X0T for
CY 2019, with a work RVU and work time values crosswalked from CPT code
92250 (Fundus photography with interpretation and report). CPT code
92250 is a clinically similar procedure that was recently reviewed
during the CY 2017 rule cycle. We are proposing a work RVU of 0.40 and
work times of 10 minutes of intraservice and 12 minutes of total time
for Category III code 03X0T based on this crosswalk to CPT code 92250.
For the direct PE inputs, we are proposing to remove the preservice
clinical labor in the facility setting for CPT codes 92X71 and 92X73.
Both of these codes are diagnostic tests under which the professional
(26 modifier) and technical (TC modifier) components will be separately
billable, and codes that have these professional and technical
components typically will not have direct PE inputs in the facility
setting since the technical component is only valued in the nonfacility
setting. We also note on this subject that the predecessor code, CPT
code 92275, does not currently include any preservice clinical labor,
nor any facility direct PE inputs.
We are proposing to remove the clinical labor time for the ``Greet
patient, provide gowning, ensure appropriate medical records are
available'' (CA009) and the ``Provide education/obtain consent''
(CA011) activities for CPT codes 92X71 and 92X73. Both of these CPT
codes will typically be reported with a same day E/M service, and we
believe that these clinical labor tasks will be carried out during the
E/M service. We believe that their inclusion in CPT codes 92X71 and
92X73 would be duplicative. We are also proposing to refine the
clinical labor time for the ``Prepare room, equipment and supplies''
(CA013) activity to 3 minutes and to refine the clinical labor time for
the ``Confirm order, protocol exam'' (CA014) activity to 0 minutes for
both codes. The predecessor CPT code 92275 did not previously have
clinical labor time assigned for the ``Confirm order, protocol exam''
clinical labor task, and we do not have any reason to believe that the
services being furnished by the clinical staff have changed in the new
codes, only the way in which this clinical labor time has been
presented on the PE worksheets. We also note that there is no effect on
the total clinical labor direct costs in these situations since the
same 3 minutes of clinical labor time is still being furnished.
We are proposing to refine the clinical labor time for the ``Clean
room/equipment by clinical staff'' (CA024) activity from 12 minutes to
8 minutes for CPT codes 92X71 and 92X73. The recommendations for these
codes stated that cleaning is carried out in several steps: The patient
is first cleaned for 2 minutes, followed by wires and electrodes being
scrubbed carefully with detergent, soaked, and then rinsed with sterile
water. We agree with the need for 2 minutes of patient cleaning time
and for the cleaning of the wires and electrodes to take place in two
different steps. However, our standard clinical labor time for room/
equipment cleaning is 3 minutes, and therefore, we are proposing a
total time of 8 minutes for these codes, based on 2 minutes for patient
cleaning and then 3 minutes for each of the two steps of wire and
electrode cleaning.
We are proposing to refine the clinical labor time for the
``Technologist QC's images in PACS, checking for all images, reformats,
and dose page'' (CA030) activity from 10 minutes to 3 minutes for CPT
codes 92X71 and 92X73. We finalized in the CY 2017 PFS final rule (81
FR 80184-80186) a range of appropriate standard minutes for this
clinical labor activity, ranging from 2 minutes for simple services up
to 5 minutes for highly complex services. We believe that the
complexity of the imaging in CPT codes 92X71 and 92X73 is comparable to
the CT and magnetic resonance (MR) codes that have been recently
reviewed, such as CPT code 76X01 (Magnetic resonance (e.g., vibration)
elastography). Therefore, in order to maintain relativity, we are
proposing the same clinical labor time of 3 minutes for CPT codes 92X71
and 92X73 that has been recommended for these CT and MR codes. We are
also proposing to refine the clinical labor time for the ``Review
examination with interpreting MD/DO'' (CA031) activity from 5 minutes
to 2 minutes for CPT codes 92X71 and 92X73. We also finalized in the CY
2017 PFS final rule a standard time of 2 minutes for reviewing
examinations with the interpreting MD, and we have no reason to believe
that these codes would typically require additional clinical labor at
more than double the standard time.
We noted that the new equipment item ``Contact lens electrode for
mfERG and ffERG'' (EQ391) was listed twice for CPT code 92X71 but only
a single time for CPT code 92X73. We are seeking additional information
about whether the recommendations intended this equipment item to be
listed twice, with one contact intended for each eye, or whether this
was a clerical mistake. We are also interested in additional
information as to why the contact lens electrode was listed twice for
CPT code 92X71 but only a single time for CPT code 92X73. Finally, we
are also proposing to refine the equipment times in accordance with our
standard equipment time formulas.
We are proposing to use the direct PE inputs for CPT code 92X73,
including the refinements detailed above, as a proxy for Category III
code 03X0T until it can be separately reviewed by the RUC.
(51) Cardiac Output Measurement (CPT Codes 93561 and 93562)
CPT codes 93561 (Indicator dilution studies such as dye or
thermodilution, including arterial and/or venous catheterization; with
cardiac output measurement) and 93562 (Indicator dilution studies such
as dye or thermodilution, including arterial and/or venous
catheterization; subsequent measurement of cardiac output) were
identified as potentially misvalued on a screen of codes with a
negative IWPUT, with 2016 estimated Medicare utilization over 10,000
for RUC reviewed codes and over 1,000 for
[[Page 35766]]
Harvard valued and CMS/Other source codes. The specialty societies
noted that CPT codes 93561 and 93562 are primarily performed in the
pediatric population, thus the Medicare utilization for these Harvard-
source services is not over 1,000. However, the specialty societies
requested and the RUC agreed that these services should be reviewed
under this negative IWPUT screen.
For CPT code 93561, we disagree with the RUC-recommended work RVU
of 0.95 and we are proposing a work RVU of 0.60 based on a crosswalk to
CPT code 77003 (Fluoroscopic guidance and localization of needle or
catheter tip for spine or paraspinous diagnostic or therapeutic
injection procedures (epidural or subarachnoid)). CPT Code 77003 is
another recently-reviewed add-on global code with the same 15 minutes
of intraservice time and 2 additional minutes of preservice evaluation
time. In our review of CPT code 93561, we found that there was a
particularly unusual relationship between the surveyed work times and
the RUC-recommended work RVU. We noted that the recommended
intraservice time for CPT code 93561 is decreasing from 29 minutes to
15 minutes (48 percent reduction), and the recommended total time for
CPT code 93561 is decreasing from 78 minutes to 15 minutes (81 percent
reduction); however, the recommended work RVU is instead increasing
from 0.25 to 0.95, which is an increase of nearly 300 percent. Although
we do not imply that the decrease in time as reflected in survey values
must equate to a one-to-one or linear decrease in the valuation of work
RVUs, we believe that since the two components of work are time and
intensity, significant decreases in time should typically be reflected
in decreases to work RVUs, not increases in valuation. We recognize
that CPT code 93561 is an unusual case, as it is shifting from 0-day
global status to add-on code status. However, when the work time for a
code is going down and the unit of service is being reduced, we would
not expect to see an increased work RVU under these circumstances, and
especially not such a large work RVU increase. Therefore, we are
proposing instead to crosswalk CPT code 93561 to CPT code 77003 at a
work RVU of 0.60, which we believe is a more accurate valuation in
relation to other recently-reviewed add-on codes on the PFS. We believe
that this proposed work RVU of 0.60 better preserves relativity with
other clinically similar codes with similar surveyed work times.
For CPT code 93562, we disagree with the recommended work RVU of
0.77 and are proposing a work RVU of 0.48 based on the intraservice
time ratio with CPT code 93561. We observed a similar pattern taking
place with CPT code 93562 as with the first code in the family, noting
that the recommended intraservice time is decreasing from 16 minutes to
12 minutes (25 percent reduction), and the recommended total time is
decreasing from 44 minutes to 12 minutes (73 percent reduction);
however, the RUC-recommended work RVU is instead increasing from 0.01
to 0.77. We recognize that CPT code 93562 is another unusual case, as
it is also shifting from 0-day global status to add-on code status, and
the current work RVU of 0.01 was a decrease from the code's former
valuation of 0.16 following the removal of moderate sedation in the CY
2017 rule cycle. However, when the work time for a code is going down
and the unit of service is being reduced, we typically would not expect
to see a work RVU increase under these circumstances, and especially
not such a large work RVU increase. Therefore, we are proposing instead
to apply the intraservice time ratio from CPT code 93561, for a ratio
of 0.80 (12 minutes divided by 15 minutes) multiplied by the proposed
work RVU of 0.60 for CPT code 93561, which results in the proposed work
RVU of 0.48 for CPT code 93562. We note that the RUC-recommended work
values also line up according to the same intraservice time ratio, with
the recommended work RVU of 0.77 for CPT code 93562 existing in a ratio
of 0.81 with the recommended work RVU of 0.95 for CPT code 93561. We
believe that this provides further rationale for our proposal to value
the work RVU of CPT code 93562 at 80 percent of the work RVU of CPT
code 93561.
There are no recommended direct PE inputs for the codes in this
family and we are not proposing any direct PE inputs.
(52) Coronary Flow Reserve Measurement (CPT Codes 93571 and 93572)
CPT code 93571 (Intravascular Doppler velocity and/or pressure
derived coronary flow reserve measurement (coronary vessel or graft)
during coronary angiography including pharmacologically induced stress;
initial vessel) was identified on a list of all services with total
Medicare utilization of 10,000 or more that have increased by at least
100 percent from 2009 through 2014. CPT code 93572 (Intravascular
Doppler velocity and/or pressure derived coronary flow reserve
measurement (coronary vessel or graft) during coronary angiography
including pharmacologically induced stress; each additional vessel) was
also included for review as part of the same family of CPT codes. The
RUC recommended a work RVU of 1.50 for CPT code 93571, which is lower
than the current work RVU of 1.80. The total time for this service
decreased by 5 minutes from 20 minutes to 15 minutes. The RUC's
recommendation is based on a crosswalk to CPT code 15136 (Dermal
autograft, face, scalp, eyelids, mouth, neck, ears, orbits, genitalia,
hands, feet, and/or multiple digits; each additional 100 sq cm, or each
additional 1% of body area of infants and children, or part thereof),
which has an identical intraservice and total time as CPT code 93571 of
15 minutes. We disagree with the recommended work RVU of 1.50 for this
CPT code because we do not believe that a reduction in work RVU from
1.80 to 1.50 is commensurate with the reduction in time for this
service of five minutes. Using the building block methodology, we
believe the work RVU for CPT code 93571 should be 1.35. We believe that
a crosswalk to CPT code 61517 (Implantation of brain intracavitary
chemotherapy agent (List separately in addition to CPT code for primary
procedure)) with a work RVU of 1.38 is more appropriate because it has
an identical intraservice and total time (15 minutes) as CPT code
93571, describes work that is similar, and is closer to the
calculations for intraservice time ratio, total time ratio, and the
building block method. Therefore, we are proposing a work RVU of 1.38
for CPT code 93571.
We are proposing the RUC-recommended work RVU for CPT code 93572
(Intravascular Doppler velocity and/or pressure derived coronary flow
reserve measurement (coronary vessel or graft) during coronary
angiography including pharmacologically induced stress; each additional
vessel) of 1.00.
Both of these codes are facility-only procedures with no
recommended direct PE inputs.
(53) Peripheral Artery Disease (PAD) Rehabilitation (CPT Code 93668)
During 2017, we issued a national coverage determination (NCD) for
Medicare coverage of supervised exercise therapy (SET) for the
treatment of peripheral artery disease (PAD). Previously, the service
had been assigned noncovered status under the PFS. CPT code 93668
(Peripheral arterial disease (PAD) rehabilitation, per session) was
payable before the end of CY 2017, retroactive to the effective date of
the NCD (May 25, 2017), and for CY 2018, CMS made payment for Medicare-
covered SET for the treatment of PAD,
[[Page 35767]]
consistent with the NCD, reported with CPT code 93668. We used the most
recent RUC-recommended work and direct PE inputs and requested that the
RUC review the service, which had not been reviewed since 2001, for
direct PE inputs. The RUC is not recommending a work RVU for CPT code
93668 due to the belief that there is no physician work involved in
this service. After reviewing this code, we are proposing a work RVU of
0.00 for CPT code 93668 and are proposing to continue valuing the code
for PE only.
(54) Home Sleep Apnea Testing (CPT Codes 95800, 95801, and 95806)
CPT codes 95800 (Sleep study, unattended, simultaneous recording;
heart rate, oxygen saturation, respiratory analysis (e.g., by airflow
or peripheral arterial tone), and sleep time), 95801 (Sleep study,
unattended, simultaneous recording; minimum of heart rate, oxygen
saturation, and respiratory analysis (e.g., by airflow or peripheral
arterial tone)), and 95806 (Sleep study, unattended, simultaneous
recording of, heart rate, oxygen saturation, respiratory airflow, and
respiratory effort (e.g., thoracoabdominal movement)) were flagged by
the CPT Editorial Panel and reviewed at the October 2014 Relativity
Assessment Workgroup meeting. Due to rapid growth in service volume,
the RUC recommended that these services be reviewed after 2 more years
of Medicare utilization data (2014 and 2015 data). These three codes
were surveyed for the April 2017 RUC meeting and new recommendations
for work and direct PE inputs were submitted to CMS.
For CPT code 95800, the RUC recommended a work RVU of 1.00 based on
the survey 25th percentile value. We disagree with the recommended
value and are proposing a work RVU of 0.85 based on a pair of crosswalk
codes: CPT code 93281 (Programming device evaluation (in person) with
iterative adjustment of the implantable device to test the function of
the device and select optimal permanent programmed values with
analysis, review and report by a physician or other qualified health
care professional; multiple lead pacemaker system) and CPT code 93260
(Programming device evaluation (in person) with iterative adjustment of
the implantable device to test the function of the device and select
optimal permanent programmed values with analysis, review and report by
a physician or other qualified health care professional; implantable
subcutaneous lead defibrillator system). Both of these codes have a
work RVU of 0.85, as well as having the same intraservice time of 15
minutes, similar total times to CPT code 95800, and recent review dates
within the last few years.
In reviewing CPT code 95800, we noted that the recommended
intraservice time is decreasing from 20 minutes to 15 minutes (25
percent reduction), and the recommended total time is decreasing from
50 minutes to 31 minutes (38 percent reduction); however, the RUC-
recommended work RVU is only decreasing from 1.05 to 1.00, which is a
reduction of less than 5 percent. Although we do not imply that the
decrease in time as reflected in survey values must equate to a one-to-
one or linear decrease in the valuation of work RVUs, we believe that
since the two components of work are time and intensity, significant
decreases in time should be reflected in decreases to work RVUs. In the
case of CPT code 95800, we believe that it would be more accurate to
propose a work RVU of 0.85 based on the aforementioned crosswalk codes
to account for these decreases in the surveyed work time. We also note
that in this case where the surveyed times are decreasing and the
utilization of CPT code 95800 is increasingly significantly
(quadrupling in the last 5 years), we have reason to believe that
practitioners are becoming more efficient at performing the procedure,
which, under the resource-based nature of the RVU system, lends further
support for a reduction in the work RVU.
For CPT code 95801, the RUC proposed a work RVU of 1.00 again based
on the survey 25th percentile. We disagree with the recommended value
and we are again proposing a work RVU of 0.85 based on the same pair of
crosswalk codes, CPT codes 93281 and 93260. We noted that CPT codes
95800 and 95801 had identical recommended work RVUs and identical
recommended survey work times. Given that these two codes also have
extremely similar work descriptors, we interpreted this to mean that
the two codes could have the same work RVU, and therefore, we are
proposing the same work RVU of 0.85 for both codes.
For CPT code 95806, the RUC recommended a work RVU of 1.08 based on
a crosswalk to CPT code 95819 (Electroencephalogram (EEG); including
recording awake and asleep). Although we disagree with the RUC-
recommended work RVU of 1.08, we concur that the relative difference in
work between CPT codes 95800 and 95801 and CPT code 95806 is equivalent
to the recommended interval of 0.08 RVUs. Therefore, we are proposing a
work RVU of 0.93 for CPT code 95806, based on the recommended interval
of 0.08 additional RVUs above our proposed work RVU of 0.85 for CPT
codes 95800 and 95801. We also note that CPT code 95806 is experiencing
a similar change in the recommended work and time values comparable to
CPT code 95800. The recommended intraservice time for CPT code 95806 is
decreasing from 25 minutes to 15 minutes (40 percent), and the
recommended total time is decreasing from 50 minutes to 31 minutes (38
percent); however, the recommended work RVU is only decreasing from
1.25 to 1.08, which is a reduction of only 14 percent. As we stated for
CPT code 95800, we do not believe that decreases in work time must
equate to a one-to-one or linear decrease in the valuation of work
RVUs, but we do believe that these changes in surveyed work time
suggest that practitioners are becoming more efficient at performing
the procedure, and that it would be more accurate to maintain the
recommended work interval with CPT codes 95800 and 95801 by proposing a
work RVU of 0.93 for CPT code 95806.
We are not proposing any direct PE refinements for this code
family.
(55) Neurostimulator Services (CPT Codes 95970, 95X83, 95X84, 95X85,
and 95X86)
In October 2013, CPT code 95971 (Electronic analysis of implanted
neurostimulator pulse generator system; simple spinal cord, or
peripheral (i.e., peripheral nerve, sacral nerve, neuromuscular)
neurostimulator pulse generator/transmitter, with intraoperative or
subsequent programming) was identified in the second iteration of the
High Volume Growth screen. In January 2014, the RUC recommended that
CPT codes 95971, 95972 (Electronic analysis of implanted
neurostimulator pulse generator system; complex spinal cord, or
peripheral (i.e., peripheral nerve, sacral nerve, neuromuscular)
(except cranial nerve) neurostimulator pulse generator/transmitter,
with intraoperative or subsequent programming) and 95974 (Electronic
analysis of implanted neurostimulator pulse generator system; complex
cranial nerve neurostimulator pulse generator/transmitter, with
intraoperative or subsequent programming, with or without nerve
interface testing, first hour) be referred to the CPT Editorial Panel
to address the entire family regarding the time referenced in the CPT
code descriptors. In June 2017, the CPT Editorial Panel revised CPT
codes 95970, 95971, and 95972, deleted CPT codes 95974, 95975
(Electronic analysis of implanted neurostimulator pulse
[[Page 35768]]
generator system; complex cranial nerve neurostimulator pulse
generator/transmitter, with intraoperative or subsequent programming,
each additional 30 minutes after first hour), 95978 (Electronic
analysis of implanted neurostimulator pulse generator system, complex
deep brain neurostimulator pulse generator/transmitter, with initial or
subsequent programming; first hour), and 95979 (Electronic analysis of
implanted neurostimulator pulse generator system, complex deep brain
neurostimulator pulse generator/transmitter, with initial or subsequent
programming; each additional 30 minutes after first hour) and created
four new CPT codes for analysis and programming of implanted cranial
nerve neurostimulator pulse generator, analysis, and programming of
brain neurostimulator pulse generator systems and analysis of stored
neurophysiology recording data.
The RUC recommended a work RVU of 0.45 for CPT code 95970
(Electronic analysis of implanted neurostimulator pulse generator/
transmitter (e.g., contact group(s), interleaving, amplitude, pulse
width, frequency (Hz), on/off cycling, burst, magnet mode, dose
lockout, patient selectable parameters, responsive neurostimulation,
detection algorithms, closed loop parameters, and passive parameters by
physician or other qualified health care professional; with brain,
cranial nerve, spinal cord, peripheral nerve, or sacral nerve
neurostimulator pulse generator/transmitter, without programming)),
which is identical to the current work RVU for this CPT code. The
descriptor for this CPT code has been modified slightly, but the
specialty societies affirmed that the work itself has not changed. To
justify its recommendation, the RUC provided two references: CPT code
62368 (Electronic analysis of programmable, implanted pump for
intrathecal or epidural drug infusion (includes evaluation of reservoir
status, alarm status, drug prescription status); with reprogramming),
with intraservice time of 15 minutes, total time of 27 minutes, and a
work RVU of 0.67; and CPT code 99213 (Office or other outpatient visit
for the evaluation and management of an established patient, which
requires at least 2 of these 3 key components: An expanded problem
focused history; An expanded problem focused examination; or Medical
decision making of low complexity. Counseling and coordination of care
with other physicians, other qualified health care professionals, or
agencies are provided consistent with the nature of the problem(s) and
the patient's and/or family's needs. Usually, the presenting problem(s)
are of low to moderate severity. Typically, 15 minutes are spent face-
to-face with the patient and/or family), with intraservice time of 15
minutes, total time of 23 minutes, and a work RVU of 0.97. We disagree
with the RUC's recommendation because we do not believe that
maintaining the work RVU, given a decrease of four minutes in total
time, is appropriate. In addition, we note that the reference CPT codes
chosen have much higher intraservice and total times than CPT code
95970, and also have higher work RVUs, making them poor comparisons.
Instead, we identified a crosswalk to CPT code 95930 (Visual evoked
potential (VEP) checkerboard or flash testing, central nervous system
except glaucoma, with interpretation and report) with 10 minutes
intraservice time, 14 minutes total time, and a work RVU of 0.35.
Therefore, we are proposing a work RVU of 0.35 for CPT code 95970.
CPT code 95X83 (Electronic analysis of implanted neurostimulator
pulse generator/transmitter (e.g., contact group(s), interleaving,
amplitude, pulse width, frequency (Hz), on/off cycling, burst, magnet
mode, dose lockout, patient selectable parameters, responsive
neurostimulation, detection algorithms, closed loop parameters, and
passive parameters) by physician or other qualified health care
professional; with simple cranial nerve neurostimulator pulse
generator/transmitter programming by physician or other qualified
health care professional) is a new CPT code replacing CPT code 95974
(Electronic analysis of implanted neurostimulator pulse generator
system (e.g., rate, pulse amplitude, pulse duration, configuration of
wave form, battery status, electrode selectability, output modulation,
cycling, impedance and patient compliance measurements); complex
cranial nerve neurostimulator pulse generator/transmitter, with
intraoperative or subsequent programming, with or without nerve
interface testing, first hour). The description of the work involved in
furnishing CPT code 95X83 differs from that of the deleted CPT code in
a few important ways, notably that the time parameter has been removed
so that the CPT code no longer describes the first hour of programming.
In addition, the new CPT code refers to simple rather than complex
programming. Accordingly, the intraservice and total times for this CPT
code are substantively different from those of the deleted CPT code.
CPT code 95X83 has an intraservice time of 11 minutes and a total time
of 24 minutes, while CPT code 95974 has an intraservice time of 60
minutes and a total time of 110 minutes. The RUC recommended a work RVU
of 0.95 for CPT code 95X83. The RUC's top reference CPT code as chosen
by the RUC survey participants was CPT code 95816 (Electroencephalogram
(EEG); including recording awake and drowsy), with an intraservice time
of 15 minutes, 26 minutes total time, and a work RVU of 1.08. The RUC
indicated that the service is similar, but somewhat more complex than
CPT code 95X83. We disagree with the RUC's recommended work RVU for
this CPT code because we do not believe that the large difference in
time between the new CPT code and CPT code 95974 is reflected in the
slightly smaller proportional decrease in work RVUs. The reduction in
total time, from 110 minutes to 24 minutes is nearly 80 percent.
However, the RUC's recommended work RVU reflects a reduction of just
under 70 percent. We believe that a more appropriate crosswalk would be
CPT code 76641 (Ultrasound, breast, unilateral, real time with image
documentation, including axilla when performed; complete) with
intraservice time of 12 minutes, total time of 22 minutes, and a work
RVU of 0.73. Therefore, we are proposing a work RVU of 0.73 for CPT
code 95X83.
CPT code 95X84 describes the same work as CPT code 95X83, but with
complex rather than simple programming. The CPT Editorial Panel refers
to simple programming of a neurostimulator pulse generator/transmitter
as the adjustment of one to three parameter(s), while complex
programming includes adjustment of more than three parameters. For
purposes of applying the building block methodology and calculating
intraservice and total time ratios, the RUC compared CPT code 94X84
with CPT code 95975 (Electronic analysis of implanted neurostimulator
pulse generator system (e.g., rate, pulse amplitude, pulse duration,
configuration of wave form, battery status, electrode selectability,
output modulation, cycling, impedance and patient compliance
measurements); complex cranial nerve neurostimulator pulse generator/
transmitter, with intraoperative or subsequent programming, each
additional 30 minutes after first hour), which is being deleted by the
CPT Editorial Panel. We believe that this was an inappropriate
comparison since it is time based (first hour of programming) and is an
add-on code. Instead we believe that the RUC
[[Page 35769]]
intended to compare CPT code 95X84 with CPT code 95974 (Electronic
analysis of implanted neurostimulator pulse generator system (e.g.,
rate, pulse amplitude, pulse duration, configuration of wave form,
battery status, electrode selectability, output modulation, cycling,
impedance and patient compliance measurements); complex cranial nerve
neurostimulator pulse generator/transmitter, with intraoperative or
subsequent programming, with or without nerve interface testing, first
hour), which has been recommended for deletion by the CPT Editorial
Panel and is also the comparison for CPT code 95X83. The RUC
recommended a work RVU of 1.19 for CPT code 95X84. The RUC disagreed
with the two top reference services CPT code 99215 (Office or other
outpatient visit for the evaluation and management of an established
patient, which requires at least 2 of these 3 key components: A
comprehensive history; A comprehensive examination; or Medical decision
making of high complexity. Counseling and/or coordination of care with
other physicians, other qualified health care professionals, or
agencies are provided consistent with the nature of the problem(s) and
the patient's and/or family's needs. Usually, the presenting problem(s)
are of moderate to high severity. Typically, 40 minutes are spent face-
to-face with the patient and/or family) and CPT code 99202 (Office or
other outpatient visit for the evaluation and management of a new
patient, which requires these 3 key components: An expanded problem
focused history; An expanded problem focused examination; or
straightforward medical decision making. Counseling and/or coordination
of care with other physicians, other qualified health care
professionals, or agencies are provided consistent with the nature of
the problem(s) and the patient's and/or family's needs. Usually, the
presenting problem(s) are of low to moderate severity. Typically, 20
minutes are spent face-to-face with the patient and/or family) and
instead compared CPT code 95X84 to CPT code 99308 (Subsequent nursing
facility care, per day, for the evaluation and management of a patient,
which requires at least 2 of these 3 key components: An expanded
problem focused interval history; An expanded problem focused
examination; or Medical decision making of low complexity. Counseling
and/or coordination of care with other physicians, other qualified
health care professionals, or agencies are provided consistent with the
nature of the problem(s) and the patient's and/or family's needs.
Usually, the patient is responding inadequately to therapy or has
developed a minor complication. Typically, 15 minutes are spent at the
bedside and on the patient's facility floor or unit.) with total time
of 31 minutes, intraservice time of 15 minutes, and a work RVU of 1.16;
and CPT code 12013 (Simple repair of superficial wounds of face, ears,
eyelids, nose, lips and/or mucous membranes; 2.6 cm to 5.0 cm), with
total time of 27 minutes, intraservice time of 15 minutes, and a work
RVU of 1.22. We disagree with the RUC's recommended work RVU of 1.19
for CPT code 95X84. Once the comparison CPT code is corrected to CPT
code 95974, the reverse building block calculation indicates that a
lower work RVU (close to 0.82) would be a better reflection of the work
involved in furnishing this service. As an alternative to the RUC's
recommendation, we added the difference in RUC-recommended work RVUs
between CPT code 95X83 and 95X84 (0.24 RVUs) to the proposed work RVU
of 0.73 for CPT code 95X83. Therefore, we propose a work RVU of 0.97
for CPT code 95X84.
CPT code 95X85 (Electronic analysis of implanted neurostimulator
pulse generator/transmitter (e.g., contact group(s), interleaving,
amplitude, pulse width, frequency (Hz), on/off cycling, burst, magnet
mode, doe lockout, patient selectable parameters, responsive
neurostimulation, detection algorithms, closed loop parameters, and
passive parameters) by physician or other qualified health care
professional; with brain neurostimulator pulse generator/transmitter
programming, first 15 minutes face-to-face time with physician or other
qualified health care professional) is the base for add-on CPT code
95X86 (Electronic analysis of implanted neurostimulator pulse
generator/transmitter (e.g., contact group(s), interleaving, amplitude,
pulse width, frequency (Hz), on/off cycling, burst, magnet mode, doe
lockout, patient selectable parameters, responsive neurostimulation,
detection algorithms, closed loop parameters, and passive parameters)
by physician or other qualified health care professional; with brain
neurostimulator pulse generator/transmitter programming, each
additional 15 minutes face-to-face time with physician or other
qualified health care professional), which is an add-on CPT code and
can only be billed with CPT code 95X85. The RUC compared CPT code 95X85
with CPT code 95978 (Electronic analysis of implanted neurostimulator
pulse generator system (e.g., rate, pulse amplitude and duration,
battery status, electrode selectability and polarity, impedance and
patient compliance measurements), complex deep brain neurostimulator
pulse generator/transmitter, with initial or subsequent programming;
first hour), which the CPT Editorial Panel is recommending for
deletion. The primary distinction between the new and old CPT codes is
that the new CPT code describes the first 15 minutes of programming
while the deleted CPT code describes up to one hour of programming. The
RUC recommended a work RVU of 1.25 for CPT code 95X85 and a work RVU of
1.00 for CPT code 95X86. For CPT code 95X85, the RUC's recommendation
is based on reference CPT codes 12013 (Simple repair of superficial
wounds of face, ears, eyelids, nose, lips and/or mucous membranes; 2.6
cm to 5.0 cm), with total time of 27 minutes, intraservice time of 15
minutes, and a work RVU of 1.22; and CPT code 70470 (Computed
tomography, head or brain; without contrast material, followed by
contrast material(s) and further sections) with 25 minutes of total
time, 15 minutes of intraservice time, and a work RVU of 1.27. We
disagree with the RUC's recommended work RVU for CPT code 95X85 because
we do not believe that the reduction in work RVU reflects the change in
time described by the CPT code. Using the reverse building block
methodology, we estimate that a work RVU of nearer to 1.11 would be
more appropriate. In addition, if we were to sum the RUC-recommended
RVUs for a single hour of programming using one of the base CPT codes
and three of the 15 minute follow-on CPT codes, 1 hour of programming
would be valued at 4.25 work RVUs. This contrasts sharply from the work
RVU of 3.50 for 1 hour of programming using the deleted CPT code 95978.
We believe that a more appropriate valuation of the work involved in
furnishing this service is reflected by a crosswalk to CPT code 93886
(Transcranial Doppler study of the intracranial arteries; complete
study), with total time 27 minutes, intraservice time of 17 minutes,
and a work RVU of 0.91. Therefore, we are proposing a work RVU of 0.91
for CPT code 95X85.
The RUC's recommended work RVU of 1.00 for CPT code 95X86 is based
on the key reference service CPT code 64645 (Chemodenervation of one
extremity; each additional extremity, 5 or more muscles), which has
total time of 26 minutes, intraservice time of 25 minutes, and a work
RVU 1.39. This new CPT code is replacing CPT code 95978 (Electronic
analysis of implanted
[[Page 35770]]
neurostimulator pulse generator system (e.g., rate, pulse amplitude and
duration, battery status, electrode selectability and polarity,
impedance and patient compliance measurements), complex deep brain
neurostimulator pulse generator/transmitter, with initial or subsequent
programming; first hour), which is being deleted by the CPT Editorial
Panel. If we add the incremental difference between CPT codes 95X85 and
95X86 to the proposed value for the base CPT code (95X85, work RVU =
0.91), we estimate that this add-on CPT code should have a work RVU of
0.75. The building block methodology results in a recommendation of a
slightly higher work RVU of 0.82. We are proposing a work RVU of 0.80
for CPT code 95X86, which falls between the calculated value using
incremental differences and the calculation from the reverse building
block, and is supported by a crosswalk to CPT code 51797 (Voiding
pressure studies, intra-abdominal (i.e., rectal, gastric,
intraperitoneal)), which is an add-on CPT code with identical total and
intraservice times (15 minutes) as CPT code 95X86.
We are not proposing any direct PE refinements for this code
family.
(56) Psychological and Neuropsychological Testing (CPT Codes 96105,
96110, 96116, 96125, 96127, 963X0, 963X1, 963X2, 963X3, 963X4, 963X5,
963X6, 963X7, 963X8, 963X9, 96X10, 96X11, 96X12)
In CY 2016, the Psychological and Neuropsychological Testing family
of codes were identified as potentially misvalued using a high
expenditure services screen across specialties with Medicare allowed
charges of $10 million or more. The entire family of codes was referred
to the CPT Editorial Panel to be revised, as the testing practices had
been significantly altered by the growth and availability of
technology, leading to confusion about how to report the codes. In June
2017, the CPT Editorial Panel revised five existing codes, added 13
codes to provide better description of psychological and
neuropsychological testing, and deleted CPT codes 96101, 96102, 96103,
96111, 96118, 96119, and 96120. The RUC and HCPAC submitted
recommendations for the 13 new codes and for the existing CPT codes
96105, 96110, 96116, 96125, and 96127.
We are proposing the RUC- and HCPAC-recommend work RVUs for several
of the CPT codes in this family: A work RVU of 1.75 for CPT code 96105;
a work RVU of 1.86 for CPT code 96116; a work RVU of 1.70 for CPT code
96125; a work RVU of 1.71 for CPT code 963X2; a work RVU of 0.55 for
CPT code 963X7; a work RVU of 0.46 for CPT code 963X8; and a work RVU
of 0.51 for CPT code 96X11. CPT codes 96110, 96127, 963X9, 96X10, and
96X12 were valued by the RUC for PE only.
This code family contains a subset of codes that describe
psychological and neuropsychological testing administration and
evaluation, not including assessment of aphasia, developmental
screening, or developmental testing. The CPT Editorial Panel's
recommended coding for this subset of services consists of seven new
codes: Two that describe either psychological or neuropsychological
testing when administered by physicians or other qualified health
professionals (CPT codes 963X7 and 963X8), and two for either type of
testing when administered by technicians (CPT codes 963X9 and 96X10);
and four new codes that describe testing evaluation by physicians or
other qualified health care professionals (CPT codes 963X3-963X6). This
new coding effectively unbundles codes that currently report the full
course of testing into separate codes for testing administration (CPT
codes 963X7, 963X8, 963X9, and 96X10) and evaluation (CPT Codes 963X3,
963X4, and 963X5). According to a stakeholder that represents the
psychologist and neuropsychologist community, this new coding will
result in significant reductions in payment for these services due to
the unbundling of the testing codes into codes for physician-
administered tests and technician-administered tests. The stakeholder
asserts that because the new coding includes testing codes with zero
work RVUs for the technician administered tests and the work RVUs are
lower than they believe to be accurate, this new valuation would ignore
the clinical evaluation and decision making performed by the physician
or other qualified health professional during the course of testing
administration and evaluation. Furthermore, the net result of the code
valuations for these new codes is a reduction in the overall work RVUs
for this family of codes. In other words, the stakeholder's analysis
found that the RUC recommendations result in a reduction in total work
RVUs, even though the actual physician work of a testing battery has
not changed.
In the interest of payment stability for these high-volume
services, we are proposing to implement work RVUs for this code family,
which would eliminate the approximately 2 percent reduction in work
spending. We are proposing to achieve work neutrality for this code
family by scaling the work RVUs upward from the RUC-recommended values
so that the size of the pool of work RVUs would be essentially
unchanged for this family of services. Therefore, we are proposing: A
work RVU of 2.56 for CPT code 963X0, rather than the RUC recommended
work RVU of 2.50; a work RVU of 1.16 for CPT code 963X1, rather than
the RUC-recommended work RVU of 1.10; a work RVU of 2.56 for CPT code
963X3, rather than the RUC-recommended work RVU of 2.50; a work RVU of
1.96 for CPT code 963X4, rather than the RUC-recommended work RVU of
1.90; a work RVU of 2.56 for CPT code 963X5, rather than the RUC-
recommended work RVU of 2.50; and a work RVU of 1.96 for CPT code
963X6, rather than the RUC-recommended work RVU of 1.90. We see no
evidence that the typical practice for these services has changed to
merit a reduction in valuation of professional services.
The RUC made several revisions to the recommended direct PE inputs
for the administration codes from their respective predecessor codes,
including revisions to quantities of testing forms. For the supply
item, ``psych testing forms, average'' there is a quantity of 0.10 in
the predecessor CPT code 96101, and a quantity of 0.33 in the
predecessor CPT code 96102. For the supply item ``neurobehavioral
status forms, average,'' there is a quantity of 1.0 in the predecessor
CPT code 96118 and a quantity of 0.30 for predecessor CPT code 96119,
and for the supply item ``aphasia assessment forms, average,'' there is
a quantity of 1.0 in the predecessor CPT code 96118 and a quantity of
0.30 in predecessor CPT code 96119. The RUC recommendation does not
include any forms for CPT codes 963X5 and 963X6. The RUC has replaced
the corresponding predecessor supply items with new items ``WAIS-IV
Record Form,'' ``WAIS-IV Response Booklet #1,'' and ``WAIS-IV Response
Booklet #2,'' and assigned quantities of 0.165 for each of these new
supply items for CPT codes 963X7-96X10. In our analysis, we find that
the RUC-recommended PE refinements contributes significantly to the
reduction in the overall payment for this code family. We see no
compelling evidence that the quantities of testing forms used in a
typical course of testing would have reduced dramatically and, in the
interest of payment stability, we are proposing to refine the direct PE
inputs for CPT codes 963X5-96X10 by including 1.0 quantity each of the
supply items ``WAIS-IV Record Form,'' ``WAIS-IV Response Booklet #1'',
and
[[Page 35771]]
``WAIS-IV Response Booklet #2.'' We believe that a typical course of
testing would involve use of one booklet for each of the relevant
codes. In addition, these proposed refinements would largely mitigate
potentially destabilizing payment reductions for these services. We are
seeking comment on our proposed work RVUs and proposed PE refinements
for this family of services.
For the direct PE inputs, we are proposing to remove the equipment
time for the CANTAB Mobile (ED055) equipment item from CPT code 96X12.
This item was listed at different points in the recommendations as a
supply item with a cost of $28 per assessment and as an equipment item
for a software license with a cost of $2,800 that could be used for up
to 100 assessments. We are unclear as to how the CANTAB Mobile would
typically be used in this procedure, and we are proposing to remove the
equipment time pending the submission of more data about the item. We
are seeking additional information about the use of this item and how
it should best be included into the PE methodology. We are also
interested in information as to whether the submitted invoice refers to
the cost of the mobile device itself, or the cost of user licenses for
the mobile device, which was unclear from the information submitted
with the recommendations.
(57) Electrocorticography (CPT Code 96X00)
CPT Code 95829 is used for Electrocorticogram performed at the time
of surgery; however, a new code was needed to account for this non-
face-to-face service for the review of a month's worth or more of
stored data. CPT code 96X00 (Electrocorticogram from an implanted brain
neurostimulator pulse generator/transmitter, including recording, with
interpretation and written report, up to 30 days) is a new code
approved at the September 2017 CPT Editorial Panel Meeting to describe
this service.
We disagree with the RUC-recommended work RVU of 2.30 for CPT code
96X00 and are proposing a work RVU of 1.98 based on a direct crosswalk
to the top reference, CPT code 95957 (Digital analysis of
electroencephalogram (EEG) (e.g., for epileptic spike analysis)). This
is a recently-reviewed code with the same intraservice time of 30
minutes and a total time only 2 minutes lower than CPT code 96X00. We
agree with the survey respondents that CPT code 95957 is an accurate
valuation for this new code, and due to the clinically similar nature
of the two procedures and their near-identical time values, we are
proposing to value both of them at the same work RVU of 1.98.
The RUC did not recommend, and we did not propose, any direct PE
inputs for CPT code 96X00.
(58) Chronic Care Remote Physiologic Monitoring (CPT Codes 990X0,
990X1, and 994X9)
In the CY 2018 PFS final rule, we finalized separate payment for
CPT code 99091 (Collection and interpretation of physiologic data
(e.g., ECG, blood pressure, glucose monitoring) digitally stored and/or
transmitted by the patient and/or caregiver to the physician or other
qualified health care professional, qualified by education, training,
licensure/regulation (when applicable) requiring a minimum of 30
minutes of time) (82 FR 53014). In that rule, we indicated that there
would be new coding describing remote monitoring forthcoming from the
CPT Editorial Panel and the RUC (82 FR 53014). In September 2017, the
CPT Editorial Panel revised one code and created three new codes to
describe remote physiologic monitoring and management and the RUC
provided valuation recommendations through our standard rulemaking
process.
CPT codes 990X0 (Remote monitoring of physiologic parameter(s)
(e.g., weight, blood pressure, pulse oximetry, respiratory flow rate),
initial; set-up and patient education on use of equipment) and 990X1
(Remote monitoring of physiologic parameter(s) (e.g., weight, blood
pressure, pulse oximetry, respiratory flow rate), initial; device(s)
supply with daily recording(s) or programmed alert(s) transmission,
each 30 days) are both PE-only codes. We are proposing the RUC-
recommended work RVU of 0.61 for CPT code 994X9 (Remote physiologic
monitoring treatment management services, 20 minutes or more of
clinical staff/physician/other qualified healthcare professional time
in a calendar month requiring interactive communication with the
patient/caregiver during the month).
For the direct PE inputs, we are proposing to accept the RUC-
recommended direct PE inputs for CPT code 990X0 and to remove the
``Monthly cellular and licensing service fee'' supply from CPT code
990X1. We do not believe that these licensing fees would be allocated
to the use of an individual patient for an individual service, and
instead believe they can be better understood as forms of indirect
costs similar to office rent or administrative expenses. Therefore, we
are proposing to remove this supply input as a form of indirect PE. We
are proposing the direct PE inputs for CPT code 994X9 without
refinement.
(59) Interprofessional Internet Consultation (CPT Codes 994X6, 994X0,
99446, 99447, 99448, and 99449)
In September 2017, the CPT Editorial Panel revised four codes and
created two codes to describe interprofessional telephone/internet/
electronic medical record consultation services. CPT codes 99446
(Interprofessional telephone/internet assessment and management service
provided by a consultative physician including a verbal and written
report to the patient's treating/requesting physician or other
qualified health care professional; 5-10 minutes of medical
consultative discussion and review), 99447 (Interprofessional
telephone/internet assessment and management service provided by a
consultative physician including a verbal and written report to the
patient's treating/requesting physician or other qualified health care
professional; 11-20 minutes of medical consultative discussion and
review), 99448 (Interprofessional telephone/internet assessment and
management service provided by a consultative physician including a
verbal and written report to the patient's treating/requesting
physician or other qualified health care professional; 21-30 minutes of
medical consultative discussion and review), and 99449
(Interprofessional telephone/internet assessment and management service
provided by a consultative physician including a verbal and written
report to the patient's treating/requesting physician or other
qualified health care professional; 31 minutes or more of medical
consultative discussion and review) describe assessment and management
services in which a patient's treating physician or other qualified
healthcare professional requests the opinion and/or treatment advice of
a physician with specific specialty expertise to assist with the
diagnosis and/or management of the patient's problem without the need
for the face-to-face interaction between the patient and the
consultant. These CPT codes are currently assigned a procedure status
of B (bundled) and are not separately payable under Medicare. The CPT
Editorial Panel revised these codes to include electronic health record
consultations, and the RUC reaffirmed the work RVUs it had previously
submitted for these codes. We reevaluated the submitted recommendations
and, in light of changes in medical practice and technology, we are
proposing to change the procedure status for CPT codes 99446, 99447,
99448, and 99449 from B
[[Page 35772]]
(bundled) to A (active). We are also proposing the RUC re-affirmed work
RVUs of 0.35 for CPT code 99446, 0.70 for CPT code 99447, 1.05 for CPT
code 99448, and 1.40 for CPT code 99449.
The CPT Editorial Panel also created two new codes, CPT code 994X0
(Interprofessional telephone/internet/electronic health record referral
service(s) provided by a treating/requesting physician or qualified
health care professional, 30 minutes) and CPT code 994X6
(Interprofessional telephone/internet/electronic health record
assessment and management service provided by a consultative physician
including a written report to the patient's treating/requesting
physician or other qualified health care professional, 5 or more
minutes of medical consultative time). The RUC-recommended work RVUs
are 0.50 for CPT code 994X0 and 0.70 for 994X6. Since the CPT code for
the treating/requesting physician or qualified healthcare professional
and the CPT code for the consultative physician have similar
intraservice times, we believe that these CPT codes should have equal
values for work. Therefore, we are proposing a work RVU of 0.50 for
both CPT codes 994X0 and 994X6.
We welcome comments on this proposal. We also direct readers to
section II.D. of this proposed rule, which includes additional detail
regarding our proposed policies for modernizing Medicare physician
payment by recognizing communication technology-based services.
There are no recommended direct PE inputs for the codes in this
family.
(60) Chronic Care Management Services (CPT Code 994X7)
In February 2017, the CPT Editorial Panel created a new code to
describe at least 30 minutes of chronic care management services
performed personally by the physician or qualified health care
professional over one calendar month. CMS began making separate payment
for CPT code 99490 (Chronic care management services, at least 20
minutes of clinical staff time directed by a physician or other
qualified health care professional, per calendar month, with the
following required elements: Multiple (two or more) chronic conditions
expected to last at least 12 months, or until the death of the patient;
chronic conditions place the patient at significant risk of death,
acute exacerbation/decompensation, or functional decline; comprehensive
care plan established, implemented, revised, or monitored) in CY 2015
(79 FR 67715). CPT code 99490 describes 20 minutes of clinical staff
time spent on care management services for patients with 2 or more
chronic conditions. CPT code 99490 also includes 15 minutes of
physician time for supervision of clinical staff. For CY 2019, the CPT
Editorial Panel created CPT code 994X7 (Chronic care management
services, provided personally by a physician or other qualified health
care professional, at least 30 minutes of physician or other qualified
health care professional time, per calendar month, with the following
required elements: Multiple (two or more) chronic conditions expected
to last at least 12 months, or until the death of the patient, chronic
conditions place the patient at significant risk of death, acute
exacerbation/decompensation, or functional decline; comprehensive care
plan established, implemented, revised, or monitored) to describe
situations when the billing practitioner is doing the care coordination
work that is attributed to clinical staff in CPT code 99490. For CPT
code 994X7, the RUC recommended a work RVU of 1.45 for 30 minutes of
physician time. We believe this work RVU overvalues the resource costs
associated with the physician performing the same care coordination
activities that are performed by clinical staff in the service
described by CPT code 99490. Additionally, this valuation of the work
is higher than that of CPT code 99487 (Complex chronic care management
services, with the following required elements: Multiple (two or more)
chronic conditions expected to last at least 12 months, or until the
death of the patient, chronic conditions place the patient at
significant risk of death, acute exacerbation/decompensation, or
functional decline, establishment or substantial revision of a
comprehensive care plan, moderate or high complexity medical decision
making; 60 minutes of clinical staff time directed by a physician or
other qualified health care professional, per calendar month), which
includes 60 minutes of clinical staff time, creating a rank order
anomaly within the family of codes if we were to accept the RUC-
recommended value.
CPT code 99490 has a work RVU of 0.61 for 15 minutes of physician
time. Therefore, as CPT code 994X7 describes 30 minutes of physician
time, we are proposing a work RVU of 1.22, which is double the work RVU
of CPT code 99490.
We are not proposing any direct PE refinements for this code
family.
(61) Diabetes Management Training (HCPCS Codes G0108 and G0109)
HCPCS codes G0108 (Diabetes outpatient self-management training
services, individual, per 30 minutes) and G0109 (Diabetes outpatient
self-management training services, group session (2 or more), per 30
minutes) were identified on a screen of CMS or Other source codes with
Medicare utilization greater than 100,000 services annually. For CY
2019, we are proposing the HCPAC-recommended work RVU of 0.90 for HCPCS
code G0108 and the HCPAC-recommended work RVU of 0.25 for HCPCS code
G0109.
For the direct PE inputs, we note that there is a significant
disparity between the specialty recommendation and the final
recommendation submitted by the HCPAC. We are concerned about the
significant decreases in direct PE inputs in the final recommendation
when compared to the current makeup of the two codes. The final HCPAC
recommendation removed a series of different syringes and the patient
education booklet that currently accompanies the procedure. We believe
that injection training is part of these services and that the supplies
associated with that training would typically be included in the
procedures. Due to these concerns, we are proposing to maintain the
current direct PE inputs for HCPCS codes G0108 and G0109. Therefore, we
will not add the new supply item ``20x30 inch self-stick easel pad,
white, 30 sheets/pad'' (SK129) to HCPCS code G0109, as it is not a
current supply for HCPCS code G0109; however, we are proposing to
accept the submitted invoice price and to add the supply to our direct
PE database.
(62) External Counterpulsation (HCPCS Code G0166)
HCPCS code G0166 (External counterpulsation, per treatment session)
was identified on a screen of CMS or Other source codes with Medicare
utilization greater than 100,000 services annually. The RUC is not
recommending a work RVU for HCPCS code G0166 due to the belief that
there is no physician work involved in this service. After reviewing
this code, we are proposing a work RVU of 0.00 for HCPCS code G0166,
and are proposing to make the code valued for PE only.
For the direct PE inputs, we are proposing to refine the equipment
times in accordance with our standard equipment time formulas.
[[Page 35773]]
(63) Wound Closure by Adhesive (HCPCS Code G0168)
HCPCS code G0168 (Wound closure utilizing tissue adhesive(s) only)
was identified as potentially misvalued on a screen of 0-day global
services reported with an E/M visit 50 percent of the time or more, on
the same day of service by the same patient and the same practitioner,
that have not been reviewed in the last 5 years with Medicare
utilization greater than 20,000. For CY 2019, the RUC recommended a
work RVU of 0.45 based on maintaining the current work RVU.
We disagree with the recommended value and we are proposing a work
RVU of 0.31 for HCPCS code G0168 based on a direct crosswalk to CPT
code 93293 (Transtelephonic rhythm strip pacemaker evaluation(s)
single, dual, or multiple lead pacemaker system, includes recording
with and without magnet application with analysis, review and report(s)
by a physician or other qualified health care professional, up to 90
days). CPT code 93293 is a recently-reviewed code with the same 5
minutes of intraservice time and 1 fewer minute of total time. In
reviewing HCPCS code G0168, the recommendations stated that the work
involved in the service had not changed even though the surveyed
intraservice time was decreasing by 50 percent, from 10 minutes to 5
minutes. Although we do not imply that the decrease in time as
reflected in survey values must equate to a one-to-one or linear
decrease in the valuation of work RVUs, we believe that since the two
components of work are time and intensity, significant decreases in
time should be reflected in decreases to work RVUs. In the case of
HCPCS code G0168, we believe that it would be more accurate to propose
a work RVU of 0.31 based on the aforementioned crosswalk to CPT code
93293 to account for these decreases in the surveyed work time.
Maintaining the current work RVU of 0.45 despite a 50 percent decrease
in the surveyed intraservice time would result in a significant
increase in the intensity of HCPCS code G0168, and we have no reason to
believe that the procedure has increased in intensity since the last
time that it was valued.
For the direct PE inputs, we are proposing to refine the equipment
times in accordance with our standard equipment time formulas.
(64) Removal of Impacted Cerumen (HCPCS Code G0268)
HCPCS code G0268 (Removal of impacted cerumen (one or both ears) by
physician on same date of service as audiologic function testing) was
identified as potentially misvalued on a screen of 0-day global
services reported with an E/M visit 50 percent of the time or more, on
the same day of service by the same patient and the same practitioner,
that have not been reviewed in the last 5 years with Medicare
utilization greater than 20,000. For CY 2019, we are proposing the RUC-
recommended work RVU of 0.61 for HCPCS code G0268.
For the direct PE inputs, we are proposing to remove the clinical
labor time for the ``Clean surgical instrument package'' (CA026)
activity. There is no surgical instrument pack included in the
recommended equipment for HCPCS code G0268, and this code already
includes the standard 3 minutes allocated for cleaning the room and
equipment. In addition, all of the instruments used in the procedure
appear to be disposable supplies that would not require cleaning since
they would only be used a single time.
(65) Structured Assessment, Brief Intervention, and Referral to
Treatment for Substance Use Disorders (HCPCS Codes G0396, G0397, and
GSBR1)
In response to the Request for Information in the CY 2018 PFS
proposed rule (82 FR 34172), commenters requested that CMS pay
separately for assessment and referral related to substance use
disorders. In the CY 2008 PFS final rule (72 FR 66371), we created two
G-codes to allow for appropriate Medicare reporting and payment for
alcohol and substance abuse assessment and intervention services that
are not provided as screening services, but that are performed in the
context of the diagnosis or treatment of illness or injury. The codes
are HCPCS code G0396 (Alcohol and/or substance (other than tobacco)
abuse structured assessment (e.g., AUDIT, DAST) and brief intervention,
15 to 30 minutes)) and HCPCS code G0397 (Alcohol and/or substance
(other than tobacco) abuse structured assessment (e.g., AUDIT, DAST)
and intervention greater than 30 minutes)). In 2008, we instructed
Medicare contractors to pay for these codes only when the services were
considered reasonable and necessary.
Given the ongoing opioid epidemic and the current needs of the
Medicare population, we expect that these services would often be
reasonable and necessary. However, the utilization for these services
is relatively low, which we believe is in part due to the service-
specific documentation requirements for these codes (the current
requirements can be found here: https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/downloads/SBIRT_Factsheet_ICN904084.pdf). We believe that removing the additional
documentation requirements will also ease the administrative burden on
providers. Therefore, for CY 2019, we are proposing to eliminate the
service-specific documentation requirements for HCPCS codes G0397 and
G0398. We welcome comments on our proposal to change the documentation
requirements for these codes.
Additionally, we are proposing to create a third HCPCS code, GSBR1,
with a lower time threshold in order to accurately account for the
resource costs when practitioners furnish these services, but do not
meet the requirements of the existing codes. The proposed code
descriptor is: Alcohol and/or substance (other than tobacco) abuse
structured assessment (e.g., AUDIT, DAST), and brief intervention, 5-14
minutes. We are proposing a work RVU of 0.33, based on the intraservice
time ratio between HCPCS codes G0396 and G0397. We welcome comments on
this code descriptor and proposed valuation for HCPCS code GSBR1.
(66) Prolonged Services (HCPCS Code GPRO1)
CPT codes 99354 (Prolonged evaluation and management or
psychotherapy service(s) (beyond the typical service time of the
primary procedure) in the office or other outpatient setting requiring
direct patient contact beyond the usual service; first hour (List
separately in addition to code for office or other outpatient
Evaluation and Management or psychotherapy service)) and 99355
(Prolonged evaluation and management or psychotherapy service(s)
(beyond the typical service time of the primary procedure) in the
office or other outpatient setting requiring direct patient contact
beyond the usual service; each additional 30 minutes (List separately
in addition to code for prolonged service)) describe additional time
spent face-to-face with a patient. Stakeholders claim that the
threshold of 60 minutes for CPT code 99354 is difficult to meet and is
an impediment to billing these codes. In response to stakeholder
feedback and as part of our proposal as discussed in section II.I. of
this proposed rule to implement a single PFS rate for E/M visit levels
2-5 while maintaining payment stability across the specialties, we are
proposing HCPCS code GPRO1 (Prolonged evaluation and management or
psychotherapy service(s) (beyond the typical service time of the
primary procedure) in the
[[Page 35774]]
office or other outpatient setting requiring direct patient contact
beyond the usual service; 30 minutes (List separately in addition to
code for office or other outpatient Evaluation and Management or
psychotherapy service)), which could be billed with any level of E/M
code. We note that we do not propose to make any changes to CPT codes
99354 and 99355, which could still be billed, as needed, when their
time thresholds and all other requirements are met. We are proposing a
work RVU of 1.17, which is equal to half of the work RVU assigned to
CPT code 99354. Additionally, we are proposing direct PE inputs for
HCPCS code GPRO1 that are equal to one half of the values assigned to
CPT code 99354, which can be found in the Direct PE Inputs public use
file for this proposed rule.
(67) Remote Pre-Recorded Services (HCPCS Code GRAS1)
For CY 2019, we are proposing to make separate payment for remote
services when a physician uses pre-recorded video and/or images
submitted by a patient in order to evaluate a patient's condition
through new HCPCS G-code GRAS1 (Remote evaluation of recorded video
and/or images submitted by the patient (e.g., store and forward),
including interpretation with verbal 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). We are
proposing to value this service by a direct crosswalk to CPT code 93793
(Anticoagulant management for a patient taking warfarin, must include
review and interpretation of a new home, office, or lab international
normalized ratio (INR) test result, patient instructions, dosage
adjustment (as needed), and scheduling of additional test(s), when
performed), as we believe the work described is similar in kind and
intensity to the work performed as part of HCPCS code GRAS1. Therefore,
we are proposing a work RVU of 0.18, preservice time of 3 minutes,
intraservice time of 4 minutes, and post service time of 2 minutes. We
are also proposing to add 6 minutes of clinical labor (L037D) in the
service period. We are seeking comment on the code descriptor and
valuation for HCPCS code GRAS1. We direct readers to section II.D. of
this proposed rule, which includes additional detail regarding our
proposed policies for modernizing Medicare physician payment by
recognizing communication technology-based services.
(68) Brief Communication Technology-Based Service, e.g., Virtual Check-
in (HCPCS Code GVCI1)
We are proposing to create a G-code, HCPCS code GVCI1 (Brief
communication technology based service, e.g. virtual check-in, by a
physician or other qualified health care professional who may 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) to facilitate payment for these brief communication
technology-based services. We propose to base the code descriptor and
valuation for HCPCS code GVCI1 on existing CPT code 99441 (Telephone
evaluation and management service by a physician or other qualified
health care professional who may report evaluation and management
services provided to an established patient, parent, or guardian 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), which is currently not separately payable under the PFS.
As CPT code 99441 only describes telephone calls, we are proposing to
create a new HCPCS code GVCI1 to encompass a broader array of
communication modalities. We do, however, believe that the resource
assumptions for CPT code 99441 would accurately account for the costs
associated with providing the proposed virtual check-in service,
regardless of the technology. We are proposing a work RVU of 0.25,
based on a direct crosswalk to CPT code 99441. For the direct PE inputs
for HCPCS code GVCI1, we are also proposing the direct PE inputs
assigned to CPT code 99441. Given the breadth of technologies that
could be described as telecommunications, we look forward to receiving
public comments and working with the CPT Editorial Panel and the RUC to
evaluate whether separate coding and payment is needed to account for
differentiation between communication modalities. We are seeking
comment on the code descriptor, as well as the proposed valuation for
HCPCS code GVCI1. We direct readers to section II.D. of this proposed
rule, which includes additional detail regarding our proposed policies
for modernizing Medicare physician payment by recognizing communication
technology-based services.
(69) Visit Complexity Inherent to Certain Specialist Visits (HCPCS Code
GCG0X)
We are proposing to create a HCPCS G-code to be reported with an E/
M service to describe the additional resource costs for specialties for
whom E/M visit codes make up a large percentage of their total allowed
charges and who we believe primarily bill level 4 and level 5 visits.
The treatment approaches for these specialties generally do not have
separate coding and are generally reported using the E/M visit codes.
We are proposing to create HCPCS code, GCG0X (Visit complexity inherent
to evaluation and management associated with endocrinology,
rheumatology, hematology/oncology, urology, neurology, obstetrics/
gynecology, allergy/immunology, otolaryngology, or interventional pain
management-centered care (Add-on code, list separately in addition to
an evaluation and management visit)). We are proposing a valuation for
HCPCS code GCG0X based on a crosswalk to 75 percent of the work RVU and
time of CPT code 90785 (Interactive complexity), which would result in
a proposed work RVU of 0.25 and a physician time of 8.25 minutes for
HCPCS code GCG0X. CPT code 90785 has no direct PE inputs. Interactive
complexity is an add-on code that may be billed when a psychotherapy or
psychiatric service requires more work due to the complexity of the
patient. We believe that this work RVU and physician time would be an
accurate representation of the additional work associated with the
higher level complex visits. For further discussion of proposals
relating to this code, see section II.I of this proposed rule. We are
seeking comment on the code descriptor, as well as the proposed
valuation for HCPCS code GCG0X.
(70) Visit Complexity Inherent to Primary Care Services (HCPCS Code
GPC1X)
We are proposing to create a HCPCS G-code for primary care
services, GPC1X (Visit complexity inherent to evaluation and management
associated with primary medical care services that serve as the
continuing focal point for all needed health care services (Add-on
code, list separately in addition to an evaluation and management
visit)). This code describes furnishing a visit to a new or existing
patient, and can include aspects of care management, counseling, or
treatment of acute or chronic
[[Page 35775]]
conditions not accounted for by other coding. HCPCS code GPC1X would be
billed in addition to the E/M visit code when the visit involved
primary care-focused services. We are proposing a work RVU of 0.07,
physician time of 1.75 minutes. This proposed valuation accounts for
the additional work resource costs associated with furnishing primary
care that distinguishes E/M primary care visits from other types of E/M
visits and maintains work budget neutrality across the office/
outpatient E/M code set. For further discussion of proposals relating
to this code, see section II.I of this proposed rule. We are seeking
comment on the code descriptor, as well as the proposed valuation for
HCPCS code GPC1X.
(71) Podiatric Evaluation and Management Services (HCPCS Codes GPD0X
and GPD1X)
We are proposing to create two HCPCS G-codes, HCPCS codes GPD0X
(Podiatry services, medical examination and evaluation with initiation
of diagnostic and treatment program, new patient) and GPD1X (Podiatry
services, medical examination and evaluation with initiation of
diagnostic and treatment program, established patient), to describe
podiatric evaluation and management services. We are proposing a work
RVU of 1.36, a physician time of 28.19 minutes, and direct costs
summing to $21.29 for HCPCS code GPD0X, and a work RVU of 0.85,
physician time of 21.73 minutes, and direct costs summing to $15.87 for
HCPCS code GPD1X. These values are based on the average rate for CPT
codes 99201-99203 and CPT codes 99211-99212 respectively, weighted by
podiatric volume. For further discussion of proposals relating to these
codes, see section II.I of this proposed rule.
(72) Comment Solicitation on Superficial Radiation Treatment Planning
and Management
In the CY 2015 PFS final rule with comment period (79 FR 67666-
67667), we noted that changes to the CPT prefatory language limited the
codes that could be reported when describing services associated with
superficial radiation treatment (SRT) delivery, described by CPT code
77401 (radiation treatment delivery, superficial and/or ortho voltage,
per day). The changes effectively meant that many other related
services were bundled with CPT code 77401, instead of being separately
reported. For example, CPT guidance clarified that certain codes used
to describe clinical treatment planning, treatment devices, isodose
planning, physics consultation, and radiation treatment management
cannot be reported when furnished in association with SRT. Stakeholders
informed us that these changes to the CPT prefatory language prevented
them from billing Medicare for codes that were previously frequently
billed with CPT code 77401. We solicited comments as to whether the
revised bundled coding for SRT allowed for accurate reporting of the
associated services. In the CY 2016 PFS final rule with comment period
(80 FR 70955), we noted that the RUC did not review the inputs for SRT
procedures, and therefore, did not assess whether changes in valuation
were appropriate in light of the bundling of associated services. In
addition, we solicited recommendations from stakeholders regarding
whether it would be appropriate to add physician work for this service,
even though physician work is not included in other radiation treatment
services. In the CY 2018 PFS proposed rule (82 FR 34012) and the CY
2018 PFS final rule (82 FR 53082), we noted that the 2016 National
Correct Coding Initiative (NCCI) Policy Manual for Medicare Services
states that radiation oncology services may not be separately reported
with E/M codes. While this NCCI edit is no longer active stakeholders
have stated that MACs have denied claims for E/M services associated
with SRT based on the NCCI policy manual language. According to
stakeholders, the bundling of SRT with associated services, as well as
coding confusion regarding the appropriate use of E/M coding to report
associated physician work, meant that practitioners were not being paid
appropriately for planning and treatment management associated with
furnishing SRT. Due to these concerns regarding reporting of services
associated with SRT, in the CY 2018 PFS proposed rule (82 FR 34012-
34013), we proposed to make separate payment for the professional
planning and management associated with SRT using HCPCS code GRRR1
(Superficial radiation treatment planning and management related
services, including but not limited to, when performed, clinical
treatment planning (for example, 77261, 77262, 77263), therapeutic
radiology simulation-aided field setting (for example, 77280, 77285,
77290, 77293), basic radiation dosimetry calculation (for example,
77300), treatment devices (for example, 77332, 77333, 77334), isodose
planning (for example, 77306, 77307, 77316, 77317, 77318), radiation
treatment management (for example, 77427, 77431, 77432, 77435, 77469,
77470, 77499), and associated E/M per course of treatment). We proposed
that this code would describe the range of professional services
associated with a course of SRT, including services similar to those
not otherwise separately reportable under CPT guidance. Furthermore, we
proposed that this code would have included several inputs associated
with related professional services such as treatment planning,
treatment devices, and treatment management. Many commenters did not
support our proposal to make separate payment for HCPCS code GRRR1 for
CY 2018, stating that our proposed valuation of HCPCS code GRRR1 would
represent a significant payment reduction for the associated services
as compared with the list of services that they could previously bill
in association with SRT. Commenters voiced concern that the proposed
coding would inhibit access to care and discourage the use of SRT as a
non-surgical alternative to Mohs surgery. We received comments
recommending a variety of potential coding solutions and found that
there was not general agreement among commenters about a preferred
alternative. In the CY 2018 PFS final rule (82 FR 53081-53083), we
solicited further comment, and stated that we would continue our
dialogue with stakeholders to address appropriate coding and payment
for professional services associated with SRT.
Given stakeholder feedback that we have continued to receive
following the publication of the CY 2018 PFS final rule, we continue to
believe that there are potential coding gaps for SRT-related
professional services. We generally rely on the CPT process to
determine coding specificity, and we believe that deferring to this
process in addressing potential coding gaps is generally preferable. As
our previous attempt at designing a coding solution in the CY 2018 PFS
proposed rule did not gain stakeholder consensus, and given that there
were various, in some cases diverging, suggestions on a coding solution
from stakeholders, we are not proposing changes relating to SRT coding,
SRT-related professional codes, or payment policies for CY 2019.
However, we are seeking comment on the possibility of creating multiple
G-codes specific to services associated with SRT, as was suggested by
one stakeholder following the CY 2018 PFS final rule. These codes would
be used separately to report services including SRT planning, initial
patient simulation visit, treatment device design and construction
associated with SRT, SRT management, and medical physics consultation.
We are seeking comment
[[Page 35776]]
on whether we should create such G codes to separately report each of
the services described above, mirroring the coding of other types of
radiation treatment delivery. For instance, HCPCS code G6003 (Radiation
treatment delivery, single treatment area, single port or parallel
opposed ports, simple blocks or no blocks: Up to 5 mev) is used to
report radiation treatment delivery, while associated professional
services are billed with codes such as CPT codes 77427 (Radiation
treatment management, 5 treatments), 77261 (Therapeutic radiology
treatment planning; simple), 77332 (Treatment devices, design and
construction; simple (simple block, simple bolus), and 77300 (Basic
radiation dosimetry calculation, central axis depth dose calculation,
TDF, NSD, gap calculation, off axis factor, tissue inhomogeneity
factors, calculation of non-ionizing radiation surface and depth dose,
as required during course of treatment, only when prescribed by the
treating physician). We are interested in public comment on whether it
would be appropriate to create separate codes for professional services
associated with SRT in a coding structure parallel to radiation
treatment delivery services such as HCPCS code G6003. We are seeking
comment on creating these codes for inclusion in this update of the
PFS. We are also interested in whether such codes should be contractor
priced for CY 2019. We would consider contractor pricing such codes for
CY 2019 because we believe that the preferable method to develop new
coding is with multi-specialty input through the CPT and RUC process,
and we prefer to defer nationally pricing such codes pending input from
the CPT Editorial Panel and the RUC process to assist in determining
the appropriate level of coding specificity for SRT-related
professional services. Based on stakeholder feedback, we continue to
believe there may be a coding gap for these services, and therefore, we
are soliciting comment on whether we should create these G codes and
allow them to be contractor priced for CY 2019. This would be an
interim approach for addressing the potential coding gap until the CPT
Editorial Panel and the RUC can address coding for SRT and SRT-related
professional services, giving the CPT Editorial Panel and the RUC an
opportunity to develop a coding solution that could be addressed in
future rulemaking.
Table 13--CY 2019 Proposed Work RVUs for New, Revised, and Potentially Misvalued Codes
----------------------------------------------------------------------------------------------------------------
CMS time
HCPCS Descriptor Current work RVU RUC work RVU CMS work RVU refinement
----------------------------------------------------------------------------------------------------------------
03X0T............. Electroretinography NEW............... C 0.40 No.
(ERG) with
interpretation and
report, pattern
(PERG).
10021............. Fine needle 1.27.............. 1.20 1.03 No.
aspiration biopsy;
without imaging
guidance; first
lesion.
10X11............. Fine needle NEW............... 0.80 0.80 No.
aspiration biopsy;
without imaging
guidance; each
additional lesion.
10X12............. Fine needle NEW............... 1.63 1.46 No.
aspiration biopsy,
including
ultrasound
guidance; first
lesion.
10X13............. Fine needle NEW............... 1.00 1.00 No.
aspiration biopsy,
including
ultrasound
guidance; each
additional lesion.
10X14............. Fine needle NEW............... 1.81 1.81 No.
aspiration biopsy,
including
fluoroscopic
guidance; first
lesion.
10X15............. Fine needle NEW............... 1.18 1.18 No.
aspiration biopsy,
including
fluoroscopic
guidance; each
additional lesion.
10X16............. Fine needle NEW............... 2.43 2.26 No.
aspiration biopsy,
including CT
guidance; first
lesion.
10X17............. Fine needle NEW............... 1.65 1.65 No.
aspiration biopsy,
including CT
guidance; each
additional lesion.
10X18............. Fine needle NEW............... C C No.
aspiration biopsy,
including MR
guidance; first
lesion.
10X19............. Fine needle NEW............... C C No.
aspiration biopsy,
including MR
guidance; each
additional lesion.
11755............. Biopsy of nail unit 1.31.............. 1.25 1.08 No.
(e.g., plate, bed,
matrix,
hyponychium,
proximal and
lateral nail folds).
11X02............. Tangential biopsy of NEW............... 0.66 0.66 No.
skin, (e.g., shave,
scoop, saucerize,
curette), single
lesion.
11X03............. Tangential biopsy of NEW............... 0.38 0.29 No.
skin, (e.g., shave,
scoop, saucerize,
curette), each
separate/additional
lesion.
11X04............. Punch biopsy of NEW............... 0.83 0.83 No.
skin, (including
simple closure when
performed), single
lesion.
11X05............. Punch biopsy of NEW............... 0.45 0.45 No.
skin, (including
simple closure when
performed), each
separate/additional
lesion.
11X06............. Incisional biopsy of NEW............... 1.01 1.01 No.
skin (e.g., wedge),
(including simple
closure when
performed), single
lesion.
11X07............. Incisional biopsy of NEW............... 0.54 0.54 No.
skin (e.g., wedge),
(including simple
closure when
performed), each
separate/additional
lesion.
20551............. Injection(s); single 0.75.............. 0.75 0.75 No.
tendon origin/
insertion.
209X3............. Allograft, includes NEW............... 13.01 13.01 No.
templating,
cutting, placement
and internal
fixation when
performed;
osteoarticular,
including articular
surface and
contiguous bone.
209X4............. Allograft, includes NEW............... 11.94 11.94 No.
templating,
cutting, placement
and internal
fixation when
performed;
hemicortical
intercalary,
partial (i.e.,
hemicylindrical).
[[Page 35777]]
209X5............. Allograft, includes NEW............... 13.00 13.00 No.
templating,
cutting, placement
and internal
fixation when
performed;
intercalary,
complete (i.e.,
cylindrical).
27X69............. Injection procedure NEW............... 0.96 0.77 No.
for contrast knee
arthrography or
contrast enhanced
CT/MRI knee
arthrography.
29105............. Application of long 0.87.............. 0.80 0.80 No.
arm splint
(shoulder to hand).
29540............. Strapping; ankle and/ 0.39.............. 0.39 0.39 No.
or foot.
29550............. Strapping; toes..... 0.25.............. 0.25 0.25 No.
31623............. Bronchoscopy, rigid 2.63.............. 2.63 2.63 No.
or flexible,
including
fluoroscopic
guidance, when
performed; with
brushing or
protected brushings.
31624............. Bronchoscopy, rigid 2.63.............. 2.63 2.63 No.
or flexible,
including
fluoroscopic
guidance, when
performed; with
bronchial alveolar
lavage.
332X0............. Transcatheter NEW............... 6.00 6.00 No.
implantation of
wireless pulmonary
artery pressure
sensor for long
term hemodynamic
monitoring,
including
deployment and
calibration of the
sensor, right heart
catheterization,
selective pulmonary
catheterization,
radiological
supervision and
interpretation, and
pulmonary artery
angiography, when
performed.
332X5............. Insertion, NEW............... 1.53 1.53 No.
subcutaneous
cardiac rhythm
monitor, including
programming.
332X6............. Removal, NEW............... 1.50 1.50 No.
subcutaneous
cardiac rhythm
monitor.
335X1............. Replacement, aortic NEW............... 64.00 64.00 No.
valve; by
translocation of
autologous
pulmonary valve and
transventricular
aortic annulus
enlargement of the
left ventricular
outflow tract with
valved conduit
replacement of
pulmonary valve
(Ross-Konno
procedure).
33X01............. Aortic hemiarch NEW............... 19.74 19.74 No.
graft including
isolation and
control of the arch
vessels, beveled
open distal aortic
anastomosis
extending under one
or more of the arch
vessels, and total
circulatory arrest
or isolated
cerebral perfusion.
33X05............. Transcatheter NEW............... 8.77 7.80 No.
insertion or
replacement of
permanent leadless
pacemaker, right
ventricular,
including imaging
guidance (e.g.,
fluoroscopy, venous
ultrasound,
ventriculography,
femoral venography)
and device
evaluation (e.g.,
interrogation or
programming), when
performed.
33X06............. Transcatheter NEW............... 9.56 8.59 No.
removal of
permanent leadless
pacemaker, right
ventricular.
36568............. Insertion of 1.67.............. 2.11 2.11 No.
peripherally
inserted central
venous catheter
(PICC), without
subcutaneous port
or pump, without
imaging guidance;
younger than 5
years of age.
36569............. Insertion of 1.70.............. 1.90 1.90 No.
peripherally
inserted central
venous catheter
(PICC), without
subcutaneous port
or pump, without
imaging guidance;
age 5 years or
older.
36584............. Replacement, 1.20.............. 1.47 1.20 No.
complete, of a
peripherally
inserted central
venous catheter
(PICC), without
subcutaneous port
or pump, through
same venous access,
including all
imaging guidance,
image
documentation, and
all associated
radiological
supervision and
interpretation
required to perform
the replacement.
36X72............. Insertion of NEW............... 2.00 1.82 No.
peripherally
inserted central
venous catheter
(PICC), without
subcutaneous port
or pump, including
all imaging
guidance, image
documentation, and
all associated
radiological
supervision and
interpretation
required to perform
the insertion;
younger than 5
years of age.
36X73............. Insertion of NEW............... 1.90 1.70 No.
peripherally
inserted central
venous catheter
(PICC), without
subcutaneous port
or pump, including
all imaging
guidance, image
documentation, and
all associated
radiological
supervision and
interpretation
required to perform
the insertion; age
5 years or older.
3853X............. Biopsy or excision NEW............... 6.74 6.74 No.
of lymph node(s);
open,
inguinofemoral
node(s).
38792............. Injection procedure; 0.52.............. 0.65 0.65 No.
radioactive tracer
for identification
of sentinel node.
[[Page 35778]]
43X63............. Replacement of NEW............... 0.75 0.75 No.
gastrostomy tube,
percutaneous,
includes removal,
when performed,
without imaging or
endoscopic
guidance; not
requiring revision
of gastrostomy
tract.
43X64............. Replacement of NEW............... 1.41 1.41 No.
gastrostomy tube,
percutaneous,
includes removal,
when performed,
without imaging or
endoscopic
guidance; requiring
revision of
gastrostomy tract.
45300............. Proctosigmoidoscopy, 0.80.............. 0.80 0.80 No.
rigid; diagnostic,
with or without
collection of
specimen(s) by
brushing or washing
(separate
procedure).
46500............. Injection of 1.42.............. 2.00 1.74 No.
sclerosing
solution,
hemorrhoids.
49422............. Removal of tunneled 6.29.............. 4.00 4.00 No.
intraperitoneal
catheter.
50X39............. Dilation of existing NEW............... 3.37 2.78 No.
tract,
percutaneous, for
an endourologic
procedure including
imaging guidance
(e.g., ultrasound
and/or fluoroscopy)
and all associated
radiological
supervision and
interpretation, as
well as post
procedure tube
placement, when
performed.
50X40............. Dilation of existing NEW............... 5.44 4.83 Yes.
tract,
percutaneous, for
an endourologic
procedure including
imaging guidance
(e.g., ultrasound
and/or fluoroscopy)
and all associated
radiological
supervision and
interpretation, as
well as post
procedure tube
placement, when
performed;
including new
access into the
renal collecting
system.
52334............. Cystourethroscopy 4.82.............. 3.37 3.37 No.
with insertion of
ureteral guide wire
through kidney to
establish a
percutaneous
nephrostomy,
retrograde.
53850............. Transurethral 10.08............. 5.42 5.42 No.
destruction of
prostate tissue; by
microwave
thermotherapy.
53852............. Transurethral 10.83............. 5.93 5.93 No.
destruction of
prostate tissue; by
radiofrequency
thermotherapy.
538X3............. Transurethral NEW............... 5.93 5.70 No.
destruction of
prostate tissue; by
radiofrequency
generated water
vapor thermotherapy.
57150............. Irrigation of vagina 0.55.............. 0.50 0.50 No.
and/or application
of medicament for
treatment of
bacterial,
parasitic, or
fungoid disease.
57160............. Fitting and 0.89.............. 0.89 0.89 No.
insertion of
pessary or other
intravaginal
support device.
58100............. Endometrial sampling 1.53.............. 1.21 1.21 No.
(biopsy) with or
without
endocervical
sampling (biopsy),
without cervical
dilation, any
method (separate
procedure).
58110............. Endometrial sampling 0.77.............. 0.77 0.77 No.
(biopsy) performed
in conjunction with
colposcopy.
64405............. Injection, 0.94.............. 0.94 0.94 No.
anesthetic agent;
greater occipital
nerve.
64455............. Injection(s), 0.75.............. 0.75 0.75 No.
anesthetic agent
and/or steroid,
plantar common
digital nerve(s)
(e.g., Morton's
neuroma).
65205............. Removal of foreign 0.71.............. 0.49 0.49 No.
body, external eye;
conjunctival
superficial.
65210............. Removal of foreign 0.84.............. 0.75 0.61 No.
body, external eye;
conjunctival
embedded (includes
concretions),
subconjunctival, or
scleral
nonperforating.
67500............. Retrobulbar 1.44.............. 1.18 1.18 No.
injection;
medication
(separate
procedure, does not
include supply of
medication).
67505............. Retrobulbar 1.27.............. 1.18 0.94 No.
injection; &
alcohol.
67515............. Injection of 1.40.............. 0.84 0.75 No.
medication or other
substance into
Tenon's capsule.
72020............. Radiologic 0.15.............. 0.15 0.23 No.
examination, spine,
single view,
specify level.
72040............. Radiologic 0.22.............. 0.22 0.23 No.
examination, spine,
cervical; 2 or 3
views.
72050............. Radiologic 0.31.............. 0.31 0.23 No.
examination, spine,
cervical; 4 or 5
views.
72052............. Radiologic 0.36.............. 0.35 0.23 No.
examination, spine,
cervical; 6 or more
views.
72070............. Radiologic 0.22.............. 0.22 0.23 No.
examination, spine;
thoracic, 2 views.
72072............. Radiologic 0.22.............. 0.22 0.23 No.
examination, spine;
thoracic, 3 views.
72074............. Radiologic 0.22.............. 0.22 0.23 No.
examination, spine;
thoracic, minimum
of 4 views.
72080............. Radiologic 0.22.............. 0.22 0.23 No.
examination, spine;
thoracolumbar
junction, minimum
of 2 views.
72100............. Radiologic 0.22.............. 0.22 0.23 No.
examination, spine,
lumbosacral; 2 or 3
views.
72110............. Radiologic 0.31.............. 0.31 0.23 No.
examination, spine,
lumbosacral;
minimum of 4 views.
72114............. Radiologic 0.32.............. 0.31 0.23 No.
examination, spine,
lumbosacral;
complete, including
bending views,
minimum of 6 views.
[[Page 35779]]
72120............. Radiologic 0.22.............. 0.22 0.23 No.
examination, spine,
lumbosacral;
bending views only,
2 or 3 views.
72200............. Radiologic 0.17.............. 0.17 0.23 No.
examination,
sacroiliac joints;
less than 3 views.
72202............. Radiologic 0.19.............. 0.18 0.23 No.
examination,
sacroiliac joints;
3 or more views.
72220............. Radiologic 0.17.............. 0.17 0.23 No.
examination, sacrum
and coccyx, minimum
of 2 views.
73070............. Radiologic 0.15.............. 0.15 0.23 No.
examination, elbow;
2 views.
73080............. Radiologic 0.17.............. 0.17 0.23 No.
examination, elbow;
complete, minimum
of 3 views.
73090............. Radiologic 0.16.............. 0.16 0.23 No.
examination;
forearm, 2 views.
73650............. Radiologic 0.16.............. 0.16 0.23 No.
examination;
calcaneus, minimum
of 2 views.
73660............. Radiologic 0.13.............. 0.13 0.23 No.
examination;
toe(s), minimum of
2 views.
74210............. Radiologic 0.36.............. 0.59 0.59 No.
examination;
pharynx and/or
cervical esophagus.
74220............. Radiologic 0.46.............. 0.67 0.67 No.
examination;
esophagus.
74230............. Swallowing function, 0.53.............. 0.53 0.53 No.
with
cineradiography/
videoradiography.
74420............. Urography, 0.36.............. 0.52 0.52 No.
retrograde, with or
without KUB.
74485............. Dilation of 0.54.............. 0.83 0.83 No.
ureter(s) or
urethra,
radiological
supervision and
interpretation.
76000............. Fluoroscopy 0.17.............. 0.30 0.30 No.
(separate
procedure), up to 1
hour physician or
other qualified
health care
professional time,
other than 71023 or
71034 (e.g.,
cardiac
fluoroscopy).
76514............. Ophthalmic 0.17.............. 0.17 0.14 No.
ultrasound,
diagnostic; corneal
pachymetry,
unilateral or
bilateral
(determination of
corneal thickness).
767X1............. Ultrasound, NEW............... 0.59 0.59 No.
elastography;
parenchyma (e.g.,
organ).
767X2............. Ultrasound, NEW............... 0.59 0.59 No.
elastography; first
target lesion.
767X3............. Ultrasound, NEW............... 0.50 0.50 No.
elastography; each
additional target
lesion.
76870............. Ultrasound, scrotum 0.64.............. 0.64 0.64 No.
and contents.
76942............. Ultrasonic guidance 0.67.............. 0.67 0.67 No.
for needle
placement (e.g.,
biopsy, fine needle
aspiration biopsy,
injection,
localization
device), imaging
supervision and
interpretation.
76X01............. Magnetic resonance NEW............... 1.29 1.10 No.
(e.g., vibration)
elastography.
76X0X............. Ultrasound, targeted NEW............... 1.62 1.27 No.
dynamic microbubble
sonographic
contrast
characterization
(non-cardiac);
initial lesion.
76X1X............. Ultrasound, targeted NEW............... 0.85 0.85 No.
dynamic microbubble
sonographic
contrast
characterization
(non-cardiac); each
additional lesion
with separate
injection.
77012............. Computed tomography 1.16.............. 1.50 1.50 No.
guidance for needle
placement (e.g.,
biopsy, aspiration,
injection,
localization
device),
radiological
supervision and
interpretation.
77021............. Magnetic resonance 1.50.............. 1.50 1.50 No.
guidance for needle
placement (e.g.,
for biopsy, fine
needle aspiration
biopsy, injection,
or placement of
localization
device)
radiological
supervision and
interpretation.
77081............. Dual-energy X-ray 0.22.............. 0.20 0.20 No.
absorptiometry
(DXA), bone density
study, 1 or more
sites; appendicular
skeleton
(peripheral) (e.g.,
radius, wrist,
heel).
77X49............. Magnetic resonance NEW............... 1.45 1.15 No.
imaging, breast,
without contrast
material;
unilateral.
77X50............. Magnetic resonance NEW............... 1.60 1.30 No.
imaging, breast,
without contrast
material; bilateral.
77X51............. Magnetic resonance NEW............... 2.10 1.80 No.
imaging, breast,
without and with
contrast
material(s),
including computer-
aided detection
(CAD-real time
lesion detection,
characterization
and pharmacokinetic
analysis) when
performed;
unilateral.
77X52............. Magnetic resonance NEW............... 2.30 2.00 No.
imaging, breast,
without and with
contrast
material(s),
including computer-
aided detection
(CAD-real time
lesion detection,
characterization
and pharmacokinetic
analysis) when
performed;
bilateral.
85060............. Blood smear, 0.45.............. 0.45 0.36 No.
peripheral,
interpretation by
physician with
written report.
85097............. Bone marrow, smear 0.94.............. 1.00 0.94 No.
interpretation.
85390............. Fibrinolysins or 0.37.............. 0.75 0.75 No.
coagulopathy
screen,
interpretation and
report.
92X71............. Electroretinography NEW............... 0.80 0.69 No.
(ERG) with
interpretation and
report; full field
(e.g., ffERG, flash
ERG, Ganzfeld ERG).
92X73............. Electroretinography NEW............... 0.72 0.61 No.
(ERG) with
interpretation and
report; multifocal
(mfERG).
[[Page 35780]]
93561............. Indicator dilution 0.25.............. 0.95 0.60 No.
studies such as dye
or thermodilution,
including arterial
and/or venous
catheterization;
with cardiac output
measurement.
93562............. Indicator dilution 0.01.............. 0.77 0.48 No.
studies such as dye
or thermodilution,
including arterial
and/or venous
catheterization;
subsequent
measurement of
cardiac output.
93571............. Intravascular 1.80.............. 1.50 1.38 No.
Doppler velocity
and/or pressure
derived coronary
flow reserve
measurement
(coronary vessel or
graft) during
coronary
angiography
including
pharmacologically
induced stress;
initial vessel.
93572............. Intravascular 1.44.............. 1.00 1.00 No.
Doppler velocity
and/or pressure
derived coronary
flow reserve
measurement
(coronary vessel or
graft) during
coronary
angiography
including
pharmacologically
induced stress;
each additional
vessel.
93668............. Peripheral arterial 0.00.............. 0.00 0.00 No.
disease (PAD)
rehabilitation, per
session.
93XX1............. Remote monitoring of NEW............... 0.70 0.70 No.
a wireless
pulmonary artery
pressure sensor for
up to 30 days
including at least
weekly downloads of
pulmonary artery
pressure
recordings,
interpretation(s),
trend analysis, and
report(s) by a
physician or other
qualified health
care professional.
95800............. Sleep study, 1.05.............. 1.00 0.85 No.
unattended,
simultaneous
recording; heart
rate, oxygen
saturation,
respiratory
analysis (e.g., by
airflow or
peripheral arterial
tone), and sleep
time.
95801............. Sleep study, 1.00.............. 1.00 0.85 No.
unattended,
simultaneous
recording; minimum
of heart rate,
oxygen saturation,
and/respiratory
analysis (e.g., by
airflow or
peripheral arterial
tone).
95806............. Sleep study, 1.25.............. 1.08 0.93 No.
unattended,
simultaneous
recording of, heart
rate, oxygen
saturation,
respiratory
airflow, and
respiratory effort
(e.g.,
thoracoabdominal
movement).
95970............. Electronic analysis 0.45.............. 0.45 0.35 No.
of implanted
neurostimulator
pulse generator/
transmitter (e.g.,
contact group(s),
interleaving,
amplitude, pulse
width, frequency
(Hz), on/off
cycling, burst,
magnet mode, dose
lockout, patient
selectable
parameters,
responsive
neurostimulation,
detection
algorithms, closed
loop parameters,
and passive
parameters) by
physician or other
qualified health
care professional;
with brain, cranial
nerve, spinal cord,
peripheral nerve,
or sacral nerve
neurostimulator
pulse generator/
transmitter,
without programming.
95X83............. Electronic analysis NEW............... 0.95 0.73 No.
of implanted
neurostimulator
pulse generator/
transmitter (e.g.,
contact group(s),
interleaving,
amplitude, pulse
width, frequency
(Hz), on/off
cycling, burst,
magnet mode, dose
lockout, patient
selectable
parameters,
responsive
neurostimulation,
detection
algorithms, closed
loop parameters,
and passive
parameters) by
physician or other
qualified health
care professional;
with simple cranial
nerve
neurostimulator
pulse generator/
transmitter
programming by
physician or other
qualified health
care professional.
95X84............. Electronic analysis NEW............... 1.19 0.97 No.
of implanted
neurostimulator
pulse generator/
transmitter (e.g.,
contact group(s),
interleaving,
amplitude, pulse
width, frequency
(Hz), on/off
cycling, burst,
magnet mode, dose
lockout, patient
selectable
parameters,
responsive
neurostimulation,
detection
algorithms, closed
loop parameters,
and passive
parameters) by
physician or other
qualified health
care professional;
with complex
cranial nerve
neurostimulator
pulse generator/
transmitter
programming by
physician or other
qualified health
care professional.
[[Page 35781]]
95X85............. Electronic analysis NEW............... 1.25 0.91 No.
of implanted
neurostimulator
pulse generator/
transmitter (e.g.,
contact group(s),
interleaving,
amplitude, pulse
width, frequency
(Hz), on/off
cycling, burst,
magnet mode, dose
lockout, patient
selectable
parameters,
responsive
neurostimulation,
detection
algorithms, closed
loop parameters,
and passive
parameters) by
physician or other
qualified health
care professional;
with brain
neurostimulator
pulse generator/
transmitter
programming, first
15 minutes face-to-
face time with
physician or other
qualified health
care professional.
95X86............. Electronic analysis NEW............... 1.00 0.80 No.
of implanted
neurostimulator
pulse generator/
transmitter (e.g.,
contact group(s),
interleaving,
amplitude, pulse
width, frequency
(Hz), on/off
cycling, burst,
magnet mode, dose
lockout, patient
selectable
parameters,
responsive
neurostimulation,
detection
algorithms, closed
loop parameters,
and passive
parameters) by
physician or other
qualified health
care professional;
with brain
neurostimulator
pulse generator/
transmitter
programming, each
additional 15
minutes face-to-
face time with
physician or other
qualified health
care professional.
96105............. Assessment of 1.75.............. 1.75 1.75 No.
aphasia (includes
assessment of
expressive and
receptive speech
and language
function, language
comprehension,
speech production
ability, reading,
spelling, writing,
e.g., by boston
diagnostic aphasia
examination) with
interpretation and
report, per hour.
96110............. Developmental 0.00.............. 0.00 0.00 No.
screening (e.g.,
developmental
milestone survey,
speech and language
delay screen) with
scoring and
documentation, per
standardized
instrument.
96116............. Neurobehavioral 1.86.............. 1.86 1.86 No.
status exam
(clinical
assessment of
thinking, reasoning
and judgment, e.g.,
acquired knowledge,
attention,
language, memory,
planning and
problem solving,
and visual spatial
abilities), by
physician or other
qualified health
care professional,
both face-to-face
time with the
patient and time
interpreting test
results and
preparing the
report; first hour.
96125............. Standardized 1.70.............. 1.70 1.70 No.
cognitive
performance testing
(e.g., ross
information
processing
assessment) per
hour of a qualified
health care
professional's
time, both face-to-
face time
administering tests
to the patient and
time interpreting
these test results
and preparing the
report.
96127............. Brief emotional/ 0.00.............. 0.00 0.00 No.
behavioral
assessment (e.g.,
depression
inventory,
attention-deficit/
hyperactivity
disorder [ADHD]
scale), with
scoring and
documentation, per
standardized
instrument.
963X0............. Developmental test NEW............... 2.50 2.56 No.
administration
(including
assessment of fine
and/or gross motor,
language, cognitive
level, social,
memory and/or
executive functions
by standardized
developmental
instruments when
performed), by
physician or other
qualified health
care professional,
with interpretation
and report; first
hour.
963X1............. Developmental test NEW............... 1.10 1.16 No.
administration
(including
assessment of fine
and/or gross motor,
language, cognitive
level, social,
memory and/or
executive functions
by standardized
developmental
instruments when
performed), by
physician or other
qualified health
care professional,
with interpretation
and report; each
additional 30
minutes.
963X2............. Neurobehavioral NEW............... 1.71 1.71 No.
status exam
(clinical
assessment of
thinking, reasoning
and judgment, e.g.,
acquired knowledge,
attention,
language, memory,
planning and
problem solving,
and visual spatial
abilities), by
physician or other
qualified health
care professional,
both face-to-face
time with the
patient and time
interpreting test
results and
preparing the
report; each
additional hour.
[[Page 35782]]
963X3............. Psychological NEW............... 2.50 2.56 No.
testing evaluation
services by
physician or other
qualified health
care professional,
including
integration of
patient data,
interpretation of
standardized test
results and
clinical data,
clinical decision
making, treatment
planning and
report, and
interactive
feedback to the
patient, family
member(s) or
caregiver(s), when
performed; first
hour.
963X4............. Psychological NEW............... 1.90 1.96 No.
testing evaluation
services by
physician or other
qualified health
care professional,
including
integration of
patient data,
interpretation of
standardized test
results and
clinical data,
clinical decision
making, treatment
planning and
report, and
interactive
feedback to the
patient, family
member(s) or
caregiver(s), when
performed; each
additional hour.
963X5............. Neuropsychological NEW............... 2.50 2.56 No.
testing evaluation
services by
physician or other
qualified health
care professional,
including
integration of
patient data,
interpretation of
standardized test
results and
clinical data,
clinical decision
making, treatment
planning and
report, and
interactive
feedback to the
patient, family
member(s) or
caregiver(s), when
performed; first
hour.
963X6............. Neuropsychological NEW............... 1.90 1.96 No.
testing evaluation
services by
physician or other
qualified health
care professional,
including
integration of
patient data,
interpretation of
standardized test
results and
clinical data,
clinical decision
making, treatment
planning and
report, and
interactive
feedback to the
patient, family
member(s) or
caregiver(s), when
performed; each
additional hour.
963X7............. Psychological or NEW............... 0.55 0.55 No.
neuropsychological
test administration
and scoring by
physician or other
qualified health
care professional,
two or more tests,
any method, first
30 minutes.
963X8............. Psychological or NEW............... 0.46 0.46 No.
neuropsychological
test administration
and scoring by
physician or other
qualified health
care professional,
two or more tests,
any method, each
additional 30
minutes.
963X9............. Psychological or NEW............... 0.00 0.00 No.
neuropsychological
test administration
and scoring by
technician, two or
more tests, any
method; first 30
minutes.
96X00............. Electrocorticogram NEW............... 2.30 1.98 No.
from an implanted
brain
neurostimulator
pulse generator/
transmitter,
including
recording, with
interpretation and
report, up to 30
days.
96X10............. Psychological or NEW............... 0.00 0.00 No.
neuropsychological
test administration
and scoring by
technician, two or
more tests, any
method; each
additional 30
minutes.
96X11............. Psychological or NEW............... 0.51 0.51 No.
neuropsychological
test administration
using single
instrument, with
interpretation and
report by physician
or other qualified
health care
professional and
interactive
feedback to the
patient, family
member(s), or
caregivers(s), when
performed.
96X12............. Psychological or NEW............... 0.00 0.00 No.
neuropsychological
test
administration,
with single
automated
instrument via
electronic
platform, with
automated result
only.
990X0............. Remote monitoring of NEW............... 0.00 0.00 No.
physiologic
parameter(s) (e.g.,
weight, blood
pressure, pulse
oximetry,
respiratory flow
rate), initial; set-
up and patient
education on use of
equipment.
990X1............. Remote monitoring of NEW............... 0.00 0.00 No.
physiologic
parameter(s) (e.g.,
weight, blood
pressure, pulse
oximetry,
respiratory flow
rate), initial;
device(s) supply
with daily
recording(s) or
programmed alert(s)
transmission, each
30 days.
[[Page 35783]]
99201............. Office or other 0.48.............. 0.48 0.48 No.
outpatient visit
for the evaluation
and management of a
new patient, which
requires these 3
key components: A
problem focused
history; A problem
focused
examination;
Straightforward
medical decision
making. Counseling
and/or coordination
of care with other
physicians, other
qualified health
care professionals,
or agencies are
provided consistent
with the nature of
the problem(s) and
the patient's and/
or family's needs.
Usually, the
presenting
problem(s) are self
limited or minor.
Typically, 10
minutes are spent
face-to-face with
the patient and/or
family.
99202............. Office or other 0.93.............. 0.93 1.90 Yes.
outpatient visit
for the evaluation
and management of a
new patient, which
requires these 3
key components: An
expanded problem
focused history; An
expanded problem
focused
examination;
Straightforward
medical decision
making. Counseling
and/or coordination
of care with other
physicians, other
qualified health
care professionals,
or agencies are
provided consistent
with the nature of
the problem(s) and
the patient's and/
or family's needs.
Usually, the
presenting
problem(s) are of
low to moderate
severity.
Typically, 20
minutes are spent
face-to-face with
the patient and/or
family.
99203............. Office or other 1.42.............. 1.42 1.90 Yes.
outpatient visit
for the evaluation
and management of a
new patient, which
requires these 3
key components: A
detailed history; A
detailed
examination;
Medical decision
making of low
complexity.
Counseling and/or
coordination of
care with other
physicians, other
qualified health
care professionals,
or agencies are
provided consistent
with the nature of
the problem(s) and
the patient's and/
or family's needs.
Usually, the
presenting
problem(s) are of
moderate severity.
Typically, 30
minutes are spent
face-to-face with
the patient and/or
family.
99204............. Office or other 2.43.............. 2.43 1.90 Yes.
outpatient visit
for the evaluation
and management of a
new patient, which
requires these 3
key components: A
comprehensive
history; A
comprehensive
examination;
Medical decision
making of moderate
complexity.
Counseling and/or
coordination of
care with other
physicians, other
qualified health
care professionals,
or agencies are
provided consistent
with the nature of
the problem(s) and
the patient's and/
or family's needs.
Usually, the
presenting
problem(s) are of
moderate to high
severity.
Typically, 45
minutes are spent
face-to-face with
the patient and/or
family.
99205............. Office or other 3.17.............. 3.17 1.90 Yes.
outpatient visit
for the evaluation
and management of a
new patient, which
requires these 3
key components: A
comprehensive
history; A
comprehensive
examination;
Medical decision
making of high
complexity.
Counseling and/or
coordination of
care with other
physicians, other
qualified health
care professionals,
or agencies are
provided consistent
with the nature of
the problem(s) and
the patient's and/
or family's needs.
Usually, the
presenting
problem(s) are of
moderate to high
severity.
Typically, 60
minutes are spent
face-to-face with
the patient and/or
family.
99211............. Office or other 0.18.............. 0.18 0.18 No.
outpatient visit
for the evaluation
and management of
an established
patient, that may
not require the
presence of a
physician or other
qualified health
care professional.
Usually, the
presenting
problem(s) are
minimal. Typically,
5 minutes are spent
performing or
supervising these
services.
[[Page 35784]]
99212............. Office or other 0.48.............. 0.48 1.22 Yes.
outpatient visit
for the evaluation
and management of
an established
patient, which
requires at least 2
of these 3 key
components: A
problem focused
history; A problem
focused
examination;
Straightforward
medical decision
making. Counseling
and/or coordination
of care with other
physicians, other
qualified health
care professionals,
or agencies are
provided consistent
with the nature of
the problem(s) and
the patient's and/
or family's needs.
Usually, the
presenting
problem(s) are self
limited or minor.
Typically, 10
minutes are spent
face-to-face with
the patient and/or
family.
99213............. Office or other 0.97.............. 0.97 1.22 Yes.
outpatient visit
for the evaluation
and management of
an established
patient, which
requires at least 2
of these 3 key
components: An
expanded problem
focused history; An
expanded problem
focused
examination;
Medical decision
making of low
complexity.
Counseling and
coordination of
care with other
physicians, other
qualified health
care professionals,
or agencies are
provided consistent
with the nature of
the problem(s) and
the patient's and/
or family's needs.
Usually, the
presenting
problem(s) are of
low to moderate
severity.
Typically, 15
minutes are spent
face-to-face with
the patient and/or
family.
99214............. Office or other 1.50.............. 1.50 1.22 Yes.
outpatient visit
for the evaluation
and management of
an established
patient, which
requires at least 2
of these 3 key
components: A
detailed history; A
detailed
examination;
Medical decision
making of moderate
complexity.
Counseling and/or
coordination of
care with other
physicians, other
qualified health
care professionals,
or agencies are
provided consistent
with the nature of
the problem(s) and
the patient's and/
or family's needs.
Usually, the
presenting
problem(s) are of
moderate to high
severity.
Typically, 25
minutes are spent
face-to-face with
the patient and/or
family.
99215............. Office or other 2.11.............. 2.11 1.22 Yes.
outpatient visit
for the evaluation
and management of
an established
patient, which
requires at least 2
of these 3 key
components: A
comprehensive
history; A
comprehensive
examination;
Medical decision
making of high
complexity.
Counseling and/or
coordination of
care with other
physicians, other
qualified health
care professionals,
or agencies are
provided consistent
with the nature of
the problem(s) and
the patient's and/
or family's needs.
Usually, the
presenting
problem(s) are of
moderate to high
severity.
Typically, 40
minutes are spent
face-to-face with
the patient and/or
family.
99446............. Interprofessional B................. 0.35 0.35 No.
telephone/Internet/
electronic health
record assessment
and management
service provided by
a consultative
physician including
a verbal and
written report to
the patient's
treating/requesting
physician or other
qualified
healthcare
professional; 5-10
minutes of medical
consultative
discussion and
review.
99447............. Interprofessional B................. 0.70 0.70 No.
telephone/Internet/
electronic health
record assessment
and management
service provided by
a consultative
physician including
a verbal and
written report to
the patient's
treating/requesting
physician or other
qualified
healthcare
professional; 11-20
minutes of medical
consultative
discussion and
review.
99448............. Interprofessional B................. 1.05 1.05 No.
telephone/Internet/
electronic health
record assessment
and management
service provided by
a consultative
physician including
a verbal and
written report to
the patient's
treating/requesting
physician or other
qualified
healthcare
professional; 21-30
minutes of medical
consultative
discussion and
review.
[[Page 35785]]
99449............. Interprofessional B................. 1.40 1.40 No.
telephone/Internet/
electronic health
record assessment
and management
service provided by
a consultative
physician including
a verbal and
written report to
the patient's
treating/requesting
physician or other
qualified
healthcare
professional; 31
minutes or more of
medical
consultative
discussion and
review.
994X0............. Interprofessional NEW............... 0.50 0.50 No.
telephone/Internet/
electronic health
record referral
service(s) provided
by a treating/
requesting
physician or
qualified health
care professional,
30 minutes.
994X6............. Interprofessional NEW............... 0.70 0.50 No.
telephone/Internet/
electronic health
record assessment
and management
service provided by
a consultative
physician including
a written report to
the patient's
treating/requesting
physician or other
qualified health
care professional,
5 or more minutes
of medical
consultative time.
994X7............. CCM provided NEW............... 1.45 1.22 No.
personally by a
physician/QHP.
994X9............. Remote physiologic NEW............... 0.61 0.61 No.
monitoring
treatment
management
services, 20
minutes or more of
clinical staff/
physician/other
qualified
healthcare
professional time
in a calendar month
requiring
interactive
communication with
the patient/
caregiver during
the month.
G0108............. Diabetes outpatient 0.90.............. 0.90 0.90 No.
self-management
training services,
individual, per 30
minutes.
G0109............. Diabetes outpatient 0.25.............. 0.25 0.25 No.
self-management
training services,
group session (2 or
more), per 30
minutes.
G0166............. External 0.07.............. 0.00 0.00 No.
counterpulsation,
per treatment
session.
G0168............. Wound closure 0.45.............. 0.45 0.31 No.
utilizing tissue
adhesive(s) only.
G0268............. Removal of impacted 0.61.............. 0.61 0.61 No.
cerumen (one or
both ears) by
physician on same
date of service as
audiologic function
testing.
GCG0X............. Visit complexity NEW............... .............. 0.25 No.
inherent to
evaluation and
management
associated with
endocrinology,
rheumatology,
hematology/
oncology, urology,
neurology,
obstetrics/
gynecology, allergy/
immunology,
otolaryngology, or
interventional pain
management-centered
care (Add-on code,
list separately in
addition to an
evaluation and
management visit).
GPC1X............. Visit complexity NEW............... .............. 0.07 No.
inherent to
evaluation and
management
associated with
primary medical
care services that
serve as the
continuing focal
point for all
needed health care
services (Add-on
code, list
separately in
addition to an
evaluation and
management visit).
GPD0X............. Podiatry services, NEW............... .............. 1.35 No.
medical examination
and evaluation with
initiation of
diagnostic and
treatment program,
new patient.
GPD1X............. Podiatry services, NEW............... .............. 0.85 No.
medical examination
and evaluation with
initiation of
diagnostic and
treatment program,
established patient.
GPRO1............. Prolonged evaluation NEW............... .............. 1.17 No.
and management or
psychotherapy
service(s) (beyond
the typical service
time of the primary
procedure) in the
office or other
outpatient setting
requiring direct
patient contact
beyond the usual
service; 30 minutes
(List separately in
addition to code
for office or other
outpatient
Evaluation and
Management or
psychotherapy
service).
GRAS1............. Remote pre-recorded NEW............... .............. 0.18 No.
service via
recorded video and/
or images submitted
by the patient
(e.g., store and
forward), including
interpretation with
verbal 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.
GSBR1............. Alcohol and/or NEW............... .............. 0.33 No.
substance (other
than tobacco) abuse
structured
assessment (e.g.,
audit, dast), and
brief intervention,
5-14 minutes.
[[Page 35786]]
GVCI1............. Brief communication NEW............... .............. 0.25 No.
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.
----------------------------------------------------------------------------------------------------------------
BILLING CODE 4120-01-P
[[Page 35787]]
[GRAPHIC] [TIFF OMITTED] TP27JY18.000
[[Page 35788]]
[GRAPHIC] [TIFF OMITTED] TP27JY18.001
[[Page 35789]]
[GRAPHIC] [TIFF OMITTED] TP27JY18.002
[[Page 35790]]
[GRAPHIC] [TIFF OMITTED] TP27JY18.003
[[Page 35791]]
[GRAPHIC] [TIFF OMITTED] TP27JY18.004
[[Page 35792]]
[GRAPHIC] [TIFF OMITTED] TP27JY18.005
[[Page 35793]]
[GRAPHIC] [TIFF OMITTED] TP27JY18.006
[[Page 35794]]
[GRAPHIC] [TIFF OMITTED] TP27JY18.007
[[Page 35795]]
[GRAPHIC] [TIFF OMITTED] TP27JY18.008
[[Page 35796]]
[GRAPHIC] [TIFF OMITTED] TP27JY18.009
[[Page 35797]]
[GRAPHIC] [TIFF OMITTED] TP27JY18.010
[[Page 35798]]
[GRAPHIC] [TIFF OMITTED] TP27JY18.011
[[Page 35799]]
[GRAPHIC] [TIFF OMITTED] TP27JY18.012
[[Page 35800]]
[GRAPHIC] [TIFF OMITTED] TP27JY18.013
[[Page 35801]]
[GRAPHIC] [TIFF OMITTED] TP27JY18.014
[[Page 35802]]
[GRAPHIC] [TIFF OMITTED] TP27JY18.015
[[Page 35803]]
[GRAPHIC] [TIFF OMITTED] TP27JY18.016
[[Page 35804]]
[GRAPHIC] [TIFF OMITTED] TP27JY18.017
[[Page 35805]]
[GRAPHIC] [TIFF OMITTED] TP27JY18.018
[[Page 35806]]
[GRAPHIC] [TIFF OMITTED] TP27JY18.019
[[Page 35807]]
[GRAPHIC] [TIFF OMITTED] TP27JY18.020
[[Page 35808]]
[GRAPHIC] [TIFF OMITTED] TP27JY18.021
[[Page 35809]]
[GRAPHIC] [TIFF OMITTED] TP27JY18.022
[[Page 35810]]
[GRAPHIC] [TIFF OMITTED] TP27JY18.023
[[Page 35811]]
[GRAPHIC] [TIFF OMITTED] TP27JY18.024
[[Page 35812]]
[GRAPHIC] [TIFF OMITTED] TP27JY18.025
[[Page 35813]]
[GRAPHIC] [TIFF OMITTED] TP27JY18.026
[[Page 35814]]
[GRAPHIC] [TIFF OMITTED] TP27JY18.027
[[Page 35815]]
[GRAPHIC] [TIFF OMITTED] TP27JY18.028
[[Page 35816]]
[GRAPHIC] [TIFF OMITTED] TP27JY18.029
[[Page 35817]]
[GRAPHIC] [TIFF OMITTED] TP27JY18.030
[[Page 35818]]
[GRAPHIC] [TIFF OMITTED] TP27JY18.031
[[Page 35819]]
[GRAPHIC] [TIFF OMITTED] TP27JY18.032
[[Page 35820]]
[GRAPHIC] [TIFF OMITTED] TP27JY18.033
[[Page 35821]]
[GRAPHIC] [TIFF OMITTED] TP27JY18.034
[[Page 35822]]
[GRAPHIC] [TIFF OMITTED] TP27JY18.035
[[Page 35823]]
[GRAPHIC] [TIFF OMITTED] TP27JY18.036
[[Page 35824]]
[GRAPHIC] [TIFF OMITTED] TP27JY18.037
[[Page 35825]]
[GRAPHIC] [TIFF OMITTED] TP27JY18.038
[[Page 35826]]
[GRAPHIC] [TIFF OMITTED] TP27JY18.039
[[Page 35827]]
[GRAPHIC] [TIFF OMITTED] TP27JY18.040
[[Page 35828]]
[GRAPHIC] [TIFF OMITTED] TP27JY18.041
[[Page 35829]]
[GRAPHIC] [TIFF OMITTED] TP27JY18.042
[[Page 35830]]
[GRAPHIC] [TIFF OMITTED] TP27JY18.043
BILLING CODE 4120-01-C
[[Page 35831]]
Table 15--Proposed CY 2019 Existing Invoices
--------------------------------------------------------------------------------------------------------------------------------------------------------
Estimated
non-
facility
allowed
CPT/HCPCS codes Item name CMS code Current Updated Percent Number of services
price price change invoices for HCPCS
codes
using this
item
--------------------------------------------------------------------------------------------------------------------------------------------------------
19085, 19086, 19287, 19288................ Breast MRI computer aided EQ370.................. 0.00 0.00 1 2,466
detection and biopsy
guidance software.
53850..................................... kit, transurethral SA036.................. 1,149.00 1,000.00 -13 1 5,608
microwave thermotherapy.
53852..................................... kit, transurethral needle SA037.................. 1,050.00 900.00 -14 2 2,476
ablation (TUNA).
85097..................................... stain, Wright's Pack (per SL140.................. 0.05 0.16 235 1 43,183
slide).
96116, 96118, 96119, 96125................ neurobehavioral status SK050.................. 5.77 4.00 -31 3 414,139
forms, average.
258 codes................................. scope video system ES031.................. 33,391.00 36,306.00 9 2,480,515
(monitor, processor,
digital capture, cart,
printer, LED light).
--------------------------------------------------------------------------------------------------------------------------------------------------------
Table 16--Proposed CY 2019 New Invoices
--------------------------------------------------------------------------------------------------------------------------------------------------------
Number of NF allowed
CPT/HCPCS codes Item name CMS code Average price invoices services
--------------------------------------------------------------------------------------------------------------------------------------------------------
10X18, 10X19............................. MREYE CHIBA BIOPSY NEEDLE... SC106.......................... 37.00 1 0
332X5.................................... subcutaneous cardiac rhythm SA127.......................... 5,032.50 4 280
monitor system.
36X72, 36X73, 36584...................... Turbo-Ject PICC Line........ SD331.......................... 170.00 1 24,402
538X3.................................... kit, Rezum delivery device.. SA128.......................... 1,150.00 1 121
538X3.................................... generator, water EQ389.......................... 27,538.00 10 121
thermotherapy procedure.
58100.................................... Uterine Sound............... SD329.......................... 3.17 1 59,152
58100.................................... Tenaculum................... SD330.......................... 3.77 1 59,152
767X1, 767X2, 767X3...................... sheer wave elastography ED060.......................... 9,600.00 1 493
software.
76X01.................................... MR Elastography Package..... EL050.......................... 200,684.50 1 350
76X0X, 76X1X............................. bubble contrast............. SD332.......................... 126.59 1 89
76X0X, 76X1X............................. Ultrasound Contrast Imaging ER108.......................... 5,760.00 1 89
Package.
77X51, 77X52............................. CAD Software................ ED058.......................... 17,200.00 0 36,675
77X49, 77X50, 77X51, 77X52............... Breast coil................. EQ388.......................... 12,238.00 0 39,785
77X51, 77X52............................. CAD Workstation (CPU + Color ED056.......................... 14,829.62 0 36,675
Monitor).
85097.................................... slide stainer, automated, EP121.......................... 8,649.43 1 34,559
hematology.
92X71.................................... Sleep mask.................. SK133.......................... 9.95 1 10,266
92X71, 92X73............................. mfERG and ffERG EQ390.......................... 102,400.00 1 25,602
electrodiagnostic unit.
92X71, 92X73............................. Contact lens electrode for EQ391.......................... 1,440.00 1 25,602
mfERG and ffERG.
963X7, 963X8, 963X9, 96X10............... WAIS-IV Record Form......... SK130.......................... 5.25 1 301,452
963X7, 963X8, 963X9, 96X10............... WAIS-IV Response Booklet #1. SK131.......................... 3.30 1 301,452
963X7, 963X8, 963X9, 96X10............... WMS-IV Response Booklet #2.. SK132.......................... 2.00 1 301,452
963X7, 963X8, 963X9, 96X10............... Wechsler Adult Intelligence EQ387.......................... 971.30 1 301,452
Scale--Fourth Edition (WAIS-
IV) Kit (less forms).
96X12.................................... CANTAB Mobile (per single ED055.......................... 2,800.00 1 0
automated assessment).
990X1.................................... heart failure patient EQ392.......................... 1,000.00 1 58
physiologic monitoring
equipment package.
G0109.................................... 20x30 inch self-stick easel SK129.......................... 0.00 0 93,576
pad, white, 30 sheets/pad.
none..................................... needle holder, Mayo Hegar, SC105.......................... 3.03 1 0
6''.
--------------------------------------------------------------------------------------------------------------------------------------------------------
Table 17--Proposed CY 2019 No PE Refinements
------------------------------------------------------------------------
HCPCS Description
------------------------------------------------------------------------
10X11............................. Fna bx w/o img gdn ea addl.
10X13............................. Fna bx w/us gdn ea addl.
10X15............................. Fna bx w/fluor gdn ea addl.
10X17............................. Fna bx w/ct gdn ea addl.
10X18............................. Fna bx w/mr gdn 1st les.
10X19............................. Fna bx w/mr gdn ea addl.
332X0............................. Tcat impl wrls p-art prs snr.
332X5............................. Insj subq car rhythm mntr.
332X6............................. Rmvl subq car rhythm mntr.
[[Page 35832]]
33X05............................. Tcat insj/rpl perm ldls pm.
33X06............................. Tcat rmvl perm ldls pm.
36568............................. Insj picc <5 yr w/o imaging.
36569............................. Insj picc 5 yr+ w/o imaging.
36584............................. Compl rplcmt picc rs&i.
3853X............................. Open bx/exc inguinofem nodes.
49422............................. Remove tunneled ip cath.
50X39............................. Dilat xst trc ndurlgc px.
50X40............................. Dilat xst trc new access rcs.
53850............................. Prostatic microwave thermotx.
53852............................. Prostatic rf thermotx.
538X3............................. Trurl dstrj prst8 tiss rf wv.
57150............................. Treat vagina infection.
57160............................. Insert pessary/other device.
58110............................. Bx done w/colposcopy add-on.
65205............................. Remove foreign body from eye.
65210............................. Remove foreign body from eye.
67500............................. Inject/treat eye socket.
67505............................. Inject/treat eye socket.
67515............................. Inject/treat eye socket.
74485............................. Dilation urtr/urt rs&i.
76514............................. Echo exam of eye thickness.
767X3............................. Use ea addl target lesion.
76942............................. Echo guide for biopsy.
77081............................. Dxa bone density/peripheral.
93668............................. Peripheral vascular rehab.
93XX1............................. Rem mntr wrls p-art prs snr.
95800............................. Slp stdy unattended.
95801............................. Slp stdy unatnd w/anal.
95806............................. Sleep study unatt&resp efft.
95970............................. Alys npgt w/o prgrmg.
95X83............................. Alys smpl cn npgt prgrmg.
95X84............................. Alys cplx cn npgt prgrmg.
95X85............................. Alys brn npgt prgrmg 15 min.
95X86............................. Alys brn npgt prgrmg addl 15.
96105............................. Assessment of aphasia.
96110............................. Developmental screen w/score.
96116............................. Neurobehavioral status exam.
96125............................. Cognitive test by hc pro.
96127............................. Brief emotional/behav assmt.
963X0............................. Devel tst phys/qhp 1st hr.
963X1............................. Devel tst phys/qhp ea addl.
963X2............................. Nubhvl xm phy/qhp ea addl hr.
963X3............................. Psycl tst eval phys/qhp 1st.
963X4............................. Psycl tst eval phys/qhp ea.
96X00............................. Ecog impltd brn npgt History of Present Illness (History),
Physical Examination (Exam) and
Medical Decision Making (MDM).
These codes are broadly referred to as E/M visit codes. There are
three to five E/M visit code levels, depending on site of service and
the extent of the three components of history, exam and MDM. For
example, there are three to four levels of E/M visit codes in the
inpatient hospital and nursing facility settings, based on a relatively
narrow degree of complexity in those settings. In contrast, there are
five levels of E/M visit codes in the office or other outpatient
setting based on a broader range of complexity in those settings.
Current PFS payment rates for E/M visit codes increase with the
level of visit billed. As for all services under the PFS, the rates are
based on the resources in terms of work (time and intensity), PE and
malpractice expense required to furnish the typical case of the
service. The current payment rates reflect typical service times for
each code that are based on RUC recommendations.
In total, E/M visits comprise approximately 40 percent of allowed
charges for PFS services, and office/outpatient E/M visits comprise
approximately 20 percent of allowed charges for PFS services. Within
these percentages, there is significant variation among specialties.
According to Medicare claims data, E/M visits are furnished by nearly
all specialties, but represent a greater share of total allowed
services for physicians and other practitioners who do not routinely
furnish procedural interventions or diagnostic tests. Generally, these
practitioners include both primary care practitioners and specialists
such as neurologists, endocrinologists and rheumatologists. Certain
specialties, such as podiatry, tend to furnish lower level E/M visits
more often than higher level E/M visits. Some specialties, such as
dermatology and otolaryngology, tend to bill more E/M visits on the
same day as they bill minor procedures.
Potential misvaluation of E/M codes is an issue that we have been
carefully considering for several years. We have discussed at length in
our recent PFS proposed and final rules that the E/M visit code set is
outdated and needs to be revised and revalued (for example: 81 FR 46200
and 76 FR 42793). We have noted that this code set represents a high
proportion of PFS expenditures, but has not been recently revalued to
account for significant changes in the disease burden of the Medicare
patient population and changes in health care practice that are
underway to meet the Medicare population's health care needs (81 FR
46200). In the CY 2012 PFS proposed rule, we proposed to refer all E/M
codes to the RUC for review as potentially misvalued (76 FR 42793).
Many commenters to that rule were concerned about the possible
inadequacies of the current E/M coding and documentation structure to
address evolving chronic care management and to support primary care
(76 FR 73060 through 73064). We did not finalize our proposal to refer
the E/M codes for RUC review at that time. Instead, we stated that we
would allow time for consideration of the findings of certain
demonstrations and other initiatives to provide improved information
for the valuation of chronic care management, primary care, and care
transitions. We stated that we would also continue to consider the
numerous policy alternatives that commenters offered, such as separate
E/M codes for established visits for patients with chronic disease
versus a post-surgical follow-up office visit.
Many stakeholders continue to similarly express to us through
letters, meetings, public comments in past rulemaking cycles, and other
avenues, that the E/M code set is outdated and needs to be revised. For
example, some stakeholders recommend an extensive research effort to
revise and revalue E/M services, especially physician work inputs (CY
2017 PFS final rule, 81 FR 80227-80228). In recent years, we have
continued to consider the best ways to recognize the significant
changes in health care practice, especially innovations in the active
management and ongoing care of chronically ill patients, under the PFS.
We have been engaged in an ongoing, incremental effort to identify gaps
in appropriate coding and payment.
b. E/M Documentation Guidelines
For coding and billing E/M visits to Medicare, practitioners may
use one of two versions of the E/M Documentation Guidelines for a
patient encounter, commonly referenced based on the year of their
release: The ``1995'' or ``1997'' E/M Documentation Guidelines. These
guidelines are available on the CMS website.\3\ They specify the
medical record information within each of the three key components
(such as number of body systems reviewed) that serves as support for
billing a given level of E/M
[[Page 35833]]
visit. The 1995 and 1997 guidelines are very similar to the guidelines
that reside within the AMA's CPT codebook for E/M visits. For example,
the core structure of what comprises or defines the different levels of
history, exam, and medical decision-making are the same. However, the
1995 and 1997 guidelines include extensive examples of clinical work
that comprise different levels of medical decision-making and do not
appear in the AMA's CPT codebook. Also, the 1995 and 1997 guidelines do
not contain references to preventive care that appear in the AMA's CPT
codebook. We provide an example of how the 1995 and 1997 guidelines
distinguish between level 2 and level 3 E/M visits in Table 18.
---------------------------------------------------------------------------
\3\ See: https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNEdWebGuide/Downloads/95Docguidelines.pdf;
https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNEdWebGuide/Downloads/97Docguidelines.pdf; and the
Evaluation and Management Services guide at https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/eval-mgmt-serv-guide-ICN006764.pdf).
---------------------------------------------------------------------------
Table 18--Key Component Documentation Requirements for Level 2 vs. 3 E/M Visit
----------------------------------------------------------------------------------------------------------------
Key component * Level 2 (1995) Level 3 (1995) Level 2 (1997) Level 3 (1997)
----------------------------------------------------------------------------------------------------------------
History (History of Present Review of Systems Problem Pertinent No change from No change from
Illness or HPI). (ROS) n/a. ROS: Inquires 1995. 1995.
about the system
directly related
to the problem(s)
identified in the
HPI.
Physical Examination (Exam)..... A limited A limited General multi- General multi-
examination of examination of system exam: system exam:
the affected body the affected body Performance and Performance and
area or organ area or organ documentation of documentation of
system. system and other one to five at least six
symptomatic or elements in one elements in one
related organ or more organ or more organ
system(s). system(s) or body system(s) or body
area(s). area(s).
Single organ Single organ
system exam: system exam:
Performance and Performance and
documentation of documentation of
one to five at least six
elements. elements.
---------------------------------------
Medical Decision Making (MDM) Straightforward: Low complexity: No change from 1995.
Measured by: **
1. Problem--Number of 1. Minimal..... 1. Limited.
diagnoses/treatment options.
2. Data--Amount and/or 2. Minimal or 2. Limited data
complexity of data to be no data review. review.
reviewed.
3. Risk--Risk of 3. Minimal risk 3. Low risk.
complications and/or
morbidity or mortality.
----------------------------------------------------------------------------------------------------------------
* For certain settings and patient types, each of these three key components must be met or exceeded (for
example, new patients; initial hospital visits). For others, only two of the three key components must be met
or exceeded (for example, established patients, subsequent hospital or other visits).
** Two of three met or exceeded.
According to both Medicare claims processing manual instructions
and CPT coding rules, when counseling and/or coordination of care
accounts for more than 50 percent of the face-to-face physician/patient
encounter (or, in the case of inpatient E/M services, the floor time)
the duration of the visit can be used as an alternative basis to select
the appropriate E/M visit level (Pub. 100-04, Medicare Claims
Processing Manual, Chapter 12, Section 30.6.1.C available at https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c12.pdf; see also 2017 CPT Codebook Evaluation and Management
Services Guidelines, page 10). Pub. 100-04, Medicare Claims Processing
Manual, Chapter 12, Section 30.6.1.B states, ``Instruct physicians to
select the code for the service based upon the content of the service.
The duration of the visit is an ancillary factor and does not control
the level of the service to be billed unless more than 50 percent of
the face-to-face time (for non-inpatient services) or more than 50
percent of the floor time (for inpatient services) is spent providing
counseling or coordination of care as described in subsection C.''
Subsection C states that ``the physician may document time spent with
the patient in conjunction with the medical decision-making involved
and a description of the coordination of care or counseling provided.
Documentation must be in sufficient detail to support the claim.'' The
example included in subsection C further states, ``The code selection
is based on the total time of the face-to-face encounter or floor time,
not just the counseling time. The medical record must be documented in
sufficient detail to justify the selection of the specific code if time
is the basis for selection of the code.''
Both the 1995 and 1997 E/M guidelines contain guidelines that
address time, which state that ``In the case where counseling and/or
coordination of care dominates (more than 50 percent of) the physician/
patient and/or family encounter (face-to-face time in the office or
other outpatient setting or floor/unit time in the hospital or nursing
facility), time is considered the key or controlling factor to qualify
for a particular level of E/M services.'' The guidelines go on to state
that ``If the physician elects to report the level of service based on
counseling and/or coordination of care, the total length of time of the
encounter (face-to-face or floor time, as appropriate) should be
documented and the record should describe the counseling and/or
activities to coordinate care.'' \4\
---------------------------------------------------------------------------
\4\ Page 16 of the 1995 E/M guidelines and page 48 of the 1997
guidelines.
---------------------------------------------------------------------------
We note that other manual provisions regarding E/M visits that are
cited in this proposed rule are housed separately within Medicare's
Internet-Only Manuals, and are not contained within the 1995 or 1997 E/
M documentation guidelines.
[[Page 35834]]
In accordance with section 1862(a)(1)(A) of the Act, which requires
services paid under Medicare Part B to be reasonable and necessary for
the diagnosis or treatment of illness or injury or to improve the
functioning of a malformed body member, medical necessity is a
prerequisite to Medicare payment for E/M visits. The Medicare Claims
Processing Manual states, ``Medical necessity of a service is the
overarching criterion for payment in addition to the individual
requirements of a CPT code. It would not be medically necessary or
appropriate to bill a higher level of evaluation and management service
when a lower level of service is warranted. The volume of documentation
should not be the primary influence upon which a specific level of
service is billed. Documentation should support the level of service
reported'' (Pub. 100-04, Medicare Claims Processing Manual, Chapter 12,
Section 30.6.1A, available on the CMS website at https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c12.pdf).
Stakeholders have long maintained that all of the E/M documentation
guidelines are administratively burdensome and outdated with respect to
the practice of medicine. Stakeholders have provided CMS with examples
of such outdated material (on history, exam and MDM) that can be found
within all versions of the E/M guidelines (the AMA's CPT codebook, the
1995 guidelines and the 1997 guidelines). Stakeholders have told CMS
that they believe the guidelines are too complex, ambiguous, fail to
meaningfully distinguish differences among code levels, and are not
updated for changes in technology, especially electronic health record
(EHR) use. Prior attempts to revise the E/M guidelines were
unsuccessful or resulted in additional complexity due to lack of
stakeholder consensus (with widely varying views among specialties),
and differing perspectives on whether code revaluation would be
necessary under the PFS as a result of revising the guidelines, which
contributed another layer of complexity to the considerations. For
example, an early attempt to revise the guidelines resulted in an
additional version designed for use by certain specialties (the 1997
version), and in CMS allowing the use of either the 1995 or 1997
versions for purposes of documentation and billing to Medicare. Another
complication in revising the guidelines is that they are also used by
many other payers, which have their own payment rules and audit
protocols. Moreover, stakeholders have suggested that there is
sometimes variation in how Medicare's own contractors (Medicare
Administrative Contractors (MACs) interpret and apply the guidelines as
part of their audit processes.
As previously mentioned, in recent years, some clinicians and other
stakeholders have requested a major CMS research initiative to overhaul
not only the E/M documentation guidelines, but also the underlying
coding structure and valuation. Stakeholders have reported to CMS that
they believe the E/M visit codes themselves need substantial updating
and revaluation to reflect changes in the practice of medicine, and
that revising the documentation guidelines without addressing the codes
themselves simply preserves an antiquated framework for payment of E/M
services.
Last year, CMS sought public comment on potential changes to the E/
M documentation rules, deferring making any changes to E/M coding
itself in order to immediately focus on revision of the E/M guidelines
to reduce unnecessary administrative burden (82 FR 34078 through
34080). In the CY 2018 PFS final rule (82 FR 53163 through 53166), we
summarized the public comments we received and stated that we would
take that feedback into consideration for future rulemaking. In
response to commenters' request that we provide additional venues for
stakeholder input, we held a listening session this year on March 18,
2018 (transcript and materials are available on the CMS website at
https://www.cms.gov/Outreach-and-Education/Outreach/NPC/National-Provider-Calls-and-Events-Items/2018-03-21-Documentation-Guidelines-and-Burden-Reduction.html?DLPage=1&DLEntries=10&DLSort=0&DLSortDir=descending). We
also sought input by participating in several listening sessions
recently hosted by the Office of the National Coordinator for Health
Information Technology (ONC) in the course of implementing section
4001(a) of the 21st Century Cures Act (Pub. L. 114-255). This provision
requires the Department of Health and Human Services to establish a
goal, develop a strategy, and make recommendations to reduce regulatory
or administrative burdens relating to the use of EHRs. The ONC
listening sessions sought public input on the E/M guidelines as one
part of broader, related and unrelated burdens associated with EHRs.
Several themes emerged from this recent stakeholder input.
Stakeholders commended CMS for undertaking to revise the E/M guidelines
and recommended a multi-year process. Many commenters advised CMS to
obtain further input across specialties. They recommended town halls,
open door forums or a task force that would come up with replacement
guidelines that would work for all specialties over the course of
several years. They urged CMS to proceed cautiously given the magnitude
of the undertaking; past failed reform attempts by the AMA, CMS, and
other payers; and the wide-ranging impact of any changes (for example,
how other payers approach the issue).
We received substantially different recommendations by specialty.
Based on this feedback, it is clear that any changes would have
substantial specialty-specific impacts, both clinical and financial.
Based on this feedback, it also seems that the history and exam
portions of the guidelines are most significantly outdated with respect
to current clinical practice.
A few stakeholders seemed to indicate that the documentation
guidelines on history and exam should be kept in their current form.
Many stakeholders believed they should be simplified or reduced, but
not eliminated. Some stakeholders indicated that the documentation
guidelines on history and exam could be eliminated altogether, and/or
that documentation of these parts of an E/M visit could be left to
practitioner discretion. We also heard from stakeholders that the
degree to which an extended history and exam enables a given
practitioner to reach a certain level of coding (and payment) varies
according to their specialty. Many stakeholders advised CMS to increase
reliance on medical decision-making (MDM) and time in determining the
appropriate level of E/M visit, or to use MDM by itself, but many of
these commenters believed that the MDM portions of the guidelines would
need to be altered before being used alone. Commenters were divided on
the role of time in distinguishing among E/M visit levels, and
expressed some concern about potential abuse or inequities among more-
or less-efficient practitioners. Some commenters expressed support for
simplifying E/M coding generally into three levels such as low, medium
and high, and potentially distinguishing those levels on the basis of
time.
2. CY 2019 Proposed Policies
Having considered the public feedback to the CY 2018 PFS proposed
rule (82 FR 53163 through 53166) and our other outreach efforts
described above, we are proposing several changes to E/M visit
documentation and
[[Page 35835]]
payment. The proposed changes would only apply to office/outpatient
visit codes (CPT codes 99201 through 99215), except where we specify
otherwise. We agree with commenters that we should take a step-wise
approach to these issues, and therefore, we would limit initial changes
to the office/outpatient E/M code set. We understand from commenters
that there are more unique issues to consider for the E/M code sets
used in other settings such as inpatient hospital or emergency
department care, such as unique clinical and legal issues and the
potential intersection with hospital Conditions of Participation
(CoPs). We may consider expanding our efforts more broadly to address
sections of the E/M code set beyond the office/outpatient codes in
future years.
We wish to emphasize that, this year, we are including our proposed
E/M documentation changes in a proposed rule due to the longstanding
nature of our instruction that practitioners may use either the 1995 or
1997 versions of the E/M guidelines to document E/M visits billed to
Medicare, the magnitude of the proposed changes, and the associated
payment policy proposals that require notice and comment rulemaking. We
believe our proposed documentation changes for E/M visits are
intrinsically related to our proposal to alter PFS payment for E/M
visits (discussed below), and the PFS payment proposal for E/M visits
requires notice and comment rulemaking. We note that we are proposing a
relatively broad outline of changes in this proposed rule, and we
anticipate that many details related to program integrity and ongoing
refinement would need to be developed over time through subregulatory
guidance. This would afford flexibility and enable us to more nimbly
and quickly make ongoing clarifications, changes and refinements in
response to continued practitioner experience moving forward.
a. Lifting Restrictions Related to E/M Documentation
(i) Eliminating Extra Documentation Requirements for Home Visits
Medicare pays for E/M visits furnished in the home (a private
residence) under CPT codes 99341 through 99350. The payment rates for
these codes are slightly more than for office visits (for example,
approximately $30 more for a level 5 established patient, non-
facility). The beneficiary need not be confined to the home to be
eligible for such a visit. However, there is a Medicare Claims
Processing Manual provision requiring that the medical record must
document the medical necessity of the home visit made in lieu of an
office or outpatient visit (Pub. 100-04, Medicare Claims Processing
Manual, Chapter 12, Section 30.6.14.1.B, available on the CMS website
at https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c12.pdf). Stakeholders have suggested that whether a
visit occurs in the home or the office is best determined by the
practitioner and the patient without applying additional rules. We
agree, so we are proposing to remove the requirement that the medical
record must document the medical necessity of furnishing the visit in
the home rather than in the office. We welcome public comments on this
proposal, including any potential, unintended consequences of
eliminating this requirement. If we finalize this proposal in the CY
2019 PFS final rule, we would update the manual to reflect the change.
(ii) Public Comment Solicitation on Eliminating Prohibition on Billing
Same-Day Visits by Practitioners of the Same Group and Specialty
The Medicare Claims Processing Manual states, ``As for all other E/
M services except where specifically noted, the Medicare Administrative
Contractors (MACs) may not pay two E/M office visits billed by a
physician (or physician of the same specialty from the same group
practice) for the same beneficiary on the same day unless the physician
documents that the visits were for unrelated problems in the office,
off campus-outpatient hospital, or on campus-outpatient hospital
setting which could not be provided during the same encounter'' (Pub.
100-04, Medicare Claims Processing Manual, Chapter 12, Section
30.6.7.B, available on the CMS website at https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c12.pdf).
This instruction was intended to reflect the idea that multiple
visits with the same practitioner, or by practitioners in the same or
very similar specialties within a group practice, on the same day as
another E/M service would not be medically necessary. However,
stakeholders have provided a few examples where this policy does not
make sense with respect to the current practice of medicine as the
Medicare enrollment specialty does not always coincide with all areas
of medical expertise possessed by a practitioner--for example, a
practitioner with the Medicare enrollment specialty of geriatrics may
also be an endocrinologist. If such a practitioner was one of many
geriatricians in the same group practice, they would not be able to
bill separately for an E/M visit focused on a patient's
endocrinological issue if that patient had another more generalized E/M
visit by another geriatrician on the same day. Stakeholders have
pointed out that in these circumstances, practitioners often respond to
this instruction by scheduling the E/M visits on two separate days,
which could unnecessarily inconvenience the patient. Given that the
number and granularity of practitioner specialties recognized for
purposes of Medicare enrollment continue to increase over time
(consistent with the medical community's requests), the value to the
Medicare program of the prohibition on same-day E/M visits billed by
physicians in the same group and medical specialty may be diminishing,
especially as we believe it is becoming more common for practitioners
to have multiple specialty affiliations, but would have only one
primary Medicare enrollment specialty. We believe that eliminating this
policy may better recognize the changing practice of medicine while
reducing administrative burden. The impact of this proposal on program
expenditures and beneficiary cost sharing is unclear. To the extent
that many of these services are currently merely scheduled and
furnished on different days in response to the instruction, eliminating
this manual provision may not significantly increase utilization,
Medicare spending and beneficiary cost sharing.
We are soliciting public comment on whether we should eliminate the
manual provision given the changes in the practice of medicine or
whether there is concern that eliminating it might have unintended
consequences for practitioners and beneficiaries. We recognize that
this instruction may be appropriate only in certain clinical
situations, so we seek public comments on whether and how we should
consider creating exceptions to, or modify this manual provision rather
than eliminating it entirely. We are also requesting that the public
provide additional examples and situations in which the current
instruction is not clinically appropriate.
b. Documentation Changes for Office or Other Outpatient E/M Visits and
Home Visits
(i) Providing Choices in Documentation--Medical Decision-Making, Time
or Current Framework
Informed by comments and examples that we have received asserting
that the current E/M documentation guidelines
[[Page 35836]]
are outdated with respect to the current practice of medicine, and in
our efforts to simplify documentation for the purposes of coding E/M
visit levels, we propose to allow practitioners to choose, as an
alternative to the current framework specified under the 1995 or 1997
guidelines, either MDM or time as a basis to determine the appropriate
level of E/M visit. This would allow different practitioners in
different specialties to choose to document the factor(s) that matter
most given the nature of their clinical practice. It would also reduce
the impact Medicare may have on the standardized recording of history,
exam and MDM data in medical records, since practitioners could choose
to no longer document many aspects of an E/M visit that they currently
document under the 1995 or 1997 guidelines for history, physical exam
and MDM. While we initially considered reducing the number of key
components that practitioners needed to document in choosing the
appropriate level of E/M service to bill, feedback from the stakeholder
community led us to believe that offering practitioners a choice to
either retain the current framework or choose among new options that
involve a reduced level of documentation would be less burdensome for
practitioners, and would allow more stability for practitioners who may
need time to prepare for any potential new documentation framework.
We wish to be clear that as part of this proposal, practitioners
could use MDM, or time, or they could continue to use the current
framework to document an E/M visit. In other words, we would be
offering the practitioner the choice to continue to use the current
framework by applying the 1995 or 1997 documentation guidelines for all
three key components. However, our proposals on payment for office-
based/outpatient E/M visits described later in this section would apply
to all practitioners, regardless of their selected documentation
approach. All practitioners, even those choosing to retain the current
documentation framework, would be paid at the proposed new payment rate
described in section II.I.2.c. of this proposed rule (one rate for new
patients and another for established patients), and could also report
applicable G-codes proposed in that section.
We also wish to be clear that we are proposing to retain the
current CPT coding structure for E/M visits (along with creating new
replacement codes for podiatry office/outpatient E/M visits) as
described later in this section. Practitioners would report on the
professional claim whatever level of visit (1 through 5) they believe
they furnished using CPT codes 99201-99215. We considered making an
alternative proposal to adopt a single G-code to describe office/
outpatient E/M visit levels 2 through 5 in conjunction with our
proposal to establish a single PFS payment rate for those visits that
is described later in this section. Because we believe the adoption of
a reduced number of G-codes to describe the visit levels 2 through 5
might result in unnecessary disruption to current billing systems and
practices, we are not proposing to modify the existing CPT coding
structure for E/M visits. Since we are proposing to create a single
rate under the PFS that would be paid for services billed using the
current CPT codes for level 2 through 5 E/M visits, it would not be
material to Medicare's payment decision which CPT code (of levels 2
through 5) is reported on the claim, except to justify billing a level
2 or higher visit in comparison to a level 1 visit (provided the visit
itself was reasonable and necessary). We expect that, for record
keeping purposes or to meet requirements of other payers, many
practitioners would continue to choose and report the level of E/M
visit they believe to be appropriate under the CPT coding structure.
Even though there would be no payment differential for E/M visits
level 2 through 5, we believe we would still need to simplify and
change our documentation requirements to better align with the current
practice of medicine and eliminate unnecessary aspects of the current
documentation framework. As a corollary to our proposal to adopt a
single payment amount for office/outpatient E/M visit levels 2 through
5 (see section II.I.2.c. of this proposed rule), we propose to apply a
minimum documentation standard where, for the purposes of PFS payment
for an office/outpatient E/M visit, practitioners would only need to
meet documentation requirements currently associated with a level 2
visit for history, exam and/or MDM (except when using time to document
the service, see below). Practitioners could choose to document more
information for clinical, legal, operational or other purposes, and we
anticipate that for those reasons, they would continue generally to
seek to document medical record information that is consistent with the
level of care furnished. For purposes of our medical review, however,
for practitioners using the current documentation framework or, as we
are proposing, MDM, Medicare would only require documentation to
support the medical necessity of the visit and the documentation that
is associated with the current level 2 CPT visit code.
For example, for a practitioner choosing to document using the
current framework (1995 or 1997 guidelines), our proposed minimum
documentation for any billed level of E/M visit from levels 2 through 5
could include: (1) A problem-focused history that does not include a
review of systems or a past, family, or social history; (2) a limited
examination of the affected body area or organ system; and (3)
straightforward medical decision making measured by minimal problems,
data review, and risk (two of these three). If the practitioner was
choosing to document based on MDM alone, Medicare would only require
documentation supporting straightforward medical decision-making
measured by minimal problems, data review, and risk (two of these
three).
Some commenters have suggested that the current framework of
guidelines for the MDM component of visits would need to be changed
before MDM could be relied upon by itself to distinguish visit levels.
We propose to allow practitioners to rely on MDM in its current form to
document their visit, and are soliciting public comment on whether and
how guidelines for MDM might be changed in subsequent years.
As described earlier, we currently allow time or duration of visit
to be used as the governing factor in selecting the appropriate E/M
visit level, only when counseling and/or coordination of care accounts
for more than 50 percent of the face-to-face physician/patient
encounter (or, in the case of inpatient E/M services, the floor time).
Our proposal to allow practitioners the choice of using time to
document office/outpatient E/M visits would mean that this time-based
standard is not limited to E/M visits in which counseling and/or care
coordination accounts for more than 50 percent of the face-to-face
practitioner/patient encounter. Rather, the amount of time personally
spent by the billing practitioner face-to-face with the patient could
be used to document the E/M visit regardless of the amount of
counseling and/or care coordination furnished as part of the face-to-
face encounter.
Some commenters have raised concerns with reliance on time to
distinguish visit levels, for example the potential for abuse,
inequities among more- or less-efficient practitioners, and specialties
for which time is less of a factor in determining visit complexity.
Relying on time as the basis for
[[Page 35837]]
identifying the E/M visit level also raises the issue of what would be
required by way of supporting documentation; for example, what amount
of time should be documented, and whether the specific activities
comprising the time need to be documented and to what degree. However,
a number of stakeholders have suggested that, within their specialties,
time is a good indicator of the complexity of the visit or patient, and
requested that we allow practitioners to use time as the single factor
in all E/M visits, not just when counseling or care coordination
dominate a visit. We agree that for some practitioners and patients,
time may be a good indicator of complexity of the visit, and are
proposing to allow practitioners the option to use time as the single
factor in selecting visit level and documenting the E/M visit,
regardless of whether counseling or care coordination dominate the
visit. If finalized, we would monitor the results of this proposed
policy for any program integrity issues, administrative burden or other
issues.
For practitioners choosing to support their coding and payment for
an E/M visit by documenting the amount of time spent with the patient,
we propose to require the practitioner to document the medical
necessity of the visit and show the total amount of time spent by the
billing practitioner face-to-face with the patient. We are soliciting
public comment on what that total time should be for payment of the
single, new rate for E/M visits levels 2 through 5. The typical time
for our proposed new payment for E/M visit levels 2 through 5 is 31
minutes for an established patient and 38 minutes for a new patient,
and we could use these times. These times are weighted averages of the
intra-service times across the current E/M visit utilization.
Accordingly, these times are higher than the current typical time for a
level 2, 3 or 4 visit, but lower than the current typical time for a
level 5 visit. We note that currently the PFS does not require the
practitioner to spend or document a specified amount of time with a
given patient in order to receive payment for an E/M visit, unless the
visit is dominated by counseling/care coordination and, on that
account, the practitioner is using time as the basis for code
selection. The times for E/M visits and most other PFS services in the
physician time files, which are used to set PFS rates, are typical
times rather than requirements, and were recommended by the AMA RUC and
then reviewed and either adopted or adjusted for Medicare through our
usual rate setting process as ``typical,'' but not strictly required.
One alternative is to apply the AMA's CPT codebook provision that,
for timed services, a unit of time is attained when the mid-point is
passed,\5\ such that we would require documentation that at least 16
minutes for an established patient (more than half of 31 minutes) and
at least 20 minutes for a new patient (more than half of 38 minutes)
were spent face-to-face by the billing practitioner with the patient,
to support making payment at the proposed single rate for visit levels
2 through 5 when the practitioner chooses to document the visit using
time.
---------------------------------------------------------------------------
\5\ 2017 CPT Codebook Introduction, p.xv.
---------------------------------------------------------------------------
Another alternative is to require documentation that the typical
time for the CPT code that is reported (which is also the typical time
listed in the AMA's CPT codebook for that code) was spent face-to-face
by the billing practitioner with the patient. For example, a
practitioner reporting CPT code 99212 (a level 2 established patient
visit) would be required to document having spent a minimum of 10
minutes, and a practitioner reporting CPT code 99214 (a level 4
established patient visit) would be required to document having spent a
minimum of 25 minutes. Under this approach, the total amount of time
spent by the billing practitioner face-to-face with the patient would
inform the level of E/M visit (of levels 2 through 5) coded by the
billing practitioner. We note that in contrast to other proposed
documentation approaches discussed above, this approach of requiring
documentation of the typical time associated with the CPT visit code
reported on the claim would introduce unique payment implications for
reporting that code, especially when the time associated with the
billed E/M code is the basis for reporting prolonged E/M services.
We are soliciting public comments on the use of time as a framework
for documentation of office/outpatient E/M visits, and whether we
should adopt any of these approaches or specify other requirements with
respect to the proposed option for documentation using time.
In providing us with feedback, we ask commenters to take into
consideration ways in which the time associated with, or required for,
the billing of any add-on codes (especially the proposed prolonged E/M
visit add-on code(s) described in section II.I.2.d.v. of this proposed
rule) would intersect with the time spent for the base E/M visit, when
the practitioner is documenting the E/M visit using only time.
Currently, when reporting prolonged E/M services, we expect the
practitioner to exceed the typical time assigned for the base E/M visit
code (also commonly referred to as the companion code). For example, in
the CY 2017 PFS final rule (81 FR 80229), we expressed appreciation for
the commenters' suggestion to display the typical times associated with
relevant services. We also discussed, and in response to those
comments, decided to post a file annually that notes the times assumed
to be typical for purposes of PFS ratesetting for practitioners to use
as a reference in deciding whether time requirements for reporting
prolonged E/M services are met. We stated that while these typical
times are not required for a practitioner to bill the displayed base
codes, we would expect that only time spent in excess of these times
would be reported using a non-face-to-face prolonged service code. We
are now proposing to formalize this policy in the case where a
practitioner uses time to document a visit, since there would be a
stricter time requirement associated with the base E/M code.
Specifically, we propose that, when a practitioner chooses to document
using time and also reports prolonged E/M services, we would require
the practitioner to document that the typical time required for the
base or ``companion'' visit is exceeded by the amount required to
report prolonged services. See section II.I.2.d.v. of this proposed
rule for further discussion of our proposal regarding reporting
prolonged E/M services.
As we discuss further in this section of the proposed rule, we
believe that allowing practitioners to choose the most appropriate
basis for distinguishing among the levels of E/M visits and applying a
minimum documentation requirement, together with reducing the payment
variation among E/M visit levels, would significantly reduce
administrative burden for practitioners, and would avoid the current
need to make coding and documentation decisions based on codes and
documentation guidelines that are not a good fit with current medical
practice. The practitioner could choose to use MDM, time or the current
documentation framework, and could also apply the proposed policies
below regarding redundancy and who can document information in the
medical record.
We heard from a few commenters on the CY 2018 PFS proposed rule
that some practitioners rely on unofficial Marshfield clinic or other
criteria to help them document E/M visit levels. These commenters
conveyed that the
[[Page 35838]]
Marshfield ``point system'' is commonly used to supplement the E/M
documentation guidelines, because of a lack of concrete criteria for
certain elements of medical decision making in the 1995 and 1997
guidelines or in CPT guidance. We are soliciting public comment on
whether Medicare should use or adopt any aspects of other E/M
documentation systems that may be in use among practitioners, such as
the Marshfield tool. We are interested in feedback as to whether the
1995 and 1997 guidelines contain adequate information for practitioners
to use in documenting visits under our proposals, or whether these
versions of the guidelines would need to be supplemented in any way.
We are seeking public comment on these proposals to provide
practitioners choice in the basis for documenting E/M visits in an
effort to allow for documentation alternatives that better reflect the
current practice of medicine and to alleviate documentation burden. We
are also interested in public comments on practitioners' ability to
avail themselves of these choices with respect to how they would impact
clinical workflows, EHR templates, and other aspects of practitioner
work. Commenters have requested that CMS not merely shift burden by
implementing another framework that might avoid issues caused by the
current guidelines, but that would be equally complex and burdensome.
Our primary goal is to reduce administrative burden so that the
practitioner can focus on the patient, and we are interested in
commenters' opinions as to whether our E/M visit proposals would, in
fact, support and further this goal. We believe these proposals would
allow practitioners to exercise greater clinical judgment and
discretion in what they document, focusing on what is clinically
relevant and medically necessary for the patient. While we propose to
no longer apply much of the E/M documentation guidelines involving
history, exam and, for those choosing to document based on time,
documentation of medical decision-making, our expectation is that
practitioners would continue to perform and document E/M visits as
medically necessary for the patient to ensure quality and continuity of
care. For example, we believe that it remains an important part of care
for the practitioner to understand the patient's social history, even
though we would no longer require that history to be documented to bill
Medicare for the visit.
(ii) Removing Redundancy in E/M Visit Documentation
Stakeholders have recently expressed that CMS should not require
documentation of information in the billing practitioner's note that is
already present in the medical record, particularly with regard to
history and exam. Currently, both the 1995 and 1997 guidelines provide
such flexibility for certain parts of the history for established
patients, stating, ``A Review of Systems ``ROS'' and/or a pertinent
past, family, and/or social history ``PFSH'' obtained during an earlier
encounter does not need to be re-recorded if there is evidence that the
physician reviewed and updated the previous information. This may occur
when a physician updates his/her own record or in an institutional
setting or group practice where many physicians use a common record.
The review and update may be documented by:
Describing any new ROS and/or PFSH information or noting
there has been no change in the information; and
Noting the date and location of the earlier ROS and/or
PFSH.
Documentation Guidelines ``DG'': The ROS and/or PFSH may be
recorded by ancillary staff or on a form completed by the patient. To
document that the physician reviewed the information, there must be a
notation supplementing or confirming the information recorded by others
(https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNEdWebGuide/Downloads/95Docguidelines.pdf; https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNEdWebGuide/Downloads/97Docguidelines.pdf).
We propose to expand this policy to further simplify the
documentation of history and exam for established patients such that,
for both of these key components, practitioners would only be required
to focus their documentation on what has changed since the last visit
or on pertinent items that have not changed, rather than re-documenting
a defined list of required elements such as review of a specified
number of systems and family/social history. Since medical decision-
making can only be accurately formed upon a substantial basis of
accurate and timely health information, and the CPT code descriptors
for all E/M visits would continue to include the elements of history
and exam, we expect that practitioners would still conduct clinically
relevant and medically necessary elements of history and physical exam,
and conform to the general principles of medical record documentation
in the 1995 and 1997 guidelines. However, practitioners would not need
to re-record these elements (or parts thereof) if there is evidence
that the practitioner reviewed and updated the previous information.
We are seeking comment on whether there may be ways to implement a
similar provision for any aspects of medical decision-making, or for
new patients, such as when prior data is available to the billing
practitioner through an interoperable EHR or other data exchange. We
believe there would be special challenges in realizing documentation
efficiencies with new patients, since they may not have received exams
or histories that were complete or relevant to the current
complaint(s), and the information in the transferred record could be
more likely to be incomplete, outdated or inaccurate.
Also, we propose that for both new and established patients,
practitioners would no longer be required to re-enter information in
the medical record regarding the chief complaint and history that are
already entered by ancillary staff or the beneficiary. The practitioner
could simply indicate in the medical record that they reviewed and
verified this information. We wish to be clear that these proposed
policy changes would be optional, where a practitioner could choose to
continue to use the current framework, and the more detailed
information could continue to be entered, re-entered or brought forward
in documenting a visit, regardless of the documentation approach
selected by the practitioner. Our goal is to allow practitioners more
flexibility to exercise greater clinical judgment and discretion in
what they document, focusing on what is clinically relevant and
medically necessary for the patient. Our expectation is that
practitioners would continue to periodically review and assess static
or baseline historical information at clinically appropriate intervals.
(iii) Podiatry Visits
As described in greater detail in section II.I.2.d.iii. of this
proposed rule, as part of our proposal to improve payment accuracy by
creating a single PFS payment rate for E/M visit levels 2 through 5
(with one proposed rate for new patients and one proposed rate for
established patients), we propose to create separate coding for
podiatry visits that are currently reported as E/M office/outpatient
visits. We propose that, rather than reporting visits under the general
E/M office/outpatient visit
[[Page 35839]]
code set, podiatrists would instead report visits under new G-codes
that more specifically identify and value their services. We propose to
apply substantially the same documentation standards for these proposed
new podiatry-specific codes as we propose above for other office/
outpatient E/M visits.
If a practitioner chose to use time to document a podiatry office/
outpatient E/M visit, we propose to apply substantially the same rules
as those we are proposing for documenting on the basis of time for
other office/outpatient E/M visits, discussed above. For practitioners
choosing to use time to provide supporting documentation for the
podiatry visit, we would require documentation supporting the medical
necessity of the visit and showing the total amount of time spent by
the billing practitioner face-to-face with the patient. We are
soliciting public comment on what that total time would be for payment
of the proposed new podiatry G-codes. The typical times for these
proposed codes are 22 minutes for an established patient and 28 minutes
for a new patient, and we could use these times. Alternatively, we
could apply the AMA's CPT codebook provision that, for timed services,
a unit of time is attained when the mid-point is passed,\6\ such that
we would require documentation that at least 12 minutes for an
established patient (more than half of 22 minutes) or at least 15
minutes for a new patient (more than half of 28 minutes) were spent
face-to-face by the billing practitioner with the patient, to support
making payment for these codes when the practitioner chooses to
document the visit using time. We are soliciting comment on the use of
time as a basis for documentation of our proposed podiatric E/M visit
codes, and whether we should adopt any of these approaches or further
specify other requirements with respect to this proposed option for
podiatric practitioners to document their visits using time.
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\6\ 2017 CPT Codebook Introduction, p.xv.
---------------------------------------------------------------------------
c. Minimizing Documentation Requirements by Simplifying Payment Amounts
As we have explained above, including in prior rulemaking, we
believe that the coding, payment, and documentation requirements for E/
M visits are overly burdensome and no longer aligned with the current
practice of medicine. We believe the current set of 10 CPT codes for
new and established office-based and outpatient E/M visits and their
respective payment rates no longer appropriately reflect the complete
range of services and resource costs associated with furnishing E/M
services to all patients across the different physician specialties,
and that documenting these services using the current guidelines has
become burdensome and out of step with the current practice of
medicine. We have included the proposals described above to mitigate
the burden associated with the outdated documentation guidelines for
these services. To alleviate the effects and mitigate the burden
associated with continued use of the outdated CPT code set, we are
proposing to simplify the office-based and outpatient E/M payment rates
and documentation requirements, and create new add-on codes to better
capture the differential resources involved in furnishing certain types
of E/M visits.
In conjunction with our proposal to reduce the documentation
requirements for E/M visit levels 2 through 5, we are proposing to
simplify the payment for those services by paying a single rate for the
level 2 through 5 E/M visits. The visit level of the E/M service is
tied to the documentation requirements in the 1995 and 1997
Documentation Guidelines for E/M Services, which may not be reflective
of changes in technology or, in particular, the ways that electronic
medical records have changed documentation and the patient's medical
record. Additionally, current documentation requirements may not
account for changes in care delivery, such as a growing emphasis on
team based care, increases in the number of recognized chronic
conditions, or increased emphasis on access to behavioral health care.
However, based on the feedback we have received from stakeholders, it
is clear to us that the burdens associated with documenting the
selection of the level of E/M service arise from not only the
documentation guidelines, but also from the coding structure itself.
Like the documentation guidelines, the distinctions between visit
levels reflect a reasonable assessment of variations in care, effort,
and resource costs as identified and articulated several decades ago.
We believe that the most important distinctions between the kinds of
visits furnished to Medicare beneficiaries are not well reflected by
the current E/M visit coding. Most significantly, we have understood
from stakeholders that current E/M coding does not reflect important
distinctions in services and differences in resources. At present, we
believe the current payment for E/M visit levels, generally
distinguished by common elements of patient history, physical exam, and
MDM, that may have been good approximations for important distinctions
in resource costs between kinds of visits in the 1990s, when the CPT
developed the E/M code set, are increasingly outdated in the context of
changing models of care and information technologies.
As described earlier in this section, we are proposing to change
the documentation requirements for E/M levels such that practitioners
have the choice to use the 1995 guidelines, 1997 guidelines, time, or
MDM to determine the E/M level. We believe that these proposed changes
will better reflect the current practice of medicine and represent
significant reductions in burdens associated with documenting visits
using the current set of E/M codes.
In alignment with our proposed documentation changes, we are
proposing to develop a single set of RVUs under the PFS for E/M office-
based and outpatient visit levels 2 through 5 for new patients (CPT
codes 99202 through 99205) and a single set of RVUs for visit levels 2
through 5 for established patients (CPT codes 99212 through 99215).
While we considered creating new HCPCS G-codes that would describe the
services associated with these proposed payment rates, given the wide
and longstanding use of these visit codes by both Medicare and private
payers, we believe it would have created unnecessary administrative
burden to propose new coding. Therefore, we are instead proposing to
maintain the current code set. Of the five levels of office-based and
outpatient E/M visits, the vast majority of visits are reported as
levels 3 and 4. In CY 2016, CPT codes 99203 and 99204 (or E/M visit
level 3 and level 4 for new patients) made up around 32 percent and 44
percent, respectively, of the total allowed charges for CPT codes
99201-99205. In the same year, CPT codes 99213 and 99214 (or E/M visit
level 3 and 4 for established patients) made up around 39 percent and
50 percent, respectively, of the allowed charges for CPT codes 99211-
99215. If our proposals to simplify the documentation requirements and
to pay a single PFS rate for new patient E/M visit levels 2 through 5
and a single rate for established patient E/M visit levels 2 through 5
are finalized, practitioners would still bill the CPT code for
whichever level of E/M service they furnished and they would be paid at
the single PFS rate. However, we believe that eliminating the
distinction in payment between visit levels 2 through 5 will eliminate
the need to audit against the visit levels, and therefore,
[[Page 35840]]
will provide immediate relief from the burden of documentation. A
single payment rate will also eliminate the increasingly outdated
distinction between the kinds of visits that are reflected in the
current CPT code levels in both the coding and the associated
documentation rules.
In order to set RVUs for the proposed single payment rate for new
and established patient office/outpatient E/M visit codes, we are
proposing to develop resource inputs based on the current inputs for
the individual E/M codes, generally weighted by the frequency at which
they are currently billed, based on the 5 most recent years of Medicare
claims data (CY 2012 through CY 2017). Specifically, we are proposing a
work RVU of 1.90 for CPT codes 99202-99205, a physician time of 37.79
minutes, and direct PE inputs that sum to $24.98, each based on an
average of the current inputs for the individual codes weighted by 5
years of accumulated utilization data. Similarly, we are proposing a
work RVU of 1.22 for CPT codes 99212-99215, with a physician time of
31.31 minutes and direct PE inputs that sum to $20.70. These inputs are
based on an average of the inputs for the individual codes, weighted by
volume based on utilization data from the past 5 years (CY 2012 through
CY 2017). Tables 19 and 20 reflect the payment rates in dollars that
would result from the approach described above were it to have been
implemented for CY 2018. In other words, the dollar amounts in the
charts below reflect how the changes we are proposing for CY 2019 would
have impacted payment rates for CY 2018. Proposed RVUs for CY 2019
appear in addendum B of this proposed rule, available on the CMS
website at https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched/index.html.
Table 19--Preliminary Comparison of Payment Rates for Office Visits New
Patients
------------------------------------------------------------------------
CY 2018 non-
CY 2018 facility
non- payment rate
HCPCS code facility under the
payment proposed
rate methodology
------------------------------------------------------------------------
99201......................................... $45 $44
99202......................................... 76 135
99203......................................... 110 ............
99204......................................... 167 ............
99205......................................... 211 ............
------------------------------------------------------------------------
Table 20--Preliminary Comparison of Payment Rates for Office Visits
Established Patients
------------------------------------------------------------------------
Current
non- Proposed non-
HCPCS code facility facility
payment payment rate
rate
------------------------------------------------------------------------
99211......................................... $22 $24
99212......................................... 45 93
99213......................................... 74 ............
99214......................................... 109 ............
99215......................................... 148 ............
------------------------------------------------------------------------
While we believe that the proposed rates for E/M visit levels 2
through 5 represent the valuation of a typical E/M service, we also
recognize that the current E/M code set itself does not appropriately
reflect differences in resource costs between certain types of E/M
visits. As a result, we believe that the way we currently value the
resource costs for E/M services through the existing HCPCS CPT code set
for office-based and outpatient E/M visits does not appropriately
reflect the resources used in furnishing the range of E/M services that
are provided through the current the practice of medicine. Based on
stakeholder comments and examples and our review of the literature on
E/M services, we have identified three types of E/M visits that differ
from the typical E/M visit and are not appropriately reflected in the
current office/outpatient E/M code set and valuation. Rather, these
three types of E/M visits can be distinguished by the mode of care
provided and, as a result, have different resource costs. The three
types of E/M visits that differ from the typical E/M service are (1)
separately identifiable E/M visits furnished in conjunction with a 0-
day global procedure, (2) primary care E/M visits for continuous
patient care, and (3) certain types of specialist E/M visits, including
those with inherent visit complexity. We address each of these
distinguishable visit types in the following proposals.
d. Recognizing the Resource Costs for Different Types of E/M Visits
Rather than maintain distinctions in services and payment that are
based on the current E/M visit codes, we believe we can better capture
differential resources costs and minimize reporting and documentation
burden by proposing several corollary payment policies and ratesetting
adjustments. These additional proposals better reflect the important
distinctions between the kinds of visits furnished to Medicare
beneficiaries, and would no longer require complex and burdensome
billing and documentation rules to effectuate payment.
In response to the CY 2018 comment solicitation on burden reduction
for E/M visits (82 FR 53163 through 53166), we received several
comments that highlighted the inadequacy of the E/M code set to
accurately pay for the resources associated with furnishing visits,
particularly for primary care visits, and visits associated with
treating patients with particular conditions for which there is not
additional procedural coding. One commenter stated that the current
structure and valuation of the E/M code set inadequately describes the
range of services provided by different specialties, and in particular
primary care services. This commenter noted that although the 10
office/outpatient E/M codes make up the bulk of the services reported
by primary care practitioners, the valuation does not reflect their
particular resource costs. Another commenter pointed out that for
specialties that principally rely on E/M visit codes to bill for their
professional services, the complex medical decision making and the
intensity of their visits is not reflected in the E/M code set or
documentation guidelines. Additionally, we believe that when a
separately identifiable visit is furnished in conjunction with a
procedure, that there are certain duplicative resource costs that are
also not accounted for by current coding and payment.
Therefore, we are proposing the following adjustments to better
capture the variety of resource costs associated with different types
of care provided in E/M visits: (1) An E/M multiple procedure payment
adjustment to account for duplicative resource costs when E/M visits
and procedures with global periods are furnished together; (2) HCPCS G-
code add-ons to recognize additional relative resources for primary
care visits and inherent visit complexity that require additional work
beyond that which is accounted for in the single payment rates for new
and established patient levels 2 through level 5 visits; (3) HCPCS G-
codes to describe podiatric E/M visits; (4) an additional prolonged
face-to-face services add-on G code; and (5) a technical modification
to the PE methodology to stabilize the allocation of indirect PE for
visit services (i) Accounting for E/M Resource Overlap between Stand-
Alone Visits and Global Periods
Under the PFS, E/M services are generally paid in one of two ways:
As standalone visits using E/M visit codes, or included in global
procedural codes. In both cases, RVUs are allocated to the services to
account for the estimated relative resources involved in furnishing
professional E/M services. In the case of procedural codes with global
periods,
[[Page 35841]]
the overall resource inputs reflect the costs of the E/M work
considered to be typically furnished with the procedure. Therefore, the
standalone E/M visit codes are not billable on the same day as the
procedure codes unless the billing professional specifically indicates
that the visit is separately identifiable from the procedure.
In cases where a physician furnishes a separately identifiable E/M
visit to a beneficiary on the same day as a procedure, payment for the
procedure and the E/M visit is based on rates generally developed under
the assumption that these services are typically furnished
independently. In CY 2017 PFS rulemaking, we noted that the current
valuation for services with global periods may not accurately reflect
much of the overlap in resource costs (81 FR 80209). We are
particularly concerned that when a standalone E/M visit occurs on the
same day as a 0-day global procedure, there are significant overlapping
resource costs that are not accounted for. We believe that separately
identifiable visits occurring on the same day as 0-day global
procedures have resources that are sufficiently distinct from the costs
associated with furnishing one of the 10 office/outpatient E/M visits
to warrant payment adjustment. There are other existing policies under
the PFS where we reduce payments if multiple procedures are furnished
on the same day to the same patient. Medicare has a longstanding policy
to reduce payment by 50 percent for the second and subsequent surgical
procedures furnished to the same patient by the same physician on the
same day, largely based on the presence of efficiencies in PE and pre-
and post-surgical physician work. Effective January 1, 1995, the MPPR
policy, with the same percentage reduction, was extended to nuclear
medicine diagnostic procedures (CPT codes 78306, 78320, 78802, 78803,
78806, and 78807). In the CY 1995 PFS final rule with comment period
(59 FR 63410), we indicated that we would consider applying the policy
to other diagnostic tests in the future. In the CYs 2009 and 2010 PFS
proposed rules (73 FR 38586 and 74 FR 33554, respectively), we stated
that we planned to analyze nonsurgical services commonly furnished
together (for example, 60 to 75 percent of the time) to assess whether
an expansion of the MPPR policy could be warranted. MedPAC encouraged
us to consider duplicative physician work, as well as PE, in any
expansion of the MPPR policy. Finally, in the CY 2011 PFS final rule,
CMS finalized the application of the MPPR to always-therapy services on
the justification that there was significant overlap in the PE portion
of these services (75 FR 73233).
Using the surgical MPPR as a template, we are proposing that, as
part of our proposal to make payment for the E/M levels 2 through 5 at
a single PFS rate, we would reduce payment by 50 percent for the least
expensive procedure or visit that the same physician (or a physician in
the same group practice) furnishes on the same day as a separately
identifiable E/M visit, currently identified on the claim by an
appended modifier -25. We believe that the efficiencies associated with
furnishing an E/M visit in combination with a same-day procedure are
similar enough to those accounted for by the surgical MPPR to merit a
reduction in the relative resources of 50 percent. We estimate based on
CY 2017 Medicare claims data that applying a 50 percent MPPR to E/M
visits furnished as separately identifiable services in the same day as
a procedure would reduce expenditures under the PFS by approximately
6.7 million RVUs. To accurately reflect resource costs of the different
types of E/M visits that we previously identified while maintaining
work budget neutrality within this proposal, we are proposing to
allocate those RVUs toward the values of the add-on codes that reflect
the additional resources associated with E/M visits for primary care
and inherent visit complexity, similar to existing policies. As we
articulated in the CY 2012 PFS final rule with comment period, where
the aggregate work RVUs within a code family change but the overall
actual physician work associated with those services does not change,
we make work budget neutrality adjustments to hold the aggregate work
RVUs constant within the code family, while maintaining the relativity
of values for the individual codes within that set (76 FR 73105).
(ii) Proposed HCPCS G-Code Add-Ons To Recognize Additional Relative
Resources for Certain Kinds of Visits
The distribution of E/M visits is not uniform across medical
specialties. We have found that certain specialists, like neurologists
and endocrinologists, for example, bill higher level E/M codes more
frequently than procedural specialists, such as dermatology. We believe
this tendency reflects a significant and important distinction between
the kinds of visits furnished by professionals whose treatment
approaches are primarily reported using visit codes versus those
professionals whose treatment approaches are primarily reported using
available procedural or testing codes. However, based on feedback we
received from the medical professionals who furnish primary care and
have visits with greater complexity, such as the comments cited above,
we do not believe the current visit definitions and the associated
documentation burdens are the most accurate descriptions of the
variation in work. Instead, we believe these professionals have been
particularly burdened by the documentation requirements given that so
much of their medical treatment is described imperfectly by relatively
generic visit codes.
Similarly stakeholders, such as the commenters responding to the CY
2018 PFS proposed rule, have articulated persuasively that visits
furnished for the purpose of primary care also involve distinct
resource costs. In developing this proposal, we consulted a variety of
resources, including the American Academy of Family Physicians (AAFP)
definition of primary care that states that the resource costs
associated with furnishing primary care services particularly include
time spent coordinating patient care, collaborating with other
physicians, and communicating with patients (see https://www.aafp.org/about/policies/all/primary-care.html). Despite our efforts in recent
years to pay separately for certain aspects of primary care services,
such as through the chronic care management or the transitional care
management services, the currently available coding still does not
adequately reflect the full range of primary care services, nor does it
allow payment to fully capture the resource costs involved in
furnishing a face-to-face primary care E/M visit. We recognize that
primary care services frequently involve substantial non-face-to-face
work, and note that there is currently coding available to account for
many of those resources, such as chronic care management (CCM),
behavioral health integration (BHI), and prolonged non-face-to-face
services. In light of the existing coding, this proposal only addresses
the additional resources involved in furnishing the face-to-face
portion of a primary care service. As the point of entry for many
patients into the healthcare system, primary care visits frequently
require additional time for communicating with the patient, patient
education, consideration and review of the patient's medical needs. We
believe the proposed value for the single payment rate for the E/M
levels 2 through 5 new and established patient visit codes does
[[Page 35842]]
not reflect these additional resources inherent to primary care visits,
as evidenced by the fact that primary care visits are generally
reported using level 4 E/M codes Therefore, to more accurately account
for the type and intensity of E/M work performed in primary care-
focused visits, we are proposing to create a HCPCS add-on G-code that
may be billed with the generic E/M code set to adjust payment to
account for additional costs beyond the typical resources accounted for
in the single payment rate for the levels 2 through 5 visits.
We are proposing to create a HCPCS G-code for primary care
services, GPC1X (Visit complexity inherent to evaluation and management
associated with primary medical care services that serve as the
continuing focal point for all needed health care services (Add-on
code, list separately in addition to an established patient evaluation
and management visit)). As we believe a primary care visit is partially
defined by an ongoing relationship with the patient, this code would
describe furnishing a visit to an established patient. HCPCS code GPC1X
can also be reported for other forms of face-to-face care management,
counseling, or treatment of acute or chronic conditions not accounted
for by other coding. We note that we believe the additional resources
to address inherent complexity in E/M visits associated with primary
care services are associated only with stand-alone E/M visits as
opposed to separately identifiable visits furnished within the global
period of a procedure. Separately identifiable visits furnished within
a global period are identified on the claim using modifier -25, and
would be subject to the MPPR. We note that we have created separate
coding that describes non-face-to-face care management and
coordination, such as CCM and BHI; however, these services describe
non-face-to-face care and can be provided by any specialty so long as
they meet the requirements for those codes. HCPCS code GPC1X is
intended to capture the additional resource costs, beyond those
involved in the base E/M codes, of providing face-to-face primary care
services for established patients. HCPCS code GPC1X would be billed in
addition to the E/M visit for an established patient when the visit
includes primary care services. For HCPCS code GPC1X, we are proposing
a work RVU of 0.07, physician time of 1.75 minutes, a PE RVU of 0.07,
and an MP RVU of 0.01. This proposed valuation accounts for the
additional resource costs associated with furnishing primary care that
distinguishes E/M primary care visits from other types of E/M visits,
and maintains work budget neutrality across the office/outpatient E/M
code set. Furthermore, the proposed add-on G-code for primary care-
focused E/M services would help to mitigate potential payment
instability that could result from our adoption of single payment rates
that apply for E/M code levels 2 through 5. As this add-on G-code would
account for the inherent resource costs associated with furnishing
primary care E/M services, we anticipate that it would be billed with
every primary care-focused E/M visit for an established patient. While
we expect that this code will mostly be utilized by the primary care
specialties, such as family practice or pediatrics, we are also aware
that, in some instances, certain specialists function as primary care
practitioners--for example, an OB/GYN or a cardiologist. Although the
definition of primary care is widely agreed upon by the medical
community and we intend for this G-code to account for the resource
costs of performing those types of visits, regardless of Medicare
enrollment specialty, we are also seeking comment on how best to
identify whether or not a primary care visit was furnished particularly
in cases where a specialist is providing those services. For especially
complex patients, we also expect that it may be billed alongside the
proposed new code for prolonged E/M services described later in this
section. We are also seeking comment on whether this policy adequately
addresses the deficiencies in CPT coding for E/M services in describing
current medical practice, and concerns about the impact on payment for
primary care and other services under the PFS. Given the broad scope of
our proposals related to E/M services, we are seeking feedback on any
unintended consequences of those proposals. We are also seeking comment
on any other concerns related to primary care that we might consider
for future rulemaking.
We are also proposing to create a HCPCS G-code to be reported with
an E/M service to describe the additional resource costs for specialty
professionals for whom E/M visit codes make up a large percentage of
their overall allowed charges and whose treatment approaches we believe
are generally reported using the level 4 and level 5 E/M visit codes
rather than procedural coding. Due to these factors, the proposed
single payment rate for E/M levels 2 through 5 visit codes would not
necessarily reflect the resource costs of those types of visits.
Therefore, we are proposing to create a new HCPCS code GCG0X (Visit
complexity inherent to evaluation and management associated with
endocrinology, rheumatology, hematology/oncology, urology, neurology,
obstetrics/gynecology, allergy/immunology, otolaryngology, cardiology,
or interventional pain management-centered care (Add-on code, list
separately in addition to an evaluation and management visit)). Given
their billing patterns, we believe that these are specialties that
apply predominantly non-procedural approaches to complex conditions
that are intrinsically diffuse to multi-organ or neurologic diseases.
While some of these specialties are surgical in nature, we believe
these surgical specialties are providing increased non-procedural care
of high complexity in the Medicare population. The high complexity of
these services is reflected in the large proportion of level 4 and
level 5 visits that we believe are reported by these specialties, and
the extent to which E/M visits are a high proportion of these
specialties' total allowed charges. Consequently, these are specialties
for which the resource costs of the visits they typically perform are
not fully captured in the proposed single payment rate for the levels 2
through level 5 office/outpatient visit codes. When billed in
conjunction with standalone office/outpatient E/M visits for new and
established patients, the combined valuation more accurately accounts
for the intensity associated with higher level E/M visits. To establish
a value for this add-on service to be applied with a standalone E/M
visit, we are proposing a crosswalk to 75 percent of the work and time
of CPT code 90785 (Interactive complexity), which results in a work RVU
of 0.25, a PE RVU of 0.07, and an MP RVU of 0.01, as well as 8.25
minutes of physician time based on the CY 2018 valuation for CPT code
90785. Interactive complexity is an add-on code that may be billed when
a psychotherapy or psychiatric service requires more resources due to
the complexity of the patient. We believe that the proposed valuation
for CPT code 90785 would be an accurate representation of the
additional work associated with the higher level complex visits. We
note that we believe the additional resources to address inherent
complexity in E/M visits are associated with stand-alone E/M visits.
Additionally, we acknowledge that resource costs for primary care are
reflected with the proposed HCPCS code GPC1X, as opposed to the
[[Page 35843]]
proposed HCPCS code GCG0X. We note that there are additional codes
available that include face-to-face and non-face-to-face work,
depending on the code, that previously would have been considered part
of an E/M visit, such as the codes for CCM, BHI, and CPT code 99483
(Assessment of and care planning for a patient with cognitive
impairment, requiring an independent historian, in the office or other
outpatient, home or domiciliary or rest home, with all of the following
required elements: Cognition-focused evaluation including a pertinent
history and examination; Medical decision making of moderate or high
complexity; Functional assessment (e.g., basic and instrumental
activities of daily living), including decision-making capacity; Use of
standardized instruments for staging of dementia (e.g., functional
assessment staging test [FAST], clinical dementia rating [CDR]);
Medication reconciliation and review for high-risk medications;
Evaluation for neuropsychiatric and behavioral symptoms, including
depression, including use of standardized screening instrument(s);
Evaluation of safety (e.g., home), including motor vehicle operation;
Identification of caregiver(s), caregiver knowledge, caregiver needs,
social supports, and the willingness of caregiver to take on caregiving
tasks; Development, updating or revision, or review of an Advance Care
Plan; Creation of a written care plan, including initial plans to
address any neuropsychiatric symptoms, neuro-cognitive symptoms,
functional limitations, and referral to community resources as needed
(e.g., rehabilitation services, adult day programs, support groups)
shared with the patient and/or caregiver with initial education and
support. Typically, 50 minutes are spent face-to-face with the patient
and/or family or caregiver), which were developed to reflect the
additional work of those practitioners furnishing primary care visits.
Likewise, we are proposing that practitioners in the specialty of
psychiatry would not use either add-on code because psychiatrists may
utilize CPT code 90785 to describe work that might otherwise be
reported with a level 4 or level 5 E/M visit.
We are seeking comment on both of these proposals.
(iii) Proposed HCPCS G-Code To Describe Podiatric E/M Visits
As described earlier, the vast majority of podiatric visits are
reported using lower level E/M codes, with most E/M visits billed at a
level 2 or 3, reflecting the type of work done by podiatrists as part
of an E/M visit. Therefore, while the proposed consolidation of
documentation and payment for E/M code levels 2 through 5 is intended
to better reflect the universal elements of E/M visits across
specialties and patients, we believe that podiatric E/M visits are not
accurately represented by the consolidated E/M structure. In order for
payment to reflect the resource costs of podiatric visits, we are also
proposing to create two HCPCS G-codes, HCPCS codes GPD0X (Podiatry
services, medical examination and evaluation with initiation of
diagnostic and treatment program, new patient) and GPD1X (Podiatry
services, medical examination and evaluation with initiation of
diagnostic and treatment program, established patient), to describe
podiatric E/M services. Under this proposal, podiatric E/M services
would be billed using these G-codes instead of the generic office/
outpatient E/M visit codes (CPT codes 99201 through 99205 and 99211
through 99215). We propose to create these separate G-codes for
podiatric E/M services to differentiate the resources associated with
podiatric E/M visits rather than proposing a negative add-on adjustment
relative to the proposed single payment rates for the generic E/M
levels 2 through 5 codes. Therefore, we are proposing to create
separate coding to describe these services, taking into account that
most podiatric visits are billed as level 2 or 3 E/M codes. We based
the coding structure and code descriptor on CPT codes 92004
(Ophthalmological services: Medical examination and evaluation with
initiation of diagnostic and treatment program; comprehensive, new
patient, 1 or more visits) and 92012 (Ophthalmological services:
medical examination and evaluation, with initiation or continuation of
diagnostic and treatment program; intermediate, established patient),
which describe visits specific to ophthalmology. To accurately reflect
payment for the resource costs associated with podiatric E/M visits, we
are proposing a work RVU of 1.35, a physician time of 28.11 minutes,
and direct PE inputs totaling $22.53 for HCPCS code GPD0X, and a work
RVU of 0.85, physician time of 21.60 minutes, and direct PE inputs
totaling $17.07 for HCPCS code GPD1X. These values are based on the
average rate for the level 2 and 3 E/M codes (CPT codes 99201-99203 and
CPT codes 99211-99212, respectively), weighted by podiatric volume.
(iv) Proposed Adjustment to the PE/HR Calculation
As we explain in section II.B. Determination of Practice Expense
(PE) Relative Value Units (RVUs), of this proposed rule, we generally
allocate indirect costs for each code on the basis of the direct costs
specifically associated with a code and the greater of either the
clinical labor costs or the work RVUs. Indirect expenses include
administrative labor, office expense, and all other PEs that are not
directly attributable to a particular service for a particular patient.
Generally, the proportion of indirect PE allocated to a service is
determined by calculating a PE/HR based upon the mix of specialties
that bill for a service.
As described earlier, E/M visits comprise a significant portion of
allowable charges under the PFS and are used broadly across specialties
such that our proposed changes can greatly impact the change in payment
at the specialty level and at the practitioner level. Our proposals
seek to simplify payment for E/M visit levels 2 through 5, and to
additionally take into consideration that there are inherent
differences in primary care-focused E/M services and in more complex E/
M services such that those visits involve greater relative resources,
while seeking to maintain overall payment stability across specialties.
However, establishing a single PFS rate for new and established patient
E/M levels 2 through-5 would have a large and unintended effect on many
specialties due to the way that indirect PE is allocated based on the
mixture of specialties that furnish a service. The single payment rates
proposed for E/M levels 2 through 5 cannot reflect the indirect PE
previously allocated differentially across those 8 codes. Historically,
a broad blend of specialties and associated PE/HR has been used in the
allocation of indirect PE and MP RVUs to E/M services to determine
payment rates for these services. As this proposal significantly alters
the PE/HR allocation for the office/outpatient E/M codes and any
previous opportunities for the public to comment on the data would not
have applied to these kinds of E/M services, we do not believe it is in
the public interest to allow the allocation of indirect PE to have such
an outsized impact on the payment rates for this proposal. Due to the
magnitude of the proposed coding and payment changes for E/M visits, it
is unclear how the distribution of specialties across E/M services
would change. We are concerned that such changes could produce
anomalous results for indirect PE allocations since we do not yet know
the extent to which specialties would utilize the proposed simplified
E/M codes and proposed G-codes. In the past, when utilization data are
not
[[Page 35844]]
available or do not accurately reflect the expected specialty mix of a
new service, we have proposed to crosswalk the PE/HR value from another
specialty (76 FR 73036). As such, we are proposing to create a single
PE/HR value for E/M visits (including all of the proposed HCPCS G-codes
discussed above) of approximately $136, based on an average of the PE/
HR across all specialties that bill these E/M codes, weighted by the
volume of those specialties' allowed E/M services. We believe that this
is consistent with the methodology used to develop the inputs for the
proposed simplified E/M payment for the levels 2 through 5 E/M visit
codes, and that, for purposes of consistency, the new PE/HR should be
applied across the additional E/M codes. We believe a new PE/HR value
would more accurately reflect the mix of specialties billing both the
generic E/M code set and the add-on codes. If we finalize this
proposal, we will consider revisiting the PE/HR after several years of
claims data become available.
(v) Proposed HCPCS G-Code for Prolonged Services
Time is often an important determining factor in the level of care,
which we consider in our proposal described earlier that physicians and
other practitioners can use time as the basis for documenting and
billing the appropriate level of E/M visit for purposes of Medicare
payment. Currently there is inadequate coding to describe services
where the primary resource of a service is physician time. CPT codes
99354 (Prolonged evaluation and management or psychotherapy service(s)
(beyond the typical service time of the primary procedure) in the
office or other outpatient setting requiring direct patient contact
beyond the usual service; first hour (List separately in addition to
code for office or other outpatient Evaluation and Management or
psychotherapy service)) and 99355 (Prolonged evaluation and management
or psychotherapy service(s) (beyond the typical service time of the
primary procedure) in the office or other outpatient setting requiring
direct patient contact beyond the usual service; each additional 30
minutes (List separately in addition to code for prolonged service))
describe additional time spent face-to-face with a patient and may be
billed when the applicable amount of time exceeds the typical service
time of the primary procedure.
Stakeholders have informed CMS that the ``first hour'' time
threshold in the descriptor for CPT code 99354 is difficult to meet and
is an impediment to billing these codes (81 FR 80228). In response to
stakeholder feedback and as part of our proposal to implement a single
payment rate for E/M visit levels 2 through 5 while maintaining payment
accuracy across the specialties, we are proposing to create a new HCPCS
code GPRO1 (Prolonged evaluation and management or psychotherapy
service(s) (beyond the typical service time of the primary procedure)
in the office or other outpatient setting requiring direct patient
contact beyond the usual service; 30 minutes (List separately in
addition to code for office or other outpatient Evaluation and
Management or psychotherapy service)). Given that the physician time of
HCPCS code GPRO1 is half of the physician time assigned to CPT code
99354, we are proposing a work RVU of 1.17, which is half the work RVU
of CPT code 99354.
In order to estimate the potential impact of these proposed
changes, we modeled the results of several options and examined the
estimated resulting impacts in overall Medicare allowed charges by
physician specialty. In order to isolate the potential impact of these
changes from other concurrent proposed changes, we conducted this
analysis largely using the code set, policies, and input data that we
developed in establishing PFS rates for CY 2018. However, we used the
suite of ratesetting programs that included several updates relevant
for CY 2019 rulemaking. Consequently, we conducted our analysis
regarding potential specialty-level impacts in order to identify the
specialties with allowed charges most likely to be impacted by the
potential change. We believe these estimates illustrate the magnitude
of potential changes for certain physician specialties. However,
because our modeling did not account for the full range of technical
changes in the input data used in PFS ratesetting, the potential
impacts for these isolated policies are relatively imprecise,
especially compared to the specialty-level impacts displayed in section
VII. of this proposed rule.
Tables 21, 22, and 23 show the estimated changes, for certain
physician specialties, and isolated from other proposed changes, in
expenditures for PFS services based on potential changes for E/M coding
and payment. We note that we are making additional data available to
the public to inform our modeling on our E/M coding and payment
proposals, available on the CMS website at https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched/index.html.
Table 21--Unadjusted Estimated Specialty Impacts of Proposed Single RVU
Amounts for Office/Outpatient E/M 2 Through 5 Levels
------------------------------------------------------------------------
Estimated potential
Allowed impact of valuing
Specialty charges (in levels 2-5 together,
millions) without additional
adjustments
------------------------------------------------------------------------
PODIATRY.......................... $2,022 12%.
DERMATOLOGY....................... 3,525 7%.
HAND SURGERY...................... 202 6%.
OTOLARNGOLOGY..................... 1,220 5%.
ORTHOPEDIC SURGERY................ 3,815 4%.
ORAL/MAXILLOFACIAL SURGERY........ 57 4%.
COLON AND RECTAL SURGERY.......... 168 Less than 3%
estimated increase
in overall payment.
OBSTETRICS/GYNECOLOGY............. 664
OPTOMETRY......................... 1,276
PHYSICIAN ASSISTANT............... 2,253
PLASTIC SURGERY................... 387
ALLERGY/IMMUNOLOGY................ 240 Minimal change to
overall payment.
ANESTHESIOLOGY.................... 1,995
AUDIOLOGIST....................... 67
CARDIAC SURGERY................... 313
[[Page 35845]]
CHIROPRACTOR...................... 789
CRITICAL CARE..................... 334
EMERGENCY MEDICINE................ 3,196
FAMILY PRACTICE................... 6,382
GASTROENTEROLOGY.................. 1,807
GENERAL PRACTICE.................. 461
GENERAL SURGERY................... 2,182
INFECTIOUS DISEASE................ 663
INTERVENTIONAL PAIN MGMT.......... 839
INTERVENTIONAL RADIOLOGY.......... 362
MULTISPECIALTY CLINIC/OTHER PHYS.. 141
NEUROSURGERY...................... 812
NUCLEAR MEDICINE.................. 50
NURSE PRACTITIONER................ 3,586
OPHTHALMOLOGY..................... 5,542
OTHER............................. 30
PATHOLOGY......................... 1,151
PHYSICAL MEDICINE................. 1,120
PSYCHIATRY........................ 1,260
RADIATION ONCOLOGY AND RADIATION 1,776
THERAPY CENTERS.
RADIOLOGY......................... 4,898
THORACIC SURGERY.................. 360
UROLOGY........................... 1,772
VASCULAR SURGERY.................. 1,132
CARDIOLOGY........................ 6,723 Less than 3%
estimated decrease
in overall payment.
INTERNAL MEDICINE................. 11,173
NEPHROLOGY........................ 2,285
PEDIATRICS........................ 64
PULMONARY DISEASE................. 1,767
GERIATRICS........................ 214 -4%.
RHEUMATOLOGY...................... 559 -7%.
NEUROLOGY......................... 1,565 -7%.
HEMATOLOGY/ONCOLOGY............... 1,813 -7%.
ENDOCRINOLOGY..................... 482 -10%.
-------------------------------------
TOTAL......................... 93,486 0.
------------------------------------------------------------------------
Table 21 characterizes the estimated overall impact for certain
physician specialties, of establishing single payment rates for the new
and established patient E/M code levels 2 through 5, without any of the
additional coding or proposed payment adjustments, including the
estimated percentage change for the specialties with an estimated
increase or decrease in payment greater than 3 percent. Those
specialties that tend to bill lower level E/M visits would benefit the
most from the proposed change to single PFS payment rates, while those
specialties that tend to bill more higher level E/M visits would see
the largest decreases in payment with the change to a single PFS rate.
The single payment rate for E/M code levels 2 through 5 would benefit
podiatry the most because, due to the nature of most podiatric E/M
visits, they tend to bill only level 2 and 3 E/M visits.
Table 22--Specialty Specific Impacts Including Payment Accuracy
Adjustments
------------------------------------------------------------------------
Estimated potential
Allowed impact of valuing
Specialty charges (in levels 2-5 together,
millions) with additional
adjustments
------------------------------------------------------------------------
OBSTETRICS/GYNECOLOGY............. $664 4%.
NURSE PRACTITIONER................ 3,586 3%.
HAND SURGERY...................... 202 Less than 3%
estimated increase
in overall payment.
INTERVENTIONAL PAIN MGMT.......... 839
OPTOMETRY......................... 1,276
PHYSICIAN ASSISTANT............... 2,253
PSYCHIATRY........................ 1,260
UROLOGY........................... 1,772
ANESTHESIOLOGY.................... 1,995 Minimal change to
overall payment.
CARDIAC SURGERY................... 313
CARDIOLOGY........................ 6,723
CHIROPRACTOR...................... 789
[[Page 35846]]
COLON AND RECTAL SURGERY.......... 168
CRITICAL CARE..................... 334
EMERGENCY MEDICINE................ 3,196
ENDOCRINOLOGY..................... 482
FAMILY PRACTICE................... 6,382
GASTROENTEROLOGY.................. 1,807
GENERAL PRACTICE.................. 461
GENERAL SURGERY................... 2,182
GERIATRICS........................ 214
INFECTIOUS DISEASE................ 663
INTERNAL MEDICINE................. 11,173
INTERVENTIONAL RADIOLOGY.......... 362
MULTISPECIALTY CLINIC/OTHER PHYS.. 141
NEPHROLOGY........................ 2,285
NEUROSURGERY...................... 812
NUCLEAR MEDICINE.................. 50
OPHTHALMOLOGY..................... 5,542
ORAL/MAXILLOFACIAL SURGERY........ 57
ORTHOPEDIC SURGERY................ 3,815
OTHER............................. 30
PATHOLOGY......................... 1,151
PEDIATRICS........................ 64
PHYSICAL MEDICINE................. 1,120
PLASTIC SURGERY................... 387
RADIOLOGY......................... 4,898
THORACIC SURGERY.................. 360
VASCULAR SURGERY.................. 1,132
ALLERGY/IMMUNOLOGY................ 240 Less than 3%
estimated decrease
in overall payment.
AUDIOLOGIST....................... 67
HEMATOLOGY/ONCOLOGY............... 1,813
NEUROLOGY......................... 1,565
OTOLARNGOLOGY..................... 1,220
PULMONARY DISEASE................. 1,767
RADIATION ONCOLOGY AND RADIATION 1,776
THERAPY CENTERS.
RHEUMATOLOGY...................... 559 -3.
DERMATOLOGY....................... 3,525 -4.
PODIATRY.......................... 2,022 -4.
-------------------------------------
TOTAL......................... 93,486 0.
------------------------------------------------------------------------
Table 22 characterizes the estimated overall impact for certain
physician specialties, including the proposed adjustments have been
made to reflect the distinctions in resource costs among certain types
of E/M visits. In other words, Table 22 shows the proposed impacts of
adopting the proposed single payment rates for new and established
patient E/M visit levels 2 through 5, the application of a MPPR to E/M
visits when furnished by the same practitioner (or practitioner in the
same practice) on the same-day as a global procedure code, the add-on
G-codes for primary care-focused services and inherent visit
complexity, and the technical adjustments to the PE/HR value. Table 22
includes the estimated percentage change for the specialties with an
estimated increase or decrease in payment greater than three percent.
In our modeling, we assumed E/M visits for specialties that provide a
significant portion of primary care like family practice, internal
medicine, pediatrics and geriatrics utilized the G-code for visit
complexity inherent to evaluation and management associated with
primary medical care services with every office/outpatient visit
furnished. Also for the purposes of our modeling, we assumed that
specialties including endocrinology, rheumatology, hematology/oncology,
urology, neurology, obstetrics/gynecology, allergy/immunology,
otolaryngology, or interventional pain management-centered care
utilized the G-code for visit complexity inherent to evaluation and
management with every office/outpatient E/M visit. Table 22 does not
include the impact of the use of the additional prolonged services
code. The specialties that we estimate would experience a decrease in
payments are those that bill a large portion of E/M visits on the same
day as procedures, and would see a reduction based on the application
of the MPPR adjustments. Some of these specialties, such as allergy/
immunology and cardiology are also negatively impacted by the proposed
single payment rates themselves, although not to the same degree as
they would have been without any adjustments to provide alternate
coding to reflect their resource costs, as illustrated in Table 21. The
specialties that we estimate will see an increase in payments from
these proposals, like psychiatry, nurse practitioner, and
endocrinology, are seeing payment increases due to a combination of the
single payment rate and the add-on codes for inherent visit complexity.
As an example, in CY 2018, a physician would bill a level 4 E/M
visit and document using the existing documentation framework for a
level 4 E/M visit. Their payment rate would be approximately $109 in
the office setting.
[[Page 35847]]
If these proposals are finalized, the physician would bill the same
visit code for a level 4 E/M visit, documenting the visit according to
the minimum documentation requirements for a level 2 E/M visit and/or
based on their choice of using time, MDM, or the 1995 or 1997
guidelines, plus either of the proposed add-on codes (HCPCS codes GPC1X
or GCG0X) depending on the type of patient care furnished, and could
bill one unit of the proposed prolonged services code (HCPCS code
GPRO1) if they meet the time threshold for this code. The combined
payment rate for the generic E/M code and HCPCS code GPRO1 would be
approximately $165 with HCPCS code GPC1X and approximately $177 with
HCPCS code GCG0X.
We welcome comments on all of these proposals.
(vi) Alternatives Considered
We considered a number of other options for simplifying coding and
payment for E/M services to align with the proposed reduction in
documentation requirements and better account for the resources
associated with inherent complexity, visit complexity, and visits
furnished on the same day as a 0-day global procedure. For example, we
considered establishing single payment rates for new and established
patients for combined E/M visit levels 2 through 4, as opposed to
combined E/M visit levels 2 through 5. This option would have retained
a separately valued payment rate for level 5 visits that would be
reserved for the most complex visits or patients. However, maintaining
a separately valued payment rate for this higher level visit based on
the current CPT code definition has the consequence of preserving some
of the current coding distinctions within the billing systems.
Ultimately we believe that providing for two levels of payment and
documentation (setting aside level 1 visits which are primarily visits
by clinical staff) relieves more burden than three levels, and that two
levels plus the proposed add-on coding more accurately captures the
differential resource costs involved in furnishing E/M services to all
patients. If we retained a coding scheme involving three or more levels
of E/M visits, it would not be appropriate to apply a minimum
documentation requirement as we propose to do. We would need to develop
documentation requirements unique to each of the higher level visits.
There would be a greater need for program integrity mechanisms to
prevent upcoding and ensure that practitioners who chose to report the
highest level visit justified their selection of code level. We could
still simplify the documentation requirements for E/M visits relative
to the current framework, but would need a more extensive, differential
documentation framework than what we propose in this rule, in order to
distinguish among visit levels. We are interested in stakeholder input
on the best number of E/M visit levels and how to best achieve a
balance between number of visit levels and simpler, updated
documentation rules. We are seeking input as to whether these two
aspects of our proposals together can reduce burden and ensure accurate
payment across the broad range of E/M visits, including those for
complex and high need beneficiaries.
Table 23--Unadjusted Estimated Specialty Impacts of Single PFS Rate for
Office/Outpatient E/M Levels 2 Through 4
------------------------------------------------------------------------
Allowed
Specialty charges Impact
(millions) (percent)
------------------------------------------------------------------------
Podiatry.................................... $2,022 10
Dermatology................................. 3,525 6
Hand Surgery................................ 202 5
Oral/Maxillofacial Surgery.................. 57 4
Otolaryngology.............................. 1,220 4
Cardiology.................................. 6,723 -3
Hematology/Oncology......................... 1,813 -3
Neurology................................... 1,565 -3
Rheumatology................................ 559 -6
Endocrinology............................... 482 -8
------------------------------------------------------------------------
Note: All other specialty level impacts were within +/- 3%.
Table 23 shows the specialties that would experience the greatest
increase or decrease by establishing single payment rates for E/M visit
levels 2 through 4, while maintaining the value of the level 1 and the
level 5 E/M visits. The specialty level impacts are similar to those in
Table 21 as the specialties that bill more higher level visits do not
benefit by maintaining a distinct payment for the level 5 visit as much
as they experience a reduction in the rate for a level 4 visit.
Similarly, the specialties that bill predominantly lower level visits
would still benefit disproportionally to the increase in rate for the
level 2 and level 3 visits.
Section 101(f) of the MACRA, enacted on April 16, 2015, added a new
subsection (r) under section 1848 of the Act entitled Collaborating
with the Physician, Practitioner, and Other Stakeholder Communities to
Improve Resource Use Measurement. Section 1848(r) of the Act requires
the establishment and use of classification code sets: Care episode and
patient condition groups and codes; and patient relationship categories
and codes. As described in the CY 2018 PFS final rule, we finalized use
of Level II HCPCS Modifiers as the patient relationship codes and
finalized that Medicare claims submitted for items and services
furnished by a physician or applicable practitioner on or after January
1, 2018, should include the applicable patient relationship codes, as
well as the NPI of the ordering physician or applicable practitioner
(if different from the billing physician or applicable practitioner).
We noted that for CY 2018, reporting of the patient relationship
modifiers would be voluntary and the use and selection of the modifiers
would not be a condition of payment (82 FR 53234). The patient
relationship codes are as follows: X1: Continuous/broad; X2:
Continuous/focused; X3: Episodic/focused; X4: Episodic/broad; and X5:
Only as ordered by another physician. These codes are to be used to
help define and distinguish the relationship and responsibility of a
clinician with a patient at the time of furnishing an item or service,
facilitate the attribution of patients and episodes to one or more
clinicians, and to allow clinicians to self-identify their patient
relationships.
We considered proposing the use of these codes to adjust payment
for E/M visits to the extent that these codes are indicative of
differentiated resources provided in E/M visits, and we considered
using these codes as an alternative to the proposed use of G-codes to
reflect visit complexity inherent to evaluation and management in
primary care and certain other specialist services, as a way to more
accurately reflect the resource costs associated with furnishing
different kinds of E/M visits. We are seeking comment on this
alternative. We are particularly interested in whether the modifiers
would accurately reflect the differences between resources for E/M
visits across specialties and would therefore be useful to adjust
payment differentially for the different types of E/M visits that we
previously identified.
e. Emergency Department and Other E/M Visit Settings
As we mentioned above, the E/M visit code set is comprised of
individual subsets of codes that are specific to various clinical
settings including office/outpatient, observation, hospital inpatient,
emergency department, critical care, nursing facility, domiciliary or
rest home, and home services. Some of these code subsets have three E/M
levels of care, while
[[Page 35848]]
others have five. Some of these E/M code subsets distinguish among
levels based heavily on time, while others do not. Recent public
comments have asserted that some E/M code subsets intersect more
heavily than others with hospital conditions of participation (CoP).
For example, the American Psychiatric Association (APA) submitted a
letter to CMS indicating that Medicare requires specific documentation
in the medical record as part of the CoPs for inpatient psychiatric
facilities. The APA believed that the required initial psychiatric
evaluation for inpatients currently closely follows the E/M criteria
for CPT codes 99221-99223, which are the codes that would be used to
bill for these services. The APA stated that any changes in these E/M
codes, without corresponding changes in the CoPs, could lead to the
unintended consequence of adding to the burden of documentation by
essentially requiring two different sets of data or areas of focus to
be included, or two different documentation formats being required.
Regarding emergency department visits (CPT codes 99281-99285), we
received more recent feedback through our coordinated efforts with ONC
this year, emphasizing that these codes may benefit from a coding or
payment compression into fewer levels of codes, or that documentation
rules may need to be reduced or altered. However, in public comments to
the CY 2018 PFS proposed rule, commenters noted several issues unique
to the emergency department setting that we believe require further
consideration. For example, commenters stated that intensity, and not
time, is the main determinant of code level in emergency departments.
They requested that CMS use caution in changing required elements for
documentation so that medical information used for legal purposes (for
example, meeting the prudent layperson standard) is not lost. They
urged caution and requested that CMS not immediately implement any
major changes. They recommended refocusing documentation on presenting
conditions and medical decision-making. Some commenters were supportive
of leaving it largely to the discretion of individual practitioners to
determine the degree to which they should perform and document the
history and physical exam in the emergency department setting. Other
commenters suggested that CMS encourage use of standardized guidelines
and minimum documentation requirements to facilitate post-treatment
evaluation, as well as analysis of records for various clinical, legal,
operational and other purposes. The commenters discussed the importance
of extensive histories and exams in emergency departments, where
usually there is no established relationship with the patient and
differential diagnosis is critical to rule out many life-threatening
conditions. They were cognizant of the need for a clear record of
services rendered and the medical necessity for each service,
procedure, diagnostic test, and MDM performed for every patient
encounter.
In addition, although the RUC is in the process of revaluing this
code set, some commenters stated that the main issue is not that the
emergency department visit codes themselves are undervalued. Rather,
these commenters believed that a greater percentage of emergency
department visits are at a higher acuity level, yet payers often do not
pay at a higher level of care and the visit is often inappropriately
down-coded based on retrospective review. These commenters believed
that the documentation needed to support a higher level of care is too
burdensome or subjective. In addition, it seems that policy proposals
regarding emergency department visits billed by physicians might best
be coordinated with parallel changes to payment policy for facility
billing of these codes, which would require more time and analyses.
Accordingly, we are not proposing any changes to the emergency
department E/M code set or to the E/M code sets for settings of care
other than office-based and outpatient settings at this time. However,
we are seeking public comment on whether we should make any changes to
it in future years, whether by way of documentation, coding, and/or
payment and, if so, what the changes should be.
Consistent with public feedback to date, we are taking a step-wise
approach and limiting our policy proposals this year to the office/
outpatient E/M code set (and the limited proposal above regarding
documentation of medical necessity for home visits in lieu of office
visits). We may consider expanding our efforts more broadly to
additional sections of the E/M visit code set in future years, and are
seeking public comment broadly on how we might proceed in this regard.
f. Proposed Implementation Date
We propose that these proposed E/M visit policies would be
effective January 1, 2019. However, we are sensitive to commenters'
suggestions that we should consider a multi-year process and proceed
cautiously, allowing adequate time to educate practitioners and their
staff; and to transition clinical workflows, EHR templates,
institutional processes and policies (such as those for provider-based
practitioners), and other aspects of practitioner work that would be
impacted by these policy changes. Our proposed documentation changes
for office/outpatient E/M visits would be optional, and practitioners
could choose to continue to document these visits using the current
framework and rules, which may reduce the need for a delayed
implementation. Nevertheless, practitioners who choose a new
documentation framework may need time to deploy it. A delayed
implementation date for our documentation proposals would also allow
the AMA time to develop changes to the CPT coding definitions and
guidance prior to our implementation, such as changes to MDM or code
definitions that we could then consider for adoption. It would also
allow other payers time to react and potentially adjust their policies.
Accordingly, we are seeking comment on whether a delayed implementation
date, such as January 1, 2020, would be appropriate for our proposals.
J. Teaching Physician Documentation Requirements for Evaluation and
Management Services
1. Background
Per 42 CFR part 415, subpart D, Medicare Part B makes payment under
the PFS for teaching physician services when certain conditions are
met, including that medical record documentation must reflect the
teaching physician's participation in the review and direction of
services performed by residents in teaching settings. Under Sec.
415.172(b), for certain procedural services, the participation of the
teaching physician may be demonstrated by the notes in the medical
records made by a physician, resident, or nurse; and for E/M visits,
the teaching physician is required to personally document their
participation in the medical record. We received stakeholder feedback
suggesting that documentation requirements for E/M services furnished
by teaching physicians are burdensome and duplicative of notations that
may have previously been included in the medical records by residents
or other members of the medical team.
2. Proposed Implementation
We are proposing to revise our regulations to eliminate potentially
duplicative requirements for notations that may have previously been
included in the medical records by residents or
[[Page 35849]]
other members of the medical team. These proposed changes are intended
to align and simplify teaching physician E/M service documentation
requirements. We believe these proposed changes will reduce burden and
duplication of effort for teaching physicians. We are proposing to
amend Sec. 415.172(b) to provide that, except for services furnished
as set forth in Sec. Sec. 415.174 (concerning an exception for
services furnished in hospital outpatient and certain other ambulatory
settings), 415.176 (concerning renal dialysis services), and 415.184
(concerning psychiatric services), the medical records must document
that the teaching physician was present at the time the service is
furnished. Additionally, the revised paragraph would specify that the
presence of the teaching physician during procedures and evaluation and
management services may be demonstrated by the notes in the medical
records made by a physician, resident, or nurse. We are also proposing
to amend Sec. 415.174, by deleting paragraph (a)(3)(v) which currently
requires the teaching physician to document the extent of their
participation in the review and direction of the services furnished to
each beneficiary, and adding new paragraph (a)(6), to provide that the
medical record must document the extent of the teaching physician's
participation in the review and direction of services furnished to each
beneficiary, and that the extent of the teaching physician's
participation may be demonstrated by the notes in the medical records
made by a physician, resident, or nurse.
K. Solicitation of Public Comments on the Low Expenditure Threshold
Component of the Applicable Laboratory Definition Under the Medicare
Clinical Laboratory Fee Schedule (CLFS)
Section 1834A of the Act, as established by section 216(a) of the
Protecting Access to Medicare Act of 2014 (PAMA), required significant
changes to how Medicare pays for clinical diagnostic laboratory tests
(CDLTs) under the CLFS. The CLFS final rule titled, Medicare Clinical
Diagnostic Laboratory Tests Payment System final rule (CLFS final
rule), published in the Federal Register on June 23, 2016, implemented
section 1834A of the Act. Under the CLFS final rule (81 FR 41036),
``reporting entities'' must report to CMS during a ``data reporting
period'' ``applicable information'' (that is, certain private payer
data) collected for a ``data collection period'' for their component
``applicable laboratories.'' In general, the payment amount for each
CDLT on the CLFS furnished beginning January 1, 2018, is based on the
applicable information collected for the 6-month data collection period
and reported to us in the 3-month data reporting period, and is equal
to the weighted median of the private payor rates for the CDLT.
An applicable laboratory is defined at Sec. 414.502, in part, as
an entity that is a laboratory (as defined under the Clinical
Laboratory Improvement Amendments (CLIA) definition at Sec. 493.2)
that bills Medicare Part B under its own National Provider Identifier
(NPI). In addition, an applicable laboratory is an entity that receives
more than 50 percent of its Medicare revenues during a data collection
period from the CLFS and/or the PFS. We refer to this component of the
applicable laboratory definition as the ``majority of Medicare revenues
threshold.'' The definition of applicable laboratory also includes a
``low expenditure threshold'' component, which requires an entity to
receive at least $12,500 of its Medicare revenues from the CLFS in a
data collection period for its CDLTs that are not advanced diagnostic
laboratory tests (ADLTs).
We established $12,500 as the low expenditure threshold because we
believed it achieved a balance between collecting sufficient data to
calculate a weighted median that appropriately reflects the private
market rate for a CDLT, and minimizing the reporting burden for
laboratories that receive a relatively small amount of revenues under
the CLFS. In the CLFS final rule (81 FR 41051), we estimated that 95
percent of physician office laboratories and 55 percent of independent
laboratories would not be required to report applicable information
under our low expenditure threshold criterion. Although we
substantially reduced the number of laboratories qualifying as
applicable laboratories (that is, approximately 5 percent of physician
office laboratories and approximately 45 percent of independent
laboratories) we estimated that the percentage of Medicare utilization
would remain high. That is, approximately 5 percent of physician office
laboratories would account for approximately 92 percent of CLFS
spending on physician office laboratories and approximately 45 percent
of independent laboratories would account for approximately 99 percent
of CLFS spending on independent laboratories (81 FR 41051).
Recently, we have heard from some laboratory stakeholders that the
low expenditure threshold excludes most physician office laboratories
and many small independent laboratories from reporting applicable
information, and that by excluding so many laboratories, the payment
rates under the new private payor rate-based CLFS reflects incomplete
data, and therefore, inaccurate CLFS pricing. However, it is our
understanding that physician offices are generally not prepared to
identify, collect, and report each unique private payor rate from each
private payor for each laboratory test code on the CLFS and the volume
associated with each unique private payor rate. As such, we believe
revising the low expenditure threshold so that more physician office
laboratories are required to report applicable information would be a
very significant administrative burden on physician's offices. We also
believe that increasing participation from physician office
laboratories would have minimal overall impact on payment rates given
that the weighted median of private payor rates is dominated by the
laboratories with the largest test volume.
However, we recognize from stakeholders that some physician office
laboratories and small independent laboratories that are not applicable
laboratories because they do not meet the current low expenditure
threshold may still want to report applicable information, despite the
administrative burden associated with qualifying as an applicable
laboratory. Therefore, we are seeking public comments on reducing the
low expenditure threshold by 50 percent, from $12,500 to $6,250, in
CLFS revenues during a data collection period. Since more physician
office laboratories would meet the low expenditure threshold, we would
expect such an approach to increase the level of applicable information
reported by physician office laboratories and small independent
laboratories. We are seeking public comments regarding the potential
administrative burden on physician office laboratories and small
independent laboratories that would result from reducing the low
expenditure threshold. We are also soliciting public comments on an
approach that would increase the low expenditure threshold by 50
percent, from $12,500 to $18,750, in CLFS revenues received in a data
collection period. Since fewer physician office laboratories and small
independent laboratories would meet the definition of applicable
laboratory, we would expect such an approach to result in a decreased
level of applicable information reported. For a complete discussion of
our solicitation of comments on the low expenditure threshold component
of the definition
[[Page 35850]]
of applicable laboratory under the Medicare CLFS, we refer readers to
section III.A. of this proposed rule.
L. GPCI Comment Solicitation
Section 1848(e)(1)(C) of the Act requires us to review and, if
necessary, adjust the GPCIs at least every 3 years. Section
1848(e)(1)(D) of the Act requires us to establish the GPCIs using the
most recent data available. The last GPCI update was implemented in CY
2017; therefore, we are required to review and make any necessary
revisions to the GPCIs for CY 2020. Please refer to the CY 2017 PFS
final rule with comment period for a discussion of the last GPCI update
(81 FR 80261 through 80270). Some stakeholders have continued to
express concerns regarding some of the data sources used in developing
the indices for PFS geographic adjustment purposes, specifically that
we use residential rent data as a proxy for commercial rent in the rent
index component of the PE GPCI--that is, the data that are used to
develop the office rent component of the PE GPCI. We will continue our
efforts to identify a nationally representative commercial rent data
source that could be made available to CMS. In support of that effort,
we are particularly interested in, and seek comments regarding
potential sources of commercial rent data for potential use in the next
GPCI update for CY 2020.
M. Therapy Services
1. Repeal of the Therapy Caps and Limitation To Ensure Appropriate
Therapy
Section 50202 of the Bipartisan Budget Act of 2018 (BBA of 2018)
amended section 1833(g) of the Act, effective January 1, 2018, to
repeal the application of the Medicare outpatient therapy caps and the
therapy cap exceptions process while retaining and adding limitations
to ensure therapy services are furnished when appropriate. Section
50202 also adds section 1833(g)(7)(A) of the Act to require that after
expenses incurred for the beneficiary's outpatient therapy services for
the year have exceeded one or both of the previous therapy cap amounts,
all therapy suppliers and providers must continue to use an appropriate
modifier such as the KX modifier on claims for subsequent services in
order for Medicare to pay for the services. We implemented this
provision by continuing to use the KX modifier. By applying the KX
modifier to the claim, the therapist or therapy provider is confirming
that the services are medically necessary as justified by appropriate
documentation in the medical record. Just as with the incurred expenses
for the prior therapy cap amounts, there is one amount for physical
therapy (PT) and speech language pathology (SLP) services combined and
a separate amount for occupational therapy (OT) services. These KX
modifier threshold amounts are indexed annually by the Medicare
Economic Index (MEI). For CY 2018, this KX modifier threshold amount is
$2,010 for PT and SLP services combined, and $2,010 for OT After the
beneficiary's incurred expenditures for outpatient therapy services
exceed the KX modifier threshold amount for the year, claims for
outpatient therapy services without the KX modifier are denied.
Along with the KX modifier thresholds, section 50202 also adds
section 1833(g)(7)(B) of the Act that retains the targeted medical
review (MR) process (first established through section 202 of the
Medicare Access and CHIP Reauthorization Act of 2015 (MACRA)), but at a
lower threshold amount of $3,000. For CY 2018 (and each successive
calendar year until 2028, at which time it is indexed annually by the
MEI), the MR threshold is $3,000 for PT and SLP services and $3,000 for
OT services. The targeted MR process means that not all claims
exceeding the MR threshold amount are subject to review as they once
were.
Section 1833(g)(8) of the Act, as redesignated by section 50202 of
the BBA of 2018, retains the provider liability procedures which first
became effective January 1, 2013, extending limitation of liability
protections to beneficiaries who receive outpatient therapy services,
when services are denied for certain reasons, including failure to
include a necessary KX modifier.
2. Proposed Payment for Outpatient PT and OT Services Furnished by
Therapy Assistants
Section 53107 of the Bipartisan Budget Act of 2018 (BBA of 2018)
amended the Act to add a new subsection 1834(v) that addresses payment
for outpatient therapy services for which payment is made under section
1848 or section 1834(k) of the Act that are furnished on or after
January 1, 2022, in whole or in part by a therapy assistant (as defined
by the Secretary). The new section 1834(v)(1) of the Act provides for
payment of those services at 85 percent of the otherwise applicable
Part B payment amount for the service. In accordance with section
1834(v)(1) of the Act, the reduced payment amount for such outpatient
therapy services is applicable when payment is made directly under the
PFS as specified in section 1848 of the Act, for example when payment
is made to therapists in private practice (TPPs); and when payment is
made based on the PFS as specified in section 1834(k)(3) of the Act,
for example, when payment is made for outpatient therapy services
identified in sections 1833(a)(8) and (9) of the Act, including payment
to providers that submit institutional claims for therapy services such
as outpatient hospitals, rehabilitation agencies, skilled nursing
facilities, home health agencies and comprehensive outpatient
rehabilitation facilities (CORFs). The reduced payment rate under
section 1834(v)(1) of the Act for outpatient therapy services when
furnished in whole or in part by a therapy assistant is not applicable
to outpatient therapy services furnished by critical access hospitals
for which payment is made as specified in section 1834(g) of the Act.
To implement this payment reduction, section 1834(v)(2)(A) of the
Act requires us to establish a new modifier, in a form and manner
specified by the Secretary, by January 1, 2019 to indicate, in the case
of an outpatient therapy service furnished in whole or in part by a
therapy assistant, that the service was furnished by a therapy
assistant. Although we generally consider all genres of outpatient
therapy services together (PT/OT/SLP), we do not believe there are
``therapy assistants'' in the case of SLP services, so we propose to
apply the new modifier only to services furnished in whole or in part
by a physical therapist assistant (PTA) or an occupational therapist
assistant (OTA). Section 1834(v)(2)(B) of the Act requires that each
request for payment or bill submitted for an outpatient PT or OT
service furnished in whole or in part by a therapy assistant on or
after January 1, 2020, must include the established modifier. As such,
the modifier will be required to be reported on claims for outpatient
PT and OT services with dates of service on and after January 1, 2020,
when the service is furnished in whole or in part by a therapy
assistant, regardless of whether the reduced payment under section
1834(v)(1) of the Act is applicable. However, the required payment
reductions do not apply for these services until January 1, 2022, as
required by section 1834(v)(1) of the Act.
To implement this provision, we are proposing to establish two new
modifiers to separately identify PT and OT services that are furnished
in whole or in part by PTAs and OTAs,
[[Page 35851]]
respectively. We are proposing to establish two modifiers because the
incurred expenses for PT and OT services are tracked and accrued
separately in order to apply the two different KX modifier threshold
amounts as specified by section 1833(g)(2) of the Act; and the use of
the two proposed modifiers will facilitate appropriate tracking and
accrual of services furnished in whole or in part by PTAs and OTAs. We
additionally propose that these two therapy modifiers would be added to
the existing three therapy modifiers--GP, GO, and GN--that are
currently used to identify all therapy services delivered under a PT,
OT or SLP plan of care, respectively. The GP, GO, and GN modifiers have
existed since 1998 to track outpatient therapy services that were
subject to the therapy caps. Although the therapy caps were repealed
through amendments made to section 1833(g) of the Act by section 50202
of the BBA of 2018, as discussed in the above section, the statute
continues to require that we track and accrue incurred expenses for all
PT, OT, and SLP services, including those above the specified per
beneficiary amounts for medically necessary therapy services for each
calendar year; one amount for PT and SLP services combined, and another
for OT services.
For purposes of implementing section 1834(v) of the Act through
rulemaking as required under section 1834(v)(2)(C) of the Act, we are
proposing to define ``therapy assistant'' as an individual who meets
the personnel qualifications set forth at Sec. 484.4 of our
regulations for a physical therapist assistant and an occupational
therapy assistant (PTA and OTA, respectively). We are proposing that
the two new therapy modifiers would be used to identify services
furnished in whole or in part by a PTA or an OTA; and, that these new
therapy modifiers would be used instead of the GP and GO modifiers that
are currently used to report PT and OT services delivered under the
respective plan of care whenever the service is furnished in whole or
in part by a PTA or OTA.
Effective for dates of service on and after January 1, 2020, the
new therapy modifiers that identify services furnished in whole or in
part by a PTA or OTA would be required to be used on all therapy claims
instead of the existing modifiers GP and GO, respectively. As a result,
in order to implement the provisions of the new subsection 1834(v) of
the Act and carry out the continuing provisions of section 1833(g) of
the Act as amended, we are proposing that, beginning in CY 2020, five
therapy modifiers be used to track outpatient therapy services instead
of the current three. These five therapy modifiers include two new
therapy modifiers to identify PT and OT services furnished by PTAs and
OTAs, respectively, and three existing therapy modifiers--GP, GO and
GN--that will be used when PT, OT, and SLP services, respectively, are
fully furnished by therapists or when fully furnished by or incident to
physicians and NPPs.
The creation of therapy modifiers specific to PT or OT services
delivered under a plan of care furnished in whole or in part by a PTA
or OTA would necessitate that we make changes to the descriptors of the
existing GP and GO modifiers to clarify which qualified professionals,
for example, therapist, physician, or NPP, can furnish the PT and OT
services identified by these modifiers, and to differentiate them from
the therapy modifiers specific to the services of PTAs and OTAs. We
also propose to revise the GN modifier descriptor to conform to the
changes to the GP and GO modifiers by clarifying the qualified
professionals that furnish SLP therapy services.
We are proposing to define the new therapy modifiers for services
furnished in whole or in part by therapy assistants and to revise the
existing therapy modifier descriptors as follows:
New--PT Assistant services modifier (to be used instead of
the GP modifier currently reported when a PTA furnishes services in
whole or in part): Services furnished in whole or in part by a physical
therapist assistant under an outpatient physical therapy plan of care;
New--OT Assistant services modifier (to be used instead of
the GO modifier currently reported when an OTA furnishes services in
whole or in part): Services furnished in whole or in part by
occupational therapy assistant under an outpatient occupational therapy
plan of care;
We are proposing that the existing GP modifier ``Services delivered
under an outpatient physical therapy plan of care'' be revised to read
as follows:
Revised GP modifier: Services fully furnished by a
physical therapist or by or incident to the services of another
qualified clinician--that is, physician, nurse practitioner, certified
clinical nurse specialist, or physician assistant--under an outpatient
physical therapy plan of care;
We are proposing that the existing GO modifier ``Services delivered
under an outpatient occupational therapy plan of care'' be revised to
read as follows:
Revised GO modifier: Services fully furnished by an
occupational therapist or by or incident to the services of another
qualified clinician--that is, physician, nurse practitioner, certified
clinical nurse specialist, or physician assistant--under an outpatient
occupational therapy plan of care; and
We are proposing that the existing GN modifier that currently reads
``Services delivered under an outpatient speech-language pathology plan
of care'' be revised to be consistent with the revisions to the GP and
GO modifiers to read as follows:
Revised GN modifier: Services fully furnished by a speech-
language pathologist or by or incident to the services of another
qualified clinician--that is, physician, nurse practitioner, certified
clinical nurse specialist, or physician assistant--under an outpatient
speech-language pathology plan of care.
As finalized in CY 2005 PFS final rule with comment (69 FR 66351
through 66354), and as required as a condition of payment under our
regulations at Sec. Sec. 410.59(a)(3)(iii), 410.60(a)(3)(iii), and
410.62(a)(3)(iii), the person furnishing outpatient therapy services
incident to the physician, PA, NP or CNS service must meet the
therapist personnel qualification and standards at Sec. 484.4, except
for licensure per section 1862(a)(20) of the Act. As such, we note that
only a therapist, not a therapy assistant, can furnish outpatient
therapy services incident to the services of a physician or a non-
physician practitioner (NPP), so the new PT- and OT-Assistant therapy
modifiers cannot be used on the line of service when the rendering
practitioner identified on the claim is a physician or an NPP. For
therapy services billed by physicians or NPPs, whether furnished
personally or incident to their professional services, the GP or GO
modifier is required for those PT or OT services furnished under an
outpatient therapy plan.
We propose that all services that are furnished ``in whole or in
part'' by a PTA or OTA are subject to the use of the new therapy
modifiers. A new therapy modifier would be required to be used whenever
a PTA or OTA furnishes all or part of any covered outpatient therapy
service. However, we do not believe the provisions of section 1834(v)
of the Act were intended to apply when a PTA or OTA performs portions
of the service such as administrative tasks that are not related to
their qualifications as a PTA or OTA. Rather, we believe the provisions
of section 1834(v) were meant to apply when a PTA or OTA is involved in
providing some or all of the therapeutic portions of an outpatient
therapy service. We are proposing to define ``in part,'' for purposes
of the proposed new modifiers, to mean any
[[Page 35852]]
minute of the outpatient therapy service that is therapeutic in nature,
and that is provided by the PTA or OTA when acting as an extension of
the therapist. Therefore, a service furnished ``in part'' by a therapy
assistant would not include a service for which the PTA or OTA
furnished only non-therapeutic services that others without the PTA's
or OTA's training can do, such as scheduling the next appointment,
greeting and gowning the patient, preparing or cleaning the room. We
remind therapists and therapy providers that we do not recognize PTAs
and OTAs to wholly furnish PT and OT evaluations and re-evaluations,
that is, CPT codes 97161 through 97164 for PT and CPT codes 97165
through 97168 for OT; but to the extent that they do furnish part of an
evaluative service, the appropriate therapy modifier must be used on
the claim to signal that the service was furnished in part by the PTA
or OTA, and the payment reduction should be applied once it goes into
effect. We continue to believe that the clinical judgment and decision
making involved in furnishing an evaluation or re-evaluation is similar
to that involved with establishing the therapy plan that can only be
established by a therapist, physician, or NPP (NP, CNS, or PA) as
specified in Sec. 410.61 of our regulations. In addition, PTAs and
OTAs are not recognized separately in the statute to enroll as
practitioners for purposes of independently billing for their services
under the Medicare program. For these reasons, Pub. 100-02, Medicare
Benefits Policy Manual, Chapter 15, sections 230.1 and 230.2 state that
PTAs and OTAs ``. . . may not provide evaluative or assessment
services, make clinical judgments or decisions; develop, manage, or
furnish skilled maintenance program services; or take responsibility
for the service.'' While we expect that the therapist will continue to
furnish the majority of an evaluative procedure service, section
1834(v)(1) of the Act requires that the adjusted payment amount (85
percent of the otherwise applicable Part B payment amount) be applied
when a therapy assistant furnishes a therapy service ``in part,''
including part of an evaluative service.
Additionally, we would like to clarify that the requirements for
evaluations, including those for documentation, are separate and
distinct from those for plans of care (plans). The plan is a statutory
requirement under section 1861(p) of the Act for outpatient PT services
(and through sections 1861(g) and 1861(ll)(2) of the Act for outpatient
OT and SLP services, respectively) and may only be established by a
therapist or physician. Through Sec. 410.61(b)(5), NPs, CNSs, and PAs
are also permitted to establish the plan. This means that if the
evaluative procedure is furnished in part by an assistant, the new
therapy modifiers that distinguish services furnished by PTAs or OTAs
must be applied to the claim; however, the plan, which is not
separately reported or paid, must be established by the supervising
therapist who furnished part of the evaluation services as specified at
Sec. 410.61(b). When an evaluative therapy service is billed by a
physician or an NPP as the rendering provider, either the physician/NPP
or the therapist furnishing the service incident to the services of the
physician or NPP, may establish the therapy plan in accordance with
Sec. 410.61(b). All regulatory and subregulatory plan requirements
continue to apply.
To implement the new statutory provision at section 1834(v)(2)(A)
of the Act, we are proposing to establish two new therapy modifiers to
identify the services furnished in whole or in part by PTAs and OTAs.
As required under section 1834(v)(2)(B) of the Act, claims from all
providers of PT and OT services furnished on and after January 1, 2020,
will be required to include these new PT- and OT-Assistant therapy
modifiers for services furnished in whole or in part by a PTA or OTA.
We propose that these modifiers will be required, when applicable, in
place of the GP and GO modifiers currently used to identify PT and OT
services furnished under an outpatient plan of care. To test our
systems ahead of the required implementation date of January 1, 2020,
we anticipate allowing voluntary reporting of the new modifiers at some
point during CY 2019, which we will announce to our contractors and
therapy providers through a Change Request, as part of our usual change
management process.
We seek comments on these proposals.
3. Proposed Functional Reporting Modifications
Since January 1, 2013, all providers of outpatient therapy
services, including PT, OT, and SLP services, have been required to
include functional status information on claims for therapy services.
In response to the Request for Information (RFI) on CMS Flexibilities
and Efficiencies that was issued in the CY 2018 PFS proposed rule (82
FR 34172 through 34173), we received comments requesting burden
reduction related to the reporting of the functional reporting
requirements that were adopted to implement the requirements of section
3005(g) of the Middle Class Tax Relief and Jobs Creation Act (MCTRJCA)
of 2012, effective January 1, 2013.
After considering comments received through the CY 2013 PFS final
rule with comment period (77 FR 68598-68978), we finalized the design
of the functional reporting system. The MCTRJCA required us to
implement a claims-based data collection strategy in order to collect
data on patient function over the course of PT, OT, and SLP services in
order to better understand patient condition and outcomes. The
functional reporting system we implemented collects data using non-
payable HCPCS G-codes (HCPCS codes G8978 through G8999 and G9158
through G9186) and modifiers (in the range CH through CN) to describe a
patient's functional limitation and severity at: (a) The time of the
initial service, (b) at periodic intervals in sync with existing
progress reporting intervals, (c) at discharge, and (d) when reporting
certain evaluative and re-evaluative procedures (often times billed at
time of initial service). Claims without the required functional
reporting information are returned to therapy services providers,
rather than denied, so that they can add the required information and
resubmit claims. Therapy services providers must also document
functional reporting information in the patient's medical record each
time it is reported. The MCTRJCA also specified that data from the
functional reporting system were to be used to aid us in recommending
changes to, and reforming Medicare payment for outpatient therapy
services that were then subject to the therapy caps under section
1833(g) of the Act. We conducted an analysis that focused on the
functional reporting data that have been submitted through the claims-
based system, both by therapy discipline and by episodes of care by
discipline using a similar episode definition (for example, clean 60
calendar day period) that was used in our prior utilization reports for
CY 2008 through CY 2010 that can be found on the Therapy Services web
page in the Studies and Reports page at https://www.cms.gov/Medicare/Billing/TherapyServices/Studies-and-Reports.html). However, we did not
find the results compelling enough to use as a basis to recommend or
undertake administrative reforms of the current payment mechanism for
therapy services. Furthermore, going forward, the functional reporting
data we would collect may be even less useful for purposes of
recommending or reforming payment for therapy services because, as
described earlier, section 50202 of the
[[Page 35853]]
Bipartisan Budget Act of 2018 (BBA of 2018) amended section 1833(g) of
the Act to repeal the application of the Medicare outpatient therapy
caps and associated exceptions process, while imposing protections to
ensure therapy services are furnished when appropriate.
The general consensus of the commenters (organizations of physical
therapists, occupational therapists, and speech-language pathologists,
as well as other organizations of providers of therapy services and
individual stakeholders) who responded to our RFI on burden reduction
was that the functional reporting requirements for outpatient therapy
services are overly complex and burdensome. The majority of commenters
urged us to substantially revise and repurpose our functional reporting
requirements for other programmatic purposes or to eliminate the
functional reporting requirements all together. Most commenters to the
RFI on burden reduction criticized us for not having shared with them
an analysis of the functional reporting data we had collected to date,
even though MCTRJCA does not require that we share any such analysis. A
couple of commenters recommended we evolve our functional reporting
requirements, at least in the short-term, with the following three
changes: (a) Require reporting only at intake and discharge; (b) permit
reporting through clinical data registries, electronic health records
(EHRs), facility-based submission vehicles, etc., instead of the
claims-based reporting required by section 3005(g) of MCTRJCA; and (c)
allow functional reporting by therapy providers under MIPS as a
clinical practice improvement activity. The short-term recommendation
for reduced reporting was based on an independent analysis by one
specialty society using a sample of our CY 2014 claims. That analysis
noted that over an episode of care: (a) 93 percent reported when an
evaluation code was reported; (b) 12 percent to 16 percent reported at
the time of progress reporting interval; and (c) 36 percent of the
episodes reported discharge data. In the long-term, these same RFI
commenters believe our functional reporting system should be eliminated
in favor of CMS policies that move therapy providers toward reporting
using standardized measures of function. Other commenters suggested
that we use standardized measures that reflect global function, or that
are condition-specific. Some commenters would like to see CMS develop
setting-appropriate quality measures for outpatient therapy that can be
used to both (a) measure functionality and (b) meld patient assessment
data and functional measures with relevant measures developed in
response to the Improving Medicare Post-Acute Care Transformation Act
of 2014 (IMPACT Act of 2014) (Pub. L. 113-185) that is applicable to
CMS post-acute care (PAC) settings.
As part of the requirements of section 3005(g) of MCTRJCA, we
established our functional reporting claims-based data collection
strategy effective January 1, 2013 in the CY 2013 PFS final rule (77 FR
689580 through 68978) and will have been collecting these functional
reporting data for the last 5 years at the close of CY 2018. Because
the data from the functional reporting system were to be used to inform
our recommendations and reform of Medicare payment for outpatient
therapy services that are subject to the therapy caps under section
1833(g) of the Act, we reviewed and analyzed the data internally but
did not find them particularly useful in considering how to reform
payment for therapy services as an alternative to the therapy caps. In
the meantime, section 50202 of BBA of 2018, as discussed previously,
amended section 1833(g) of the Act to reform therapy payment. Because
section 3005(g) of MCTRJCA was not codified into the Act, and did not
specify how long the data collection strategy should last, we do not
believe it was intended to last indefinitely. We note that we share
commenters' concerns, including those who favor the elimination of
functional reporting because it is overly complex and burdensome to
report, and that those that questioned the utility of the collected
data given the lack of standardized measures used to report the
severity of the functional limitation being reported. In response to
commenters' concerns that we have not yet shared an analysis of the
collected functional reporting data with them, we note that we have not
published or shared the results to date because we did not find the
results informative when reviewing them for purpose of the section
3005(g) of MCTRJCA requirement. A few commenters requested that we
continue to collect functional reporting data in a reduced format--at
the outset and at discharge of the therapy episode--as a collective
short-term solution, while favoring the elimination of functional
reporting in the long-term because, according to our data and the
commenters' own data, the discharge data are only infrequently
reported. However, we do not believe that collecting additional years
of functional reporting data in this reduced format would add utility
to our data collection efforts. After consideration of these comments
on the RFI along with a review of all of the requirements under section
3005(g) of MCTRJCA, and in light of the recent statutory amendments to
section 1833(g) of the Act, we have concluded that continuing to
collect more years of these functional reporting data, whether through
the same or a reduced format, will not yield additional information
that would be useful to inform future analyses, and that allowing the
current functional reporting requirements to remain in place could
result in unnecessary burden for providers of therapy services without
providing further benefit to the Medicare program in the form of
additional data.
As a result, we are proposing to discontinue the functional
reporting requirements for services furnished on or after January 1,
2019. Specifically, we are proposing to amend our regulations by
removing the following: (1) Conditions of payment at Sec. Sec.
410.59(a)(4), 410.60(a)(4), 410.62(a)(4), and 410.105(d) that require
claims for OT, PT, SLP, and Comprehensive Outpatient Rehabilitation
Facility (CORF) PT, OT, and SLP services, respectively, to contain
prescribed information on patient functional limitations; and, (2) the
functional reporting-related phrase that requires the plan's goals to
be consistent with functional information on the claim at Sec.
410.61(c) for outpatient PT, OT, and SLP services and at Sec.
410.105(c)(1)(ii) for the PT, OT, and SLP services in CORFs. In
addition, we would: (1) Remove the functional reporting subregulatory
requirements implemented primarily through Change Request 8005 last
issued on December 21, 2012, via Transmittal 2622; (2) eliminate the
functional reporting standard systems edits we have applied to claims;
and (3) remove the functional reporting requirement provisions in our
internet Only Manual (IOM) provisions including the Medicare Claims
Processing Manual, Chapter 5; and, the functional reporting
requirements in Chapters 12 and 15 of the Medicare Benefits Policy
Manual.
If finalized, our proposal would end the requirements for the
reporting and documentation of functional limitation G-codes (HCPCS
codes G8978 through G8999 and G9158 through G9186) and severity
modifiers (in the range CH through CN) for outpatient therapy claims
with dates of service on and after January 1, 2019. Accordingly, with
the conclusion of our functional reporting system for dates of service
after
[[Page 35854]]
December 31, 2018, we would delete the applicable non-payable HCPCS G-
codes specifically developed to implement that system through the CY
2013 PFS final rule with comment period (77 FR 68598 through 68978).
We are seeking comment on these proposals.
N. Part B Drugs: Application of an Add-On Percentage for Certain
Wholesale Acquisition Cost (WAC)-Based Payments
Consistent with statutory provisions in section 1847A of the Act,
many current Medicare Fee For Service (FFS) payments for separately
payable drugs and biologicals furnished by providers and suppliers
include an add-on set at 6 percent of the volume-weighted average sales
price (ASP) or wholesale acquisition cost (WAC) for the drug or
biological (the ``6 percent add-on''). Although section 1847A of the
Act does not specifically state what the 6 percent add-on represents,
it is widely believed to include services associated with drug
acquisition that are not separately paid for, such as handling, and
storage, as well as additional mark-ups in drug distribution channels.
The 6 percent add-on described in section 1847A of the Act has raised
concerns because more revenue can be generated from percentage-based
add-on payments for expensive drugs, and an opportunity to generate
more revenue may create an incentive for the use of more expensive
drugs (MedPAC Report to the Congress: Medicare and the Health Care
Delivery System June 2015, http://medpac.gov/docs/default-source/reports/june-2015-report-to-the-congress-medicare-and-the-health-care-delivery-system.pdf, pages 65 through 72). Also, the Office of the
Assistant Secretary for Planning and Evaluation (ASPE) March 8, 2016,
Issue Briefing pointed out that that administrative complexity and
overhead costs are not exactly proportional to the price of a drug
(https://aspe.hhs.gov/pdf-report/medicare-part-b-drugs-pricing-and-incentives). Thus, the suitability of using a percentage of the volume-
weighted average sales price or WAC of the drug or biological for an
add-on payment may vary depending on the price of the drug or how the
payment rate has been determined.
While the add-on percentage for drug payments made under section
1847A of the Act is typically applied to the ASP, the same 6 percent
add-on is also applied to the WAC to determine the Part B drug payment
allowances in the following situations. First, for single source drugs
as authorized in section 1847A(b)(4) of the Act, payment is made using
the lesser of ASP or WAC; and section 1847A(b)(1) of the Act requires
that a 6 percent add-on be applied regardless of whether WAC or ASP is
less. Second, for drugs and biologicals where average sales price
during first quarter of sales is unavailable, section 1847A(c)(4) of
the Act allows the Secretary to determine the payment amount for the
drug or biological based on the WAC or payment methodologies in effect
on November 1, 2003. We note that this provision does not specify that
an add-on percentage be applied if WAC-based payment is used, nor is an
add-on percentage specified in the implementing regulations at Sec.
414.904(e)(4). The application of the add-on percentage to WAC-based
payments during a period where partial quarter ASP data was available
was discussed in the 2011 PFS final rule with comment (75 FR 73465
through 73466). Third, in situations where Medicare Administrative
Contractors (MACs) determine pricing for drugs that do not appear on
the ASP pricing files and for new drugs, WAC-based payment amounts may
also be used, as discussed in Chapter 17, Section 20.1.3 of the
Medicare Claims Processing Manual. This section of the Manual describes
the use of a 6 percent add-on.
The incorporation of discounts in the determination of payment
amounts made for Part B drug varies. Most Part B drug payments are
based on the drug's or biological's ASP; as provided in section
1847A(c)(3) of the Act, the ASP is net of many discounts such as volume
discounts, prompt pay discounts, cash discounts, free goods that are
contingent on any purchase, chargebacks, rebates (other than rebates
under Medicaid drug rebate program), etc. In contrast, the WAC of a
drug or biological is defined in section 1847A(c)(6)(B) of the Act as
the manufacturer's list price for the drug or biological to wholesalers
or direct purchasers in the United States, not including prompt pay or
other discounts, rebates or reductions in price, for the most recent
month for which the information is available, as reported in wholesale
price guides or other publications of drug or biological pricing data.
Because the WAC does not include discounts, it typically exceeds ASP,
and the use of a WAC-based payment amount for the same drug results in
higher dollar payments than the use of an ASP-based payment amount.
Although discussions about the add-on tend to focus on ASP-based
payments (because ASP-based payments are more common than WAC-based
payments), the add-on for WAC-based payments has also been raised in
the June 2017 MedPAC Report to the Congress (http://www.medpac.gov/docs/default-source/reports/jun17_reporttocongress_sec.pdf, pages 42
through 44). The MedPAC report focused on how the 2 quarter lag in
payments determined under section 1847A of the Act led to a situation
where undiscounted WAC-based payment amounts determined using
information from 2 quarters earlier were used to pay for drugs that
providers purchased at a discount. To determine the extent of the
discounts, MedPAC sampled new, high-expenditure Part B drugs and found
that these drugs' ASPs were generally lower than their WACs. Seven out
of the 8 drugs showed pricing declines from initial WAC to ASP one year
after being listed in the ASP pricing files with the remaining product
showing no change, which suggests purchasers received discounts that
WAC did not reflect. MedPAC further cited a 2014 OIG report (OIG,
Limitations in Manufacturer Reporting of Average Sales Price Data for
Part B Drugs, (OEI-12-13-00040), July 2014) to illustrate that there
may be differences between WAC and ASP in other instances in which CMS
utilizes WAC instead of ASP and noted that OIG found that ``WACs often
do not reflect actual market prices for drugs.'' MedPAC also
characterized Part B payments based on undiscounted list prices for
products that were available at a discount as excessive. The report
suggested that greater parity between ASP-based acquisition costs and
WAC-based payments for Part B drugs could be achieved and recommended
changing the 6 percent add-on for WAC-based payments to 3 percent. A 3
percent change was recommended based on statements made by industry,
MedPAC's analysis of new drug pricing, and OIG data. The report also
mentioned that discounts on WAC, such as prompt pay discounts, were
available soon after the drug went on the market.
In the case of a drug or biological during an initial sales period
in which data on the prices for sales for the drug or biological is not
sufficiently available from the manufacturer, section 1847A(c)(4) of
the Act permits the Secretary to make payments that are based on WAC.
In other words, although payments under this section may be based on
WAC, unlike section 1847A(b) of the Act (which specifies that certain
payments must be made with a 6 percent add-on), section 1847A(c)(4) of
the Act does not require that a particular add-on amount be applied to
partial quarter WAC-based pricing. Consistent with section 1847A(c)(4)
of the Act, we are proposing that effective January 1,
[[Page 35855]]
2019, WAC based payments for Part B drugs made under section
1847A(c)(4) of the Act, utilize a 3 percent add-on in place of the 6
percent add-on that is currently being used. We are proposing a 3
percent add-on because this percentage is consistent with MedPAC's
analysis and recommendations discussed in the paragraph above and cited
in their June 2017 Report to the Congress. Although other approaches
for modifying the add-on amount, such as a flat fee, or percentages
that vary with the cost of a drug, are possible, we are proposing a
fixed percentage in order to be consistent with other provisions in
section 1847A of the Act which specify fixed add-on percentages of 6
percent (1847A(b)) or 3 percent (section 1847A(d)(3)(C) of the Act). A
fixed percentage is also administratively simple to implement and
administer, is predictable, and is easy for manufacturers, providers
and the public to understand.
We have also reviewed corresponding regulation text at Sec.
414.904(e)(4). To conform the regulation text more closely to the
statutory language at section 1847A(c)(4) of the Act, we are also
proposing to strike the word ``applicable'' from paragraph (e)(4).
Section 1847A(c)(4) of the Act does not use the term ``applicable'' to
describe the payment methodologies in effect on November 1, 2003.
If we were to finalize these proposals, we would also change the
policy articulated in the Claims Processing Manual that describes the
application of the 6 percent add-on to payment determinations made by
MACs for new drugs and biologicals. Chapter 17 section 20.1.3 of the
Claims Processing Manual (https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c17.pdf) states that WAC-based payment
limits for drugs and biologicals that are produced or distributed under
a new drug application (or other new application) approved by the Food
and Drug Administration, and that are not included in the ASP Medicare
Part B Drug Pricing File or Not Otherwise Classified (NOC) Pricing
File, are based on 106 percent of WAC. Invoice-based pricing is used if
the WAC is not published. In OPPS, the payment allowance limit is 95
percent of the published Average Wholesale Price (AWP). We would change
our policy to permit MACs to use an add-on percentage of up to 3
percent for WAC-based payments for new drugs. MACs have longstanding
authority to make payment determinations when we do not publish a
payment limit in our national Part B drug pricing files and when new a
drug becomes available. This proposal would preserve consistency with
our proposed national pricing policy and would apply when MACs perform
pricing determinations, for example during the period when ASPs have
not been reported. This proposed policy would not alter OPPS payment
limits.
We note that these proposals do not include WAC-based payments for
single source drugs under section 1847A(b) of the Act, that is, where
the statute specifies that the payment limit is 106 percent of the
lesser of ASP or WAC.
We have stated in previous rulemaking that it is desirable to have
fair reimbursement in a healthy marketplace that encourages product
development (80 FR 71101). We have also stated that we seek to promote
innovation to provide more options to patients and physicians, and
competition to drive prices down (82 FR 53183). These positions have
not changed. However, since 2011, concern about the impact of drug
pricing and spending on Part B drugs has continued to grow. From 2011
to 2016, Medicare Part B drug spending increased from $17.6 billion to
$28.0 billion, representing a compound annual growth rate of 9.8
percent, with per capita spending increasing 54 percent, from $532 to
$818 (Based on Spending and Enrollment Data from Centers for Medicare
and Medicaid Services Office of Enterprise Data and Analytics). These
increases affect the spending by Medicare and beneficiary out-of-pocket
costs. In the context of these concerns, we believe that implementation
of these proposals will improve Medicare payment rates by better
aligning payments with drug acquisition costs, especially for the
growing number of drugs with high annual spending and high launch
prices where single doses can cost tens or even hundreds of thousands
of dollars. The proposals will also decrease beneficiary cost sharing.
A 3 percentage point reduction in the total payment allowance will
reduce a patient's 20 percent Medicare Part B copayment--for a drug
that costs many thousands of dollars per dose, this can result in
significant savings to an individual. The proposed approach would help
Medicare beneficiaries afford to pay for new drugs by reducing out of
pocket expenses and would help counteract the effects of increasing
launch prices for newly approved drugs and biologicals. Finally, the
proposals are consistent with recent MedPAC recommendations.
III. Other Provisions of the Proposed Rule
A. Clinical Laboratory Fee Schedule
1. Background
Prior to January 1, 2018, Medicare paid for clinical diagnostic
laboratory tests (CDLTs) on the Clinical Laboratory Fee Schedule (CLFS)
under sections 1832, 1833(a), (b) and (h), and 1861 of the Social
Security Act (the Act). Under the previous methodology, CDLTs were paid
based on the lesser of: (1) The amount billed; (2) the local fee
schedule amount established by the Medicare Administrative Contractor
(MAC); or (3) a national limitation amount (NLA), which is a percentage
of the median of all the local fee schedule amounts (or 100 percent of
the median for new tests furnished on or after January 1, 2001). In
practice, most tests were paid at the NLA. Under the previous system,
the CLFS amounts were updated for inflation based on the percentage
change in the Consumer Price Index for All Urban Consumers (CPI-U), and
reduced by a multi-factor productivity adjustment and other statutory
adjustments, but were not otherwise updated or changed.
Section 1834A of the Act, as established by section 216(a) of the
Protecting Access to Medicare Act of 2014 (PAMA), required significant
changes to how Medicare pays for CDLTs under the CLFS. The CLFS final
rule, entitled Medicare Clinical Diagnostic Laboratory Tests Payment
System (CLFS final rule), published in the Federal Register on June 23,
2016, implemented section 1834A of the Act. Under the CLFS final rule,
``reporting entities'' must report to CMS during a ``data reporting
period'' ``applicable information'' collected during a ``data
collection period'' for their component ``applicable laboratories.''
Applicable information is defined at Sec. 414.402 as, with respect to
each CDLT for a data collection period: Each private payor rate for
which final payment has been made during the data collection period;
the associated volume of tests performed corresponding to each private
payor rate; and the specific Healthcare Common Procedure Coding System
(HCPCS) code associated with the test. Applicable information does not
include information about a test for which payment is made on a
capitated basis. An applicable laboratory is defined at Sec. 414.502,
in part, as an entity that is a laboratory (as defined under the
Clinical Laboratory Improvement Amendments (CLIA) definition at Sec.
493.2) that bills Medicare Part B under its own National Provider
Identifier
[[Page 35856]]
(NPI). In addition, an applicable laboratory is an entity that receives
more than 50 percent of its Medicare revenues during a data collection
period from the CLFS and/or the Physician Fee Schedule (PFS). We refer
to this component of the applicable laboratory definition as the
``majority of Medicare revenues threshold.'' The definition of
applicable laboratory also includes a ``low expenditure threshold''
component which requires an entity to receive at least $12,500 of its
Medicare revenues from the CLFS for its CDLTs that are not advanced
diagnostic laboratory tests (ADLTs).
The first data collection period, for which applicable information
was collected, occurred from January 1, 2016 through June 30, 2016. The
first data reporting period, during which reporting entities reported
applicable information to CMS, occurred January 1, 2017 through March
31, 2017. On March 30, 2017, we announced a 60-day enforcement
discretion period of the assessment of Civil Monetary Penalties (CMPs)
for reporting entities that failed to report applicable information.
Additional information about the 60-day enforcement discretion period
may be found on the CMS website at https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/ClinicalLabFeeSched/Downloads/2017-March-Announcement.pdf.
In general, the payment amount for each CDLT on the CLFS furnished
beginning January 1, 2018, is based on the applicable information
collected during the data collection period and reported to us during
the data reporting period, and is equal to the weighted median of the
private payor rates for the test. The weighted median is calculated by
arraying the distribution of all private payor rates, weighted by the
volume for each payor and each laboratory. The payment amounts
established under the CLFS are not subject to any other adjustment,
such as geographic, budget neutrality, or annual update, as required by
section 1834A(b)(4)(B) of the Act. Additionally, section 1834A(b)(3) of
the Act, implemented at Sec. 414.507(d), provides a phase-in of
payment reductions, limiting the amounts the CLFS rates for each CDLT
(that is not a new ADLT or new CDLT) can be reduced as compared to the
payment rates for the preceding year. For the first 3 years after
implementation (CY 2018 through CY 2020), the reduction cannot be more
than 10 percent per year, and for the next 3 years (CY 2021 through CY
2023), the reduction cannot be more than 15 percent per year. For most
CDLTs, the data collection period, data reporting period, and payment
rate update occur every 3 years. As such, the next data collection
period for most CDLTs will be January 1, 2019 through June 30, 2019,
and the next data reporting period will be January 1, 2020 through
March 31, 2020, with the next update to CLFS occurring on January 1,
2021. Additional information on the private payor rate-based CLFS is
detailed in the CLFS final rule (81 FR 41036 through 41101).
2. Recent Stakeholder Feedback
After the initial data collection and data reporting periods, we
received stakeholder feedback on a range of topics related to the
private payor rate-based CLFS. Some stakeholders expressed concern that
the CY 2018 CLFS payments rates are based on applicable information
from only a relatively small number of laboratories. Some stakeholders
stated that, because most hospital-based laboratories were not
applicable laboratories, and therefore, did not report applicable
information during the initial data reporting period, the CY 2018 CLFS
payment rates do not reflect their information and are inaccurate.
Other stakeholders were concerned that the low expenditure threshold
excluded most physician office laboratories and many small independent
laboratories from reporting applicable information.
In determining payment rates under the private payor rate-based
CLFS, one of our objectives is to obtain as much applicable information
as possible from the broadest possible representation of the national
laboratory market on which to base CLFS payment amounts, for example,
from independent laboratories, hospital outreach laboratories, and
physician office laboratories, without imposing undue burden on those
entities. As we noted throughout the CLFS final rule, we believe it is
important to achieve a balance between collecting sufficient data to
calculate a weighted median that appropriately reflects the private
market rate for a CDLT, and minimizing the reporting burden for
entities. In response to stakeholder feedback and in the interest of
facilitating our goal, we are proposing one change, discussed below, to
the Medicare CLFS for CY 2019. We believe this proposal may result in
more data being used on which to base CLFS payment rates.
In addition to this proposal, we are soliciting public comments on
other approaches that have been requested by some stakeholders who
suggested that such approaches would result in CMS receiving even more
applicable information to use in establishing CLFS payment rates. The
approaches include revising the definition of applicable laboratory and
changing the low expenditure threshold. These topics are discussed
below.
3. Proposed Change to the Majority of Medicare Revenues Threshold in
Definition of Applicable Laboratory
In order for a laboratory to meet the majority of Medicare revenues
threshold, section 1834A(a)(2) of the Act requires that, ``with respect
to its revenues under this title, a majority of such revenues are
from'' the CLFS and the PFS in a data collection period. In the CLFS
final rule, we stated that ``revenues under this title'' are payments
received from the Medicare program, which includes fee-for-service
payments under Medicare Parts A and B, as well as Medicare Advantage
(MA) payments under Medicare Part C, and prescription drug payments
under Medicare Part D, and any associated Medicare beneficiary
deductible or coinsurance amounts for Medicare services furnished
during the data collection period (81 FR 41043). This total Medicare
revenues amount (the denominator in the majority of Medicare revenues
threshold calculation) is compared to the total of Medicare revenues
received from the CLFS and/or PFS (the numerator in the majority of
Medicare revenues threshold calculation). If the numerator is greater
than 50 percent of the denominator for a data collection period, the
entity has met the majority of Medicare revenues threshold criterion.
We reflected that requirement in Sec. 414.502 in the third paragraph
of the definition of applicable laboratory.
We have considered that our current interpretation of total
Medicare revenues may have the effect of excluding laboratories that
furnish Medicare services to a significant number of beneficiaries
enrolled in MA plans under Medicare Part C from meeting the majority of
Medicare revenues threshold criterion, and therefore, from qualifying
as applicable laboratories. For instance, if a laboratory has a
significant enough Part C component so that it is receiving greater
than 50 percent of its total Medicare revenues from MA payments under
Part C, it would not meet the majority of Medicare revenues threshold
because its revenues derived from the CLFS and/or PFS would not
constitute a majority of its total Medicare revenues. We believe that
if we were to exclude MA plan revenues from total Medicare revenues,
more laboratories of all types may meet the majority of Medicare
revenues threshold, and therefore, the definition
[[Page 35857]]
of applicable laboratory, because it would have the effect of
decreasing the amount of total Medicare revenues and increase the
likelihood that a laboratory's CLFS and PFS revenues would constitute a
majority of its Medicare revenues.
We believe section 1834A of the Act permits an interpretation that
MA plan payments to laboratories not be included in the total Medicare
revenues component of the majority of Medicare revenues threshold
calculation. Rather, MA plan payments to laboratories can be considered
to only be private payor payments under the CLFS. We emphasize here
that this characterization of MA plan payments is limited to only the
CLFS for purposes of defining applicable laboratory. Whether MA plan
payments to laboratories or other entities are considered Medicare
``revenues'' or ``private payor payments'' in other contexts in the
Medicare program is irrelevant here. Nor does our characterization of
MA plan payments as private payor payments for purposes of the CLFS
have any bearing on any aspect of the Medicare program other than the
CLFS. This is because of language included in section 1834A of the Act
that is specifically targeted to the CLFS, explained below.
As noted above, we defined total Medicare revenues for purposes of
the majority of Medicare revenues threshold calculation to include fee-
for-service payments under Medicare Parts A and B, as well as MA
payments under Medicare Part C, and prescription drug payments under
Medicare Part D, and any associated Medicare beneficiary deductible or
coinsurance amounts for Medicare services furnished during the data
collection period. However, section 1834A(a)(8) of the Act, which
defines the term ``private payor,'' identifies at section
1834A(a)(8)(B) a ``Medicare Advantage plan under Part C'' as a type of
private payor. Under the private payor rate-based CLFS, CLFS payment
amounts are based on private payor rates that are reported to CMS. So,
an applicable laboratory that receives Medicare Advantage (MA) plan
payments is to consider those MA plan payments in identifying its
applicable information, which must be reported to CMS. We believe it is
more logical to not consider MA plan payments under Part C to be both
Medicare revenues for determining applicable laboratory status and
private payor rates for purposes of reporting applicable information.
Congress contemplated that applicable laboratories would furnish MA
services, as reflected in the requirement that private payor rates must
be reported for MA services. However, under our current definition of
applicable laboratory, laboratories that furnish MA services,
particularly those that furnish a significant amount, are less likely
to meet the majority of Medicare revenues threshold, which means they
would be less likely to qualify as applicable laboratories, and
therefore, to report private payor rates for MA services.
Therefore, after further review and consideration of the new
private payor rate-based CLFS, we believe it is appropriate to include
MA plan revenues as only private payor payments rather than both
Medicare revenues, for the purpose of determining applicable laboratory
status, and private payor payments, for the purpose of specifying what
is applicable information. Such a change would have the effect of
eliminating the laboratory revenue generated from a laboratory's Part
C-enrolled patient population as a factor in determining whether a
majority of the laboratory's Medicare revenues are comprised of
services paid under the CLFS or PFS. We believe this change would
permit a laboratory with a significant Medicare Part C revenue
component to be more likely to meet the majority of Medicare revenues
threshold and qualify as an applicable laboratory. In other words, MA
payments are currently included as total Medicare revenues (the
denominator). In order to meet the majority of Medicare revenues
threshold, the statute requires a laboratory to receive the majority of
its Medicare revenues from the CLFS and or PFS. If MA plan payments
were excluded from the total Medicare revenues calculation, the
denominator amount would decrease. If the denominator amount decreases,
the likelihood increases that a laboratory would qualify as an
applicable laboratory. Therefore, we believe this proposal responds
directly to stakeholders' concerns regarding the number of laboratories
for which applicable information must be reported because a broader
representation of the laboratory industry may qualify as applicable
laboratories, which means we would receive more applicable information
to use in setting CLFS payment rates.
For these reasons, we are proposing that MA plan payments under
Part C would not be considered Medicare revenues for purposes of the
applicable laboratory definition. We would revise paragraph (3) of the
definition of applicable laboratory at Sec. 414.502 accordingly. We
reiterate that not characterizing MA plan payments under Medicare Part
C as Medicare revenues would be limited to the definition of applicable
laboratory under the CLFS, and would not affect, reflect on, or
otherwise have any bearing on any other aspect of the Medicare program.
In an effort to provide stakeholders a better understanding of the
potential reporting burden that may result from this proposal, we are
providing a summary of the distribution of data reporting that occurred
for the first data reporting period. If we were to finalize the
proposed change to the majority of Medicare revenues threshold
component of the definition of applicable laboratory, additional
laboratories of all types serving a significant population of
beneficiaries enrolled in Medicare Part C could potentially qualify as
applicable laboratories, in which case their data would be reported to
us. As discussed previously, we received over 4.9 million records from
1,942 applicable laboratories for the initial data reporting period,
which we used to set CY 2018 CLFS rates. Additional analysis shows that
the average number of records reported for an applicable laboratory was
2,573. The largest number of records reported for an applicable
laboratory was 457,585 while the smallest amount was 1 record. A
summary of the distribution of reported records from the first data
collection period is illustrated in the Table 24.
Table 24--Summary of Records Reported for First Data Reporting Period
[By applicable laboratory]
--------------------------------------------------------------------------------------------------------------------------------------------------------
Percentile distribution of records
Total records Average Min records Max records ---------------------------------------------------------------------
records 10th 25th 50th 75th 90th
--------------------------------------------------------------------------------------------------------------------------------------------------------
4,995,877............................... 2,573 1 457,585 23 79 294 1,345 4,884
--------------------------------------------------------------------------------------------------------------------------------------------------------
[[Page 35858]]
Assuming a similar distribution of data reporting for the next data
reporting period, the mid-point of reported records for an applicable
laboratory would be approximately 300 (50th percentile for the first
data reporting period was 294). However, as illustrated in Table 24,
the number of records reported varies greatly, depending on the volume
of services performed by a given laboratory. Laboratories with larger
test volumes, for instance at the 90th percentile, should expect to
report more records as compared to the midpoint used for this analysis.
Likewise, laboratories with smaller test volume, for instance at the
10th percentile, should expect to report less records as compared to
the midpoint.
We welcome comments on our proposal to modify the definition of
applicable laboratory to exclude MA plan payments under Part C as
Medicare revenues.
4. Solicitation of Public Comments on Other Approaches to Defining
Applicable Laboratory
As noted previously, we define applicable laboratory at the NPI
level, which means the laboratory's own billing NPI is used to identify
a laboratory's revenues for purposes of determining whether it meets
the majority of Medicare revenues threshold and the low expenditure
threshold components of the applicable laboratory definition. For
background purposes, the following summarizes some of the
considerations we made in establishing this policy.
In the CLFS proposed rule, entitled Medicare Clinical Diagnostic
Laboratory Tests Payment System, published in the October 1, 2015
Federal Register, we proposed to define applicable laboratory at the
TIN level so that an applicable laboratory would be an entity that
reports tax-related information to the IRS under a TIN with which all
of the NPIs in the entity are associated, and was itself a laboratory
or had at least one component that was a laboratory, as defined in
Sec. 493.2. In the CLFS proposed rule, we discussed that we considered
proposing to define applicable laboratory at the NPI level. However, we
did not propose that approach because we believed private payor rates
for CDLTs are negotiated at the TIN level and not by individual
laboratory locations at the NPI level. Numerous stakeholders had
indicated that the TIN-level entity is the entity negotiating pricing,
and therefore, is the entity in the best position to compile and report
applicable information across its multiple NPIs when there are multiple
NPIs associated with a TIN-level entity. We stated that we believed
defining applicable laboratory by TIN rather than NPI would result in
the same applicable information being reported, and would require
reporting by fewer entities, and therefore, would be less burdensome to
applicable laboratories. In addition, we stated that we did not believe
reporting at the TIN level would affect or diminish the quality of the
applicable information reported. To the extent the information is
accurately reported, we expected reporting at a higher organizational
level to produce exactly the same applicable information as reporting
at a lower level (80 FR 59391 through 59393).
Commenters who objected to our proposal to define applicable
laboratory at the TIN level stated that our definition would exclude
hospital laboratories because, in calculating the applicable
laboratory's majority of Medicare revenues amount, which looks at the
percentage of Medicare revenues from the PFS and CLFS across the entire
TIN-level entity, virtually all hospital laboratories would not be
considered an applicable laboratory. Many commenters expressed
particular concern that our proposed definition would exclude hospital
outreach laboratories, stating that hospital outreach laboratories,
which do not provide laboratory services to hospital patients, are
direct competitors of the broader independent laboratory market, and
therefore, excluding them from the definition of applicable laboratory
would result in incomplete and inappropriate applicable information,
which would skew CLFS payment rates. Commenters maintained that CMS
needed to ensure reporting by a broad scope of the laboratory market to
meet what they viewed as Congressional intent that all sectors of the
laboratory market be included to establish accurate market-based rates
(81 FR 41045).
In issuing the CLFS final rule, we found particularly compelling
the comments that urged us to adopt a policy that would better enable
hospital outreach laboratories to be applicable laboratories because we
agreed hospital outreach laboratories should be accounted for in the
new CLFS payment rates. We noted that hospital outreach laboratories
are laboratories that furnish laboratory tests for patients who are not
admitted hospital inpatients or registered outpatients of the hospital
and who are enrolled in Medicare separately from the hospital of which
they are a part as independent laboratories that do not serve hospital
patients. We believed it was important to facilitate reporting of
private payor rates for hospital outreach laboratories to ensure a
broader representation of the national laboratory market to use in
setting CLFS payment amounts (81 FR 41045).
We were clear in the CLFS final rule, however, that we believe
Congressional intent was to effectively exclude hospital laboratories
as applicable laboratories, which was apparent from the statutory
language, in particular, the majority of Medicare revenues threshold
criterion in section 1834A(a)(2) of the Act. Section 1834A(a)(2) of the
Act provides that, to qualify as an applicable laboratory, an entity's
revenues from the CLFS and the PFS needs to constitute a majority of
its total Medicare payments received from the Medicare program for a
data collection period. What we found significant was that most
hospital laboratories would not meet that majority of Medicare revenues
threshold because their revenues under the IPPS and OPPS alone would
likely far exceed the revenues they received under the CLFS and PFS.
Therefore, we believe the statute intended to limit reporting primarily
to independent laboratories and physician offices (81 FR 41045 through
41047). For a more complete discussion of the definition of applicable
laboratory, see the CLFS final rule (81 FR 41041 through 41051).
a. Stakeholder Continuing Comments and Stakeholder-Suggested
Alternative Approaches
As noted above, in response to public comments, we finalized that
an applicable laboratory is the NPI-level entity so that a hospital
outreach laboratory assigned a unique NPI, separate from the hospital
of which it is a part, is able to meet the definition of applicable
laboratory and its applicable information can be used for CLFS rate-
setting. We continue to believe that the NPI is the most effective
mechanism for identifying Medicare revenues for purposes of determining
applicable laboratory status and identifying private payor rates for
purposes of reporting applicable information. Once a hospital outreach
laboratory obtains its own unique billing NPI and bills for services
using its own unique NPI, Medicare and private payor revenues are
directly attributable to the hospital outreach laboratory. By defining
applicable laboratory using the NPI, Medicare payments (for purposes of
determining applicable laboratory status) and private payor rates and
the associated volume of CDLTs can be more easily identified and
reported to us. We also believe that, if finalized, our proposal to
exclude MA plan revenues under Medicare Part C from total Medicare
revenues in the
[[Page 35859]]
definition of applicable laboratory may increase the number of entities
meeting the majority of Medicare revenues threshold, and therefore,
qualifying for applicable laboratory status. In summary, we believe the
proposed change to the total Medicare revenues component of the
applicable laboratory definition and our current policy that requires
an entity to bill Medicare Part B under its own NPI, may increase the
number of hospital outreach laboratories qualifying as applicable
laboratories.
In addition, we are confident that our current policy supports our
collecting sufficient applicable information in the next data reporting
period, and that we received sufficient and reliable applicable
information with which we set CY 2018 CLFS rates, and that those rates
are accurate. For instance, we received applicable information from
laboratories in every state, the District of Columbia, and Puerto Rico.
This data included private payor rates for almost 248 million
laboratory tests conducted by 1,942 applicable laboratories, with over
4 million records of applicable information. In addition, as we've
noted, the largest laboratories dominate the market, and therefore,
most significantly affect the payment weights (81 FR 41049). Given that
the largest laboratories reported their applicable information to CMS
in the initial data reporting period, along with many smaller
laboratories, we believe the data we used to calculate the CY 2018 CLFS
rates was sufficient and resulted in accurate weighted medians of
private payor rates.
However, we continue to consider refinements to our policies that
could lead to including even more applicable information for the next
data reporting period. To that end, the comments and alternative
approaches suggested by stakeholders, even though some were first
raised prior to the CLFS final rule, are presented and considered for
comment now.
(1) Using Form CMS-1450 Bill Type 14x To Determine Majority of Medicare
Revenues and Low Expenditure Thresholds
Some stakeholders that expressed concern over the CY 2018 CLFS
payments rates stated that the NPI-based definition of applicable
laboratory reduces the number of hospital outreach laboratories
reporting data. These stakeholders suggested we revise the definition
specifically for the purpose of including more hospital outreach
laboratories. Under a suggested approach, a laboratory could determine
whether it meets the majority of Medicare revenues threshold and low
expenditure threshold using only the revenues from services reported on
the Form CMS-1450 (approved Office of Management and Budget number
0938-0997) 14x bill type, which is used only by hospital outreach
laboratories. Therefore, per the stakeholder suggestions, we are
seeking public comments on the following approach.
This approach would revise the definition of applicable laboratory
to permit the revenues identified on the Form CMS-1450 14x bill type to
be used instead of the revenues associated with the NPI the laboratory
uses, to determine whether it meets the majority of Medicare revenues
threshold (and the low expenditure threshold). Under this approach, the
applicable revenues would be based on the bills used for hospital
laboratory services provided to non-patients, which are paid under
Medicare Part B (that is, the 14x bill type). If we pursued this
approach, we would have to modify the definition of applicable
laboratory in Sec. 414.502 by indicating that an applicable laboratory
may include an entity that bills Medicare Part B on the Form CMS-1450
14x bill type.
Although using the 14x bill type could alleviate some initial,
albeit limited, administrative burden on hospital outreach laboratories
to obtain a unique billing NPI, we would have operational and statutory
authority concerns about defining applicable laboratory by the Form
CMS-1450 14x bill type.
First, defining applicable laboratory using the Form CMS-1450 14x
bill type does not identify an entity the way an NPI does. Whereas an
NPI is associated with a provider or supplier to determine specific
Medicare revenues, the 14x bill type is merely a billing mechanism that
is currently used only for a limited set of services. Under an approach
that permits laboratories to meet the majority of Medicare revenues
threshold using the 14x bill type, private payor rates (and the volume
of tests paid at those rates) would have to be identified that are
associated with only the outreach laboratory services of a hospital's
laboratory business. However, some private payors, such as MA plans,
may not require hospital laboratories to use the 14x bill type for
their outreach laboratory services. To the extent a private payor does
not require hospital outreach laboratory services to be billed on a 14x
bill type (which specifically identifies outreach services), hospitals
may need to develop their own mechanism for identifying and reporting
only the applicable information associated with its hospital outreach
laboratory services. In light of this possible scenario, we are
interested in public comments about the utility of using the 14x bill
type in the way we have described and on the level of administrative
burden created if we defined applicable laboratory using the Form CMS-
1450 14x bill type.
Second, we question whether hospitals would have sufficient time
after publication of a new final rule that included using the Form CMS-
1450 14x bill type, and any related subregulatory guidance, to develop
and implement the information systems necessary to collect private
payor rate data before the start of the next data collection period,
that is, January 1, 2019. To that end, we are interested in public
comments as to whether revising the definition of applicable laboratory
to use the Form CMS-1450 14x bill type would allow laboratories
sufficient time to make the necessary systems changes to identify
applicable information before the start of the next data collection
period.
Third, we believe defining applicable laboratory at the NPI level,
as we currently do, provides flexibility for hospital outreach
laboratories to not obtain a unique billing NPI, which may be
significant particularly where a hospital outreach laboratory performs
relatively few outreach services under Medicare Part B. For example,
under the current definition of applicable laboratory, if a hospital
outreach laboratory's CLFS revenues in a data collection period are
typically much less than the low expenditure threshold, the hospital of
which it is a part could choose not to obtain a separate NPI for its
outreach laboratory and could thus avoid determining applicable
laboratory status for its outreach laboratory component. In contrast,
if laboratories were permitted to use the Form CMS-1450 14x bill type,
revenues attributed to the hospital outreach laboratory would have to
be calculated in every instance where those services exceeded the low
expenditure threshold. This would be true even for a hospital outreach
laboratory that performs relatively few outreach services under
Medicare Part B. Therefore, we are interested in comments concerning
this aspect of using the 14x bill type definition.
Fourth, and significantly, we believe that if we were to utilize
such an approach in defining applicable laboratory, all hospital
outreach laboratories would meet the majority of Medicare revenues
threshold. At this time, we believe that this approach would be
inconsistent with the statute. By virtue of the majority of Medicare
revenues threshold, the statute defines applicable laboratory in such a
way that
[[Page 35860]]
not all laboratories qualify as applicable laboratories. However, if we
were to use the CMS-1450 14x bill type to define an applicable
laboratory, all hospital outreach laboratories that use the 14x bill
type would meet the majority of Medicare revenues threshold.
Accordingly, we are interested in public comments regarding whether
this definition would indeed be inconsistent with the statute, as well
as comments that can identify circumstances under this definition
whereby a hospital outreach laboratory would not meet the majority of
Medicare revenues threshold.
(2) Using CLIA Certificate To Define Applicable Laboratories
Some industry stakeholders have requested that we use the CLIA
certificate rather than the NPI to identify a laboratory that would be
considered an applicable laboratory. We discussed in the CLFS proposed
rule (80 FR 59392) why not all entities that meet the CLIA regulatory
definition at Sec. 493.2 would be applicable laboratories, and
therefore, we did not propose to use CLIA as the mechanism for defining
applicable laboratory. However, some commenters to the CLFS proposed
rule suggested we use the CLIA certificate to identify the
organizational entity that would be considered an applicable laboratory
so that each entity that had a CLIA certificate would be an applicable
laboratory (81 FR 41045). We considered those comments in the CLFS
final rule and discussed why we chose not to adopt that approach.
Among other reasons, we explained in the CLFS final rule that we
believed a CLIA certificate-based definition of applicable laboratory
would be overly inclusive by including all hospital laboratories, as
opposed to just hospital outreach laboratories. In addition, the CLIA
certificate is used to certify that a laboratory meets applicable
health and safety regulations in order to furnish laboratory services.
It is not associated with Medicare billing so, unlike for example, the
NPI, with which revenues for specific services can easily be
identified, the CLIA certificate cannot be used to identify revenues
for specific services. We also indicated that we did not see how a
hospital would determine whether its laboratories would meet the
majority of Medicare revenues threshold (and the low expenditure
threshold) using the CLIA certificate as the basis for defining an
applicable laboratory. In addition, we stated that, given the
difficulties many hospitals would likely have in determining whether
their laboratories are applicable laboratories, we also believed
hospitals may object to using the CLIA certificate (81 FR 41045).
However, in light of stakeholders' suggestions to use the CLIA
certificate to include hospital outreach laboratories in the definition
of applicable laboratories, we are soliciting public comments on that
approach. Under such approach, the majority of Medicare revenues
threshold and low expenditure threshold components of the definition of
applicable laboratory would be determined at the CLIA certificate level
instead of the NPI level. If we pursued such approach, we would have to
modify the definition of applicable laboratory in Sec. 414.502 to
indicate that an applicable laboratory is one that holds a CLIA
certificate under Sec. 493.2 of the chapter. We would have concerns,
however, about defining applicable laboratory by the CLIA certificate.
First, as we discussed in the CLFS final rule, given that
information regarding the CLIA certificate is not required on the Form
CMS-1450 14x bill type, which is the billing form used by hospitals for
their laboratory outreach services, it is not clear how a hospital
would identify and distinguish revenues generated by its separately
CLIA-certified laboratories for their outreach services. We are
interested in public comments regarding the mechanisms a hospital would
need to develop to identify revenues if we used the CLIA certificate
for purposes of determining applicable laboratory status, as well as
comments about the administrative burden associated with developing
such mechanisms.
In addition, we understand there could be a scenario where one CLIA
certificate is assigned to a hospital's entire laboratory business,
which would include laboratory tests performed for hospital patients as
well as non-patients (that is, patients who are not admitted inpatients
or registered outpatients of the hospital). For example, hospital
laboratories with an outreach laboratory component would be assigned a
single CLIA certificate if the hospital outreach laboratory has the
same mailing address or location as the hospital laboratory. In this
scenario, the majority of Medicare revenues threshold would be applied
to the entire hospital laboratory, not just its outreach laboratory
component. If a single CLIA certificate is assigned to the hospital's
entire laboratory business, the hospital laboratory would be unlikely
to meet the majority of Medicare revenues threshold because its
laboratory revenues under the IPPS and OPPS alone would likely far
exceed the revenues it receives under the CLFS and PFS. As a result, a
hospital outreach laboratory that could otherwise meet the definition
of applicable laboratory, as currently defined at the NPI level, would
not be an applicable laboratory if we were to require the CLIA
certificate to define applicable laboratory. Given that this approach
could have the effect of decreasing as opposed to increasing the number
of applicable laboratories, we are requesting public comments on this
potential drawback of defining applicable laboratory at the CLIA
certificate level.
We believe that feedback on the topics discussed in this section
could help inform us regarding potential refinements to the definition
of applicable laboratory. We welcome comments on these topics from the
public, including, physicians, laboratories, hospitals, and other
interested stakeholders. We are especially interested in comments
regarding the administrative burden of using the Form CMS-1450 14x bill
type or CLIA certificate to identify applicable information attributed
only to the hospital outreach laboratory portion of a hospital's total
laboratory business. Depending on the comments we receive, it is
possible we would consider approaches described in this section.
Again, we continue to believe that our current regulatory
definitions and data collection processes are reasonable pursuant to
governing law. The above public comments are solicited as part of the
agency's ongoing engagement with stakeholders to receive the most up-
to-date information and comments from those affected by the CLFS fee
schedule.
5. Solicitation of Public Comments on the Low Expenditure Threshold in
the Definition of Applicable Laboratory
a. Decreasing the Low Expenditure Threshold
In the CLFS final rule, we established a low expenditure threshold
component in the definition of applicable laboratory at Sec. 414.502,
which is reflected in paragraph (4). To be an applicable laboratory, at
least $12,500 of an entity's Medicare revenues in a data collection
period must be CLFS revenues (with the exception that there is no low
expenditure threshold for an entity with respect to the ADLTs it
furnishes). We established $12,500 as the low expenditure threshold
because we believed it achieved a balance between collecting sufficient
data to calculate a weighted median that appropriately reflects the
private market rate for a test, and minimizing the reporting burden for
laboratories that receive a relatively small amount of revenues under
the CLFS. We indicated in the CLFS final rule (81 FR 41049) that once
we
[[Page 35861]]
obtained applicable information under the new payment system, we may
decide to reevaluate the low expenditure threshold in future years and
propose a different threshold amount through notice and comment
rulemaking.
Recently, we have heard from some laboratory stakeholders that the
low expenditure threshold excludes most physician office laboratories
and many small independent laboratories from reporting applicable
information, and that by excluding so many laboratories, the payment
rates under the new private payor rate-based CLFS reflect incomplete
data, and therefore, inaccurate CLFS pricing.
As noted above, we discussed in the CLFS final rule that we
believed a $12,500 low expenditure threshold would reduce the reporting
burden on small laboratories. In the CLFS final rule (81 FR 41051), we
estimated that 95 percent of physician office laboratories and 55
percent of independent laboratories would not be required to report
applicable information under our low expenditure criterion. Although we
substantially reduced the number of laboratories qualifying as
applicable laboratories (that is, approximately 5 percent of physician
office laboratories and approximately 45 percent of independent
laboratories), we estimated that the percentage of Medicare utilization
would remain high. That is, approximately 5 percent of physician office
laboratories would account for approximately 92 percent of CLFS
spending on physician office laboratories and approximately 45 percent
of independent laboratories would account for approximately 99 percent
of CLFS spending on independent laboratories (81 FR 41051).
It is our understanding that physician offices are generally not
prepared to identify, collect, and report each unique private payor
rate from each private payor for each laboratory test code subject to
the data collection and reporting requirements, and the volume
associated with each unique private payor rate. As such, we believe
revising the low expenditure threshold so that more physician office
laboratories are required to report applicable information would likely
impose significant administrative burdens on physician offices. We also
believe that increasing participation from physician office
laboratories would have minimal overall impact on payment rates given
that the weighted median of private payor rates is dominated by the
laboratories with the largest test volume. We note that our
participation simulations from the first data reporting period show
that increasing the volume of physician office laboratories reporting
applicable information has minimal overall impact on the weighted
median of private payor rates. For more information on our
participation simulations, please visit the CLFS website at https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/ClinicalLabFeeSched/Downloads/CY2018-CLFS-Payment-System-Summary-Data.pdf.
We continue to believe the current low expenditure threshold
strikes an appropriate balance between collecting enough private payor
rate data to accurately represent the weighted median of private payor
rates while limiting the administrative burden on small laboratories.
In addition, as discussed previously in this section, we are proposing
to exclude MA plan revenues under Part C from total Medicare revenues
in the definition of applicable laboratory, and if we finalize that
proposal, we expect more laboratories of all types, including physician
office laboratories, may meet the majority of Medicare revenues
threshold.
However, we recognize from stakeholders that some physician office
laboratories and small independent laboratories that are not applicable
laboratories because they do not meet the current low expenditure
threshold may still want to report applicable information despite the
administrative burden associated with qualifying as an applicable
laboratory. Therefore, we are seeking public comments on revising the
low expenditure threshold to increase the level of participation among
physician office laboratories and small independent laboratories. One
approach could be for us to decrease the low expenditure threshold by
50 percent, from $12,500 to $6,250, in CLFS revenues during a data
collection period. Under such approach, a laboratory would need to
receive at least $6,250 in CLFS revenues in a data collection period.
If we were to adopt such an approach, we would need to revise paragraph
(4) of the definition of applicable laboratory at Sec. 414.502 to
replace $12,500 with $6,250. We are seeking public comments on this
approach.
We are particularly interested in comments from the physician
community and small independent laboratories as to the administrative
burden associated with such a revision to the low expenditure
threshold. Specifically, we are requesting comments on the following
issues: (1) Whether physician offices and small independent
laboratories currently have adequate staff levels to meet the data
collection and data reporting requirements; (2) whether data systems
are currently in place to identify, collect, and report each unique
private payor rate from each private payor for each CLFS test code and
the volume of tests associated with each unique private payor rate; (3)
if physician offices and small independent laboratories are generally
not prepared to conduct the data collection and data reporting
requirements, what is the anticipated timeframe needed for physician
office and small independent laboratories to be able to meet the data
collection and data reporting requirements; and (4) any other
administrative concerns that decreasing the low expenditure threshold
may impose on offices and small independent laboratories.
b. Increasing the Low Expenditure Threshold
We recognize that many small laboratories may not want the
additional administrative burden of data collection and reporting and,
because their test volume is relatively low, their data is unlikely to
have a meaningful impact on the weighted median of private payor rates
for CDLTs under the CLFS. Mindful of stakeholder feedback from smaller
laboratories that prefer to not be applicable laboratories because of
the burden of collecting and reporting applicable information, we could
increase the low expenditure threshold in the definition of applicable
laboratory by 50 percent, from $12,500 to $18,750, in CLFS revenues
during a data collection period. Because physician office laboratories
would be less likely to meet a higher threshold, such approach would
decrease the number of physician office laboratories and small
independent laboratories required to collect and report applicable
information. We expect decreasing the number of physician office
laboratories and small independent laboratories reporting applicable
information will have minimal impact on determining CLFS rates because
we believe the largest laboratories with the highest test volumes will
continue to dominate the weighted median of private payor rates.
If we were to adopt such an approach, we would need to revise
paragraph (4) of the definition of applicable laboratory at Sec.
414.502 to replace $12,500 with $18,750. We are seeking public comments
on this approach. We are particularly interested in comments from the
physician community and small independent laboratories on the
administrative burden and relief of increasing the low expenditure
[[Page 35862]]
threshold. We believe that feedback on the topics discussed in this
section will help inform us regarding potential refinements to the low
expenditure threshold. We welcome comments on these topics from the
public including, physicians, laboratories, hospitals, and other
interested stakeholders. We are particularly interested in receiving
comments from the physician community and small independent
laboratories as to the administrative burden and relief associated with
revisions to the low expenditure threshold. Depending on the comments
we receive, it is possible we would consider approaches described in
this section.
B. Proposed Changes to the Regulations Associated With the Ambulance
Fee Schedule
1. Overview of Ambulance Services
a. Ambulance Services
Under the ambulance fee schedule, the Medicare program pays for
ambulance transportation services for Medicare beneficiaries under
Medicare Part B when other means of transportation are contraindicated
by the beneficiary's medical condition and all other coverage
requirements are met. Ambulance services are classified into different
levels of ground (including water) and air ambulance services based on
the medically necessary treatment provided during transport.
These services include the following levels of service:
For Ground--
++ Basic Life Support (BLS) (emergency and non-emergency)
++ Advanced Life Support, Level 1 (ALS1) (emergency and non-emergency)
++ Advanced Life Support, Level 2 (ALS2)
++ Paramedic ALS Intercept (PI)
++ Specialty Care Transport (SCT)
For Air--
++ Fixed Wing Air Ambulance (FW)
++ Rotary Wing Air Ambulance (RW)
b. Statutory Coverage of Ambulance Services
Under sections 1834(l) and 1861(s)(7) of the Act, Medicare Part B
(Supplemental Medical Insurance) covers and pays for ambulance
services, to the extent prescribed in regulations, when the use of
other methods of transportation would be contraindicated by the
beneficiary's medical condition.
The House Ways and Means Committee and Senate Finance Committee
Reports that accompanied the 1965 Social Security Amendments suggest
that the Congress intended that--
The ambulance benefit cover transportation services only
if other means of transportation are contraindicated by the
beneficiary's medical condition; and
Only ambulance service to local facilities be covered
unless necessary services are not available locally, in which case,
transportation to the nearest facility furnishing those services is
covered (H.R. Rep. No. 213, 89th Cong., 1st Sess. 37 and Rep. No. 404,
89th Cong., 1st Sess. Pt 1, 43 (1965)).
The reports indicate that transportation may also be provided from
one hospital to another, to the beneficiary's home, or to an extended
care facility.
c. Medicare Regulations for Ambulance Services
The regulations relating to ambulance services are set forth at 42
CFR part 410, subpart B, and 42 CFR part 414, subpart H. Section
410.10(i) lists ambulance services as one of the covered medical and
other health services under Medicare Part B. Therefore, ambulance
services are subject to basic conditions and limitations set forth at
Sec. 410.12 and to specific conditions and limitations included at
Sec. Sec. 410.40 and 410.41. Part 414, subpart H, describes how
payment is made for ambulance services covered by Medicare Part B.
2. Ambulance Extender Provisions
a. Amendment to Section 1834(l)(13) of the Act
Section 146(a) of the Medicare Improvements for Patients and
Providers Act of 2008 (MIPPA), (Pub. L. 110-275) amended section
1834(l)(13)(A) of the Act to specify that, effective for ground
ambulance services furnished on or after July 1, 2008, and before
January 1, 2010, the ambulance fee schedule amounts for ground
ambulance services shall be increased as follows:
For covered ground ambulance transports that originate in
a rural area or in a rural census tract of a metropolitan statistical
area, the fee schedule amounts shall be increased by 3 percent.
For covered ground ambulance transports that do not
originate in a rural area or in a rural census tract of a metropolitan
statistical area, the fee schedule amounts shall be increased by 2
percent.
The payment add-ons under section 1834(l)(13)(A) of the Act have
been extended several times. Most recently, section 50203(a)(1) of the
Bipartisan Budget Act of 2018 (BBA) (Pub. L. 115-123, enacted on
February 9, 2018) amended section 1834(l)(13)(A) of the Act to extend
the payment add-ons through December 31, 2022. Thus, these payment add-
ons apply to covered ground ambulance transports furnished before
January 1, 2023. We are proposing to revise Sec. 414.610(c)(1)(ii) to
conform the regulations to this statutory requirement. (For further
information regarding the implementation of this provision for claims
processing, please see CR 10531. For a discussion of past legislation
extending section 1834(l)(13) of the Act, please see the CY 2014 PFS
final rule with comment period (78 FR 74438 through 74439), the CY 2015
PFS final rule with comment period (79 FR 67743) and the CY 2016 PFS
final rule with comment period (80 FR 71071 through 71072)).
This statutory requirement is self-implementing. A plain reading of
the statute requires only a ministerial application of the mandated
rate increase, and does not require any substantive exercise of
discretion on the part of the Secretary.
b. Amendment to Section 1834(l)(12) of the Act
Section 414(c) of the Medicare Prescription Drug, Improvement and
Modernization Act of 2003 (Pub. L. 108-173, enacted on December 8,
2003) (MMA) added section 1834(l)(12) to the Act, which specified that,
in the case of ground ambulance services furnished on or after July 1,
2004, and before January 1, 2010, for which transportation originates
in a qualified rural area (as described in the statute), the Secretary
shall provide for a percent increase in the base rate of the fee
schedule for such transports. The statute requires this percent
increase to be based on the Secretary's estimate of the average cost
per trip for such services (not taking into account mileage) in the
lowest quartile of all rural county populations as compared to the
average cost per trip for such services (not taking into account
mileage) in the highest quartile of rural county populations. Using the
methodology specified in the July 1, 2004 interim final rule (69 FR
40288), we determined that this percent increase was equal to 22.6
percent. As required by the MMA, this payment increase was applied to
ground ambulance transports that originated in a ``qualified rural
area,'' that is, to transports that originated in a rural area included
in those areas comprising the lowest 25th percentile of all rural
populations arrayed by population density. For this purpose, rural
areas included Goldsmith areas (a type of
[[Page 35863]]
rural census tract). This rural bonus is sometimes referred to as the
``Super Rural Bonus'' and the qualified rural areas (also known as
``super rural'' areas) are identified during the claims adjudicative
process via the use of a data field included in the CMS-supplied ZIP
code file.
The Super Rural Bonus under section 1834(l)(12) of the Act has been
extended several times. Most recently, section 50203(a)(2) of the BBA
amended section 1834(l)(12)(A) of the Act to extend this rural bonus
through December 31, 2022. Therefore, we are continuing to apply the
22.6 percent rural bonus described in this section (in the same manner
as in previous years) to ground ambulance services with dates of
service before January 1, 2023 where transportation originates in a
qualified rural area. Accordingly, we are proposing to revise Sec.
414.610(c)(5)(ii) to conform the regulations to this statutory
requirement. (For further information regarding the implementation of
this provision for claims processing, please see CR 10531. For a
discussion of past legislation extending section 1834(l)(12) of the
Act, please see the CY 2014 PFS final rule with comment period (78 FR
74439 through 74440), CY 2015 PFS final rule with comment period (79 FR
67743 through 67744) and the CY 2016 PFS final rule with comment period
(80 FR 71072)).
This statutory provision is self-implementing. It requires an
extension of this rural bonus (which was previously established by the
Secretary) through December 31, 2022, and does not require any
substantive exercise of discretion on the part of the Secretary.
3. Amendment to Section 1834(l)(15) of the Act
Section 637 of the American Taxpayer Relief Act of 2012 (ATRA)
(Pub.L. 112-240), added section 1834(l)(15) of the Act to specify that
the fee schedule amount otherwise applicable under the preceding
provisions of section 1834(l) of the Act shall be reduced by 10 percent
for ambulance services furnished on or after October 1, 2013,
consisting of non-emergency basic life support (BLS) services involving
transport of an individual with end-stage renal disease for renal
dialysis services (as described in section 1881(b)(14)(B) of the Act)
furnished other than on an emergency basis by a provider of services or
a renal dialysis facility. In the CY 2014 PFS final rule with comment
period (78 FR 74440), we revised Sec. 414.610 by adding paragraph
(c)(8) to conform the regulations to this statutory requirement.
Section 53108 of the BBA amended section 1834(l)(15) of the Act to
increase the reduction from 10 percent to 23 percent effective for
ambulance services (as described in section 1834(l)(15) of the Act)
furnished on or after October 1, 2018. The 10 percent reduction applies
for ambulance services (as described in section 1834(l)(15) of the Act)
furnished during the period beginning on October 1, 2013 and ending on
September 30, 2018. Accordingly, we are proposing to revise Sec.
414.610(c)(8) to conform the regulations to this statutory requirement.
This statutory requirement is self-implementing. A plain reading of
the statute requires only a ministerial application of the mandated
rate decrease, and does not require any substantive exercise of
discretion on the part of the Secretary. Accordingly, for ambulance
services described in section 1834(l)(15) of the Act furnished during
the period beginning on October 1, 2013 and ending on September 30,
2018, the fee schedule amount otherwise applicable (both base rate and
mileage) is reduced by 10 percent, and for ambulance services described
in section 1834(l)(15) of the Act furnished on or after October 1,
2018, the fee schedule amount otherwise applicable (both base rate and
mileage) is reduced by 23 percent. (For further information regarding
application of this mandated rate decrease, please see CR 10549.)
C. Rural Health Clinics (RHCs) and Federally Qualified Health Centers
(FQHCs)
1. Payment for Care Management Services
In the CY 2018 PFS final rule, we revised the payment methodology
for Chronic Care Management (CCM) services furnished by RHCs and FQHCs,
and established requirements and payment for general Behavioral Health
Integration (BHI) and psychiatric Collaborative Care Management (CoCM)
services furnished in RHCs and FQHCs, beginning on January 1, 2018.
For CCM services furnished by RHCs or FQHCs between January 1,
2016, and December 31, 2017, payment is at the PFS national average
payment rate for CPT 99490. For CCM, general BHI, and psychiatric CoCM
services furnished by RHCs or FQHCs on or after January 1, 2018, we
established 2 new HCPCS codes. The first HCPCS code, G0511, is a
General Care Management code for use by RHCs or FQHCs when at least 20
minutes of qualified CCM or general BHI services are furnished to a
patient in a calendar month. The second HCPCS code, G0512, is a
psychiatric CoCM code for use by RHCs or FQHCs when at least 70 minutes
of initial psychiatric CoCM services or 60 minutes of subsequent
psychiatric CoCM services are furnished to a patient in a calendar
month.
The payment amount for HCPCS code G0511 is set at the average of
the 3 national non-facility PFS payment rates for the CCM and general
BHI codes and updated annually based on the PFS amounts. The 3 codes
are CPT 99490 (20 minutes or more of CCM services), CPT 99487 (60
minutes or more of complex CCM services), and CPT 99484 (20 minutes or
more of BHI services).
The payment amount for HCPCS code G0512 is set at the average of
the 2 national non-facility PFS payment rates for CoCM codes and
updated annually based on the PFS amounts. The 2 codes are CPT 99492
(70 minutes or more of initial psychiatric CoCM services) and CPT 99493
(60 minutes or more of subsequent psychiatric CoCM services).
For practitioners billing under the PFS, we are proposing for CY
2019 a new CPT code, 994X7, which would correspond to 30 minutes or
more of CCM furnished by a physician or other qualified health care
professional and is similar to CPT codes 99490 and 99487. For RHCs and
FQHCs, we are proposing to add CPT code 994X7 as a general care
management service and to include it in the calculation of HCPCS code
G0511. That is, we propose that starting on January 1, 2019, RHCs and
FQHC would be paid for G0511 based on the average of the national non-
facility PFS payment rates for CPT codes 99490, 99487, 99484, and
994X7.
We propose to revise Sec. 405.2464 to reflect the current payment
methodology that was finalized in the CY 2018 PFS and incorporate the
addition of new CPT codes to HCPCS G0511.
2. Communication Technology-Based Services and Remote Evaluations
RHC and FQHC visits are face-to-face (in-person) encounters between
a patient and an RHC or FQHC practitioner during which time one or more
RHC or FQHC qualifying services are furnished. RHC and FQHC
practitioners are physicians, nurse practitioners, physician
assistants, certified nurse midwives, clinical psychologists, and
clinical social workers, and under certain conditions, a registered
nurse or licensed practical nurse furnishing care to a homebound RHC or
FQHC patient. A Transitional Care Management service can also be an RHC
or FQHC visit. A Diabetes Self-Management Training (DSMT) service or a
Medical Nutrition Therapy (MNT)
[[Page 35864]]
service furnished by a certified DSMT or MNT provider may also be an
FQHC visit.
RHCs are paid an all-inclusive rate (AIR) for medically-necessary,
face-to-face visits with an RHC practitioner. The rate is subject to a
payment limit, except for those RHCs that have an exception to the
payment limit for being ``provider-based'' (see Sec. 413.65). FQHCs
are paid the lesser of their charges or the FQHC Prospective Payment
System (PPS) rate for medically-necessary, face-to-face visits with an
FQHC practitioner. Only medically-necessary medical, mental health, or
qualified preventive health services that require the skill level of an
RHC or FQHC practitioner can be RHC or FQHC billable visits.
The RHC and FQHC payment rates reflect the cost of all services and
supplies that an RHC or FQHC furnishes to a patient in a single day,
and are not adjusted for the complexity of the patient health care
needs, the length of the visit, or the number or type of practitioners
involved in the patient's care.
Services furnished by auxiliary personnel (such as nurses, medical
assistants, or other clinical personnel acting under the supervision of
the RHC or FQHC practitioner) are considered incident to the visit and
are included in the per-visit payment. This may include services
furnished prior to or after the billable visit that occur within a
medically appropriate time period, which is usually 30 days or less.
RHCS and FQHCs are also paid for care management services,
including chronic care management services, general behavioral health
integration services, and psychiatric Collaborative Care Model
services. These are typically non-face-to-face services that do not
require the skill level of an RHC or FQHC practitioner and are not
included in the RHC or FQHC payment methodologies.
For practitioners billing under the PFS, we are proposing for CY
2019 separate payment for certain communication technology-based
services. This includes what is referred to as ``Brief Communication
Technology-based Service'' for a ``virtual check-in'' and separate
payment for remote evaluation of recorded video and/or images. The
``virtual check-in'' visit would be billable when a physician or non-
physician practitioner has a brief (5 to 10 minutes), non-face-to-face
check in with a patient via communication technology to assess whether
the patient's condition necessitates an office visit. This service
could be billed only in situations where the medical discussion was for
a condition not related to an E/M service provided within the previous
7 days, and does not lead to an E/M service or procedure within the
next 24 hours or at the soonest available appointment. We are also
proposing payment for practitioners billing under the PFS for remote
evaluation services. This payment would be for the remote evaluation of
patient-transmitted information conducted via pre-recorded ``store and
forward'' video or image technology, including interpretation with
verbal 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. Both of these services would be
priced under the PFS at a rate that reflects the resource costs of
these non-face-to-face services relative to other PFS services,
including face-to-face and in-person visits.
The RHC and FQHC payment models are distinct from the PFS model in
that the payment is for a comprehensive set of services and supplies
associated with an RHC or FQHC visit. A direct comparison between the
payment for a specific service furnished in an RHC or FQHC and the same
service furnished in a physician's office is not possible, because the
payment for RHCs and FQHCs is a per diem payment that includes the cost
for all services and supplies rendered during an encounter, and payment
for a service furnished in a physician's office and billed under the
PFS is only for that service.
We recognize that there are occasions when it may be beneficial to
both the patient and the RHC or FQHC to utilize communications-based
technology to determine the course of action for a health issue.
Currently under the RHC and FQHC payment systems, if the communication
results in a face-to-face billable visit with an RHC or FQHC
practitioner, the cost of the prior communication would be included in
the RHC AIR or the FQHC PPS. However, if as a result of the
communication it is determined that a visit is not necessary, there
would not be a billable visit and there would be no payment.
RHCs and FQHCs furnish services in rural and urban areas that have
been determined to be medically underserved areas or health
professional shortage areas. They are an integral component of the
Nation's health care safety net, and we want to assure that Medicare
patients who are served by RHCs and FQHCs are able to communicate with
their RHC or FQHC practitioner in a manner that enhances access to
care, consistent with evolving medical care. Particularly in rural
areas where transportation is limited and distances may be far, we
believe the use of communication technology may help some patients to
determine if they need to schedule a visit at the RHC or FQHC. If it is
determined that a visit is not necessary, the RHC or FQHC practitioner
would be available for other patients who need their care.
When communication-based technology services are furnished in
association with an RHC or FQHC billable visit, the costs of these
services are included in the RHC AIR or the FQHC PPS and are not
separately billable. However, if there is no RHC or FQHC billable
visit, these costs are not paid as part of an RHC AIR or FQHC PPS
payment. We are therefore proposing that, effective January 1, 2019,
RHCs and FQHCs receive an additional payment for the costs of
communication technology-based services or remote evaluation services
that are not already captured in the RHC AIR or the FQHC PPS payment
when the requirements for these services are met.
We propose that RHCs and FQHCs receive payment for communication
technology-based services or remote evaluation services when at least 5
minutes of communications-based technology or remote evaluation
services are furnished by an RHC or FQHC practitioner to a patient that
has been seen in the RHC or FQHC within the previous year. These
services may only be billed when the medical discussion or remote
evaluation is for a condition not related to an RHC or FQHC service
provided within the previous 7 days, and does not lead to an RHC or
FQHC service within the next 24 hours or at the soonest available
appointment, since in those situation the services are already paid as
part of the RHC or FQHC per-visit payment.
We propose to create a new Virtual Communications G code for use by
RHCs and FQHCs only, with a payment rate set at the average of the PFS
national non-facility payment rates for HCPCS code GVCI1 for
communication technology-based services, and HCPCS code GRAS1 for
remote evaluation services. RHCs and FQHCs would be able to bill the
Virtual Communications G-code either alone or with other payable
services. The payment rate for the Virtual Communications G-code would
be updated annually based on the PFS amounts.
We also propose to waive the RHC and FQHC face-to-face requirements
when these services are furnished to an
[[Page 35865]]
RHC or FQHC patient. Coinsurance would be applied to FQHC claims, and
coinsurance and deductibles would apply to RHC claims for these
services. Services that are currently being furnished and paid under
the RHC AIR or FQHC PPS payment methodology will not be affected by the
ability of the RHC or FQHC to receive payment for additional services
that are not included in the RHC AIR or FQHC PPS.
3. Other Options Considered
We considered other options for payment for these services. First,
we considered adding communication technology-based and remote
evaluation services as an RHC or FQHC stand-alone service. Under this
option, payment for RHCs would be at the AIR, and payment for FQHCs
would be the lesser of total charges or the PPS rate. We are not
proposing this payment option because these services do not meet the
requirements for an RHC or FQHC billable visit and payment at the RHC
AIR or FQHC PPS would result in a payment rate incongruent with
efficiencies inherent in the provision of the technology-based
services.
The second option we considered was to allow RHCs and FQHCs to bill
HCPCS codes GVCI1 or GRAS1 separately on an RHC or FQHC claim. We are
not proposing this payment option because we believe that a combined G
code is less burdensome and will allow expansion of these services
without adding additional codes on an RHC or FQHC claim.
We invite comments on this proposal. In particular, we are
interested in comments regarding the appropriateness of payment for
communication technology-based and remote evaluation services in the
absence of an RHC or FQHC visit, the burden associated with
documentation for billing these codes (RHC or FQHC practitioner's time,
medical records, etc.), and any potential impact on the per diem nature
of RHC and FQHC billing and payment structure as a result of payment
for these services. We are also seeking public comment on whether it
would be clinically appropriate to apply a frequency limitation on the
use of the new Virtual Communications G code by the same RHC or FQHC
with the same patient, and on what would be a reasonable frequency
limitation to ensure that this code is appropriately utilized.
4. Other Regulatory Updates
In addition to the regulatory change described in this section of
the rule, we propose the following for accuracy:
Removal of the extra section mark in the definition of
``Federally qualified health center (FQHC)'' in Sec. 405.2401.
Replacing the word ``his'' with ``his or her'' in the
definition of ``Secretary'' in Sec. 405.2401.
D. Appropriate Use Criteria for Advanced Diagnostic Imaging Services
Section 218(b) of the Protecting Access to Medicare Act (PAMA)
amended Title XVIII of the Act to add section 1834(q) of the Act
directing us to establish a program to promote the use of appropriate
use criteria (AUC) for advanced diagnostic imaging services. The CY
2016 PFS final rule with comment period addressed the initial component
of the new Medicare AUC program, specifying applicable AUC. In that
rule (80 FR 70886), we established an evidence-based process and
transparency requirements for the development of AUC, defined provider-
led entities (PLEs) and established the process by which PLEs may
become qualified to develop, modify or endorse AUC. The first list of
qualified PLEs was posted on the CMS website at the end of June 2016 at
which time their AUC libraries became specified applicable AUC for
purposes of section 1834(q)(2)(A) of the Act. The CY 2017 PFS final
rule addressed the second component of this program, specification of
qualified clinical decision support mechanisms (CDSMs). In the CY 2017
PFS final rule (81 FR 80170), we defined CDSM, identified the
requirements CDSMs must meet for qualification, including preliminary
qualification for mechanisms documenting how and when each requirement
is reasonably expected to be met, and established a process by which
CDSMs may become qualified. We also defined applicable payment systems
under this program, specified the first list of priority clinical
areas, and identified exceptions to the requirement that ordering
professionals consult specified applicable AUC when ordering applicable
imaging services. The first list of qualified CDSMs was posted on the
CMS website in July 2017.
The CY 2018 PFS final rule addressed the third component of this
program, the consultation and reporting requirements. In the CY 2018
PFS final rule (82 FR 53190), we established the start date of January
1, 2020 for the Medicare AUC program for advanced diagnostic imaging
services. It is for services ordered on and after this date that
ordering professionals must consult specified applicable AUC using a
qualified CDSM when ordering applicable imaging services, and
furnishing professionals must report AUC consultation information on
the Medicare claim. We further specified that the AUC program will
begin on January 1, 2020 with a year-long educational and operations
testing period during which time claims will not be denied for failure
to include proper AUC consultation information. We also established a
voluntary period from July 2018 through the end of 2019 during which
ordering professionals who are ready to participate in the AUC program
may consult specified applicable AUC through qualified CDSMs and
communicate the results to furnishing professionals, and furnishing
professionals who are ready to do so may report AUC consultation
information on the claim (https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM10481.pdf). Additionally, to incentivize early use of qualified CDSMs
to consult AUC, we established in the CY 2018 Updates to the Quality
Payment Program; and Quality Payment Program: Extreme and
Uncontrollable Circumstances Policy for the Transition Year final rule
with comment period and interim final rule (hereinafter ``CY 2018
Quality Payment Program final rule'') a high-weight improvement
activity for ordering professionals who consult specified AUC using a
qualified CDSM for the Merit-based Incentive Payment System (MIPS)
performance period that began January 1, 2018 (82 FR 54193).
This rule proposes additions to the definition of applicable
setting, clarification around who may perform the required AUC
consultation using a qualified CDSM under this program, clarification
that reporting is required across claim types and by both the
furnishing professional and furnishing facility, changes to the policy
for significant hardship exceptions for ordering professionals under
this program, mechanisms for claims-based reporting, and a solicitation
of feedback regarding the methodology to identify outlier ordering
professionals.
1. Background
AUC present information in a manner that links: A specific clinical
condition or presentation; one or more services; and an assessment of
the appropriateness of the service(s). Evidence-based AUC for imaging
can assist clinicians in selecting the imaging study that is most
likely to improve health outcomes for patients based on their
individual clinical presentation. For purposes of this program AUC is a
set or library of individual appropriate use criteria. Each individual
criterion is
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an evidence-based guideline for a particular clinical scenario based on
a patient's presenting symptoms or condition.
AUC need to be integrated as seamlessly as possible into the
clinical workflow. CDSMs are the electronic portals through which
clinicians access the AUC during the patient workup. They can be
standalone applications that require direct entry of patient
information, but may be more effective when they are integrated into
Electronic Health Records (EHRs). Ideally, practitioners would interact
directly with the CDSM through their primary user interface, thus
minimizing interruption to the clinical workflow.
2. Statutory Authority
Section 218(b) of the PAMA added a new section 1834(q) of the Act
entitled, ``Recognizing Appropriate Use Criteria for Certain Imaging
Services,'' which directs the Secretary to establish a new program to
promote the use of AUC. Section 1834(q)(4) of the Act requires ordering
professionals to consult with specified applicable AUC through a
qualified CDSM for applicable imaging services furnished in an
applicable setting and paid for under an applicable payment system; and
payment for such service may only be made if the claim for the service
includes information about the ordering professional's consultation of
specified applicable AUC through a qualified CDSM.
3. Discussion of Statutory Requirements
There are four major components of the AUC program under section
1834(q) of the Act, and each component has its own implementation date:
(1) Establishment of AUC by November 15, 2015 (section 1834(q)(2) of
the Act); (2) identification of mechanisms for consultation with AUC by
April 1, 2016 (section 1834(q)(3) of the Act); (3) AUC consultation by
ordering professionals, and reporting on AUC consultation by January 1,
2017 (section 1834(q)(4) of the Act); and (4) annual identification of
outlier ordering professionals for services furnished after January 1,
2017 (section 1834(q)(5) of the Act). We did not identify mechanisms
for consultation by April 1, 2016. Therefore, we did not require
ordering professionals to consult CDSMs or furnishing professionals to
report information on the consultation by the January 1, 2017 date.
a. Establishment of AUC
In the CY 2016 PFS final rule with comment period, we addressed the
first component of the Medicare AUC program under section 1834(q)(2) of
the Act--the requirements and process for establishment and
specification of applicable AUC, along with relevant aspects of the
definitions under section 1834(q)(1) of the Act. This included defining
the term PLE (provider-led entity) and finalizing requirements for the
rigorous, evidence-based process by which a PLE would develop AUC, upon
which qualification is based, as provided in section 1834(q)(2)(B) of
the Act and in the CY 2016 PFS final rule with comment period. Using
this process, once a PLE is qualified by CMS, the AUC that are
developed, modified or endorsed by the qualified PLE are considered to
be specified applicable AUC under section 1834(q)(2)(A) of the Act. We
defined PLE to include national professional medical societies, health
systems, hospitals, clinical practices and collaborations of such
entities such as the High Value Healthcare Collaborative or the
National Comprehensive Cancer Network. Qualified PLEs may collaborate
with third parties that they believe add value to their development of
AUC, provided such collaboration is transparent. We expect qualified
PLEs to have sufficient infrastructure, resources, and the relevant
experience to develop and maintain AUC according to the rigorous,
transparent, and evidence-based processes detailed in the CY 2016 PFS
final rule with comment period.
In the same rule we established a timeline and process under Sec.
414.94(c)(2) for PLEs to apply to become qualified. Consistent with
this timeline the first list of qualified PLEs was published at https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Appropriate-Use-Criteria-Program/PLE.html in June 2016 (OMB
Control Number 0938-1288).
b. Mechanism for AUC Consultation
In the CY 2017 PFS final rule, we addressed the second major
component of the Medicare AUC program--the specification of qualified
CDSMs for use by ordering professionals for consultation with specified
applicable AUC under section 1834(q)(3) of the Act, along with relevant
aspects of the definitions under section 1834(q)(1) of the Act. This
included defining the term CDSM and finalizing functionality
requirements of mechanisms, upon which qualification is based, as
provided in section 1834(q)(3)(B) of the Act and in the CY 2017 PFS
final rule. CDSMs may receive full qualification or preliminary
qualification if most, but not all, of the requirements are met at the
time of application. The preliminary qualification period began June
30, 2017 and ends when the AUC consulting and reporting requirements
become effective on January 1, 2020. The preliminarily qualified CDSMs
must meet all requirements by that date. We defined CDSM as an
interactive, electronic tool for use by clinicians that communicates
AUC information to the user and assists them in making the most
appropriate treatment decision for a patient's specific clinical
condition. Tools may be modules within or available through certified
EHR technology (as defined in section 1848(o)(4) of the Act) or private
sector mechanisms independent from certified EHR technology or a
mechanism established by the Secretary.
In the CY 2017 PFS final rule, we established a timeline and
process in Sec. 414.94(g)(2) for CDSM developers to apply to have
their CDSMs qualified. Consistent with this timeline, the first list of
qualified CDSMs was published at https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Appropriate-Use-Criteria-Program/CDSM.html in July 2017 (OMB Control Number 0938-1315).
c. AUC Consultation and Reporting
In the CY 2018 PFS final rule, we addressed the third major
component of the Medicare AUC program--consultation with applicable AUC
by the ordering professional and reporting of such consultations under
section 1834(q)(4) of the Act. We established a January 1, 2020
effective date for the AUC consultation and reporting requirements for
this program. We also established a voluntary period during which early
adopters can begin reporting limited consultation information on
Medicare claims from July 2018 through December 2019. During the
voluntary period there is no requirement for ordering professionals to
consult AUC or furnishing professionals to report information related
to the consultation. On January 1, 2020, the program will begin with an
educational and operations testing period and during this time we will
continue to pay claims whether or not they correctly include AUC
consultation information. Ordering professionals must consult specified
applicable AUC through qualified CDSMs for applicable imaging services
furnished in an applicable setting, paid for under an applicable
payment system and ordered on or after January 1, 2020; and furnishing
professionals must report the AUC consultation information on the
Medicare claim for these services ordered on or after January 1, 2020.
Consistent with section 1834(q)(4)(B) of the Act, we also
established that furnishing professionals must report the
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following information on Medicare claims for advanced diagnostic
imaging services as specified in section 1834(q)(1)(C) of the Act and
defined in Sec. 414.94(b), furnished in an applicable setting as
defined in section 1834(q)(1)(D) of the Act, paid for under an
applicable payment system as defined in section 1834(q)(4)(D) of the
Act, and ordered on or after January 1, 2020: (1) The qualified CDSM
consulted by the ordering professional; (2) whether the service ordered
would or would not adhere to specified applicable AUC, or whether the
specified applicable AUC consulted was not applicable to the service
ordered; and (3) the NPI of the ordering professional (if different
from the furnishing professional). Proposed clarifying revisions to the
reporting requirement are discussed later in this preamble.
Section 1834(q)(4)(C) of the Act provides for exceptions to the AUC
consultation and reporting requirements in the case of: A service
ordered for an individual with an emergency medical condition, a
service ordered for an inpatient and for which payment is made under
Medicare Part A, and a service ordered by an ordering professional for
whom the Secretary determines that consultation with applicable AUC
would result in a significant hardship. In the CY 2017 PFS final rule,
we adopted a regulation at Sec. 414.94(h)(1)(i) to specify the
circumstances under which AUC consultation and reporting requirements
are not applicable. These include applicable imaging services ordered:
(1) For an individual with an emergency medical condition (as defined
in section 1867(e)(1) of the Act); (2) for an inpatient and for which
payment is made under Medicare Part A; and (3) by an ordering
professional who is granted a significant hardship exception to the
Medicare EHR Incentive Program payment adjustment for that year under
42 CFR 495.102(d)(4), except for those granted under Sec.
495.102(d)(4)(iv)(C). We are proposing changes to the conditions for
significant hardship exceptions, and our proposals are discussed later
in this preamble. We remind readers that consistent with section
1834(q)(4)(A) of the Act, ordering professionals must consult AUC for
every applicable imaging service furnished in an applicable setting and
paid under an applicable payment system unless a statutory exception
applies.
Section 1834(q)(4)(D) of the Act specifies the applicable payment
systems for which AUC consultation and reporting requirements apply
and, in the CY 2017 PFS final rule, consistent with the statute, we
defined applicable payment system in our regulation at Sec. 414.94(b)
as: (1) The PFS established under section 1848(b) of the Act; (2) the
prospective payment system for hospital outpatient department services
under section 1833(t) of the Act; and (3) the ambulatory surgical
center payment system under section 1833(i) of the Act.
Section 1834(q)(1)(D) of the Act specifies the applicable settings
in which AUC consultation and reporting requirements apply: A
physician's office, a hospital outpatient department (including an
emergency department), an ambulatory surgical center, and any other
``provider-led outpatient setting determined appropriate by the
Secretary.'' In the CY 2017 PFS final rule, we added this definition to
our regulation at Sec. 414.94(b). Proposed additional applicable
settings are discussed later in this preamble.
d. Identification of Outliers
The fourth component of the Medicare AUC program is specified in
section 1834(q)(5) of the Act, Identification of Outlier Ordering
Professionals. The identification of outlier ordering professionals
under this paragraph facilitates a prior authorization requirement that
applies for outlier professionals beginning January 1, 2020, as
specified under section 1834(q)(6) of the Act. Because we established a
start date of January 1, 2020 for AUC consultation and reporting
requirements, we will not have identified any outlier ordering
professionals by that date. As such, implementation of the prior
authorization component is delayed. However, we did finalize in the CY
2017 PFS final rule the first list of priority clinical areas to guide
identification of outlier ordering professionals as follows:
Coronary artery disease (suspected or diagnosed).
Suspected pulmonary embolism.
Headache (traumatic and non-traumatic).
Hip pain.
Low back pain.
Shoulder pain (to include suspected rotator cuff injury).
Cancer of the lung (primary or metastatic, suspected or
diagnosed).
Cervical or neck pain.
We are not including proposals to expand or modify the list of
priority clinical areas in this proposed rule.
4. Proposals for Continuing Implementation
We propose to amend Sec. 414.94 of our regulations, ``Appropriate
Use Criteria for Certain Imaging Services,'' to reflect the following
proposals.
a. Expanding Applicable Settings
Section 1834(q)(1)(D) of the Act specifies that the AUC
consultation and reporting requirements apply only in an applicable
setting, which means a physician's office, a hospital outpatient
department (including an emergency department), an ambulatory surgical
center, and any other provider-led outpatient setting determined
appropriate by the Secretary. In the CY 2017 PFS final rule, we
codified this definition in Sec. 414.94(b). We are proposing to revise
the definition of applicable setting to add an independent diagnostic
testing facility (IDTF).
We believe the addition of IDTFs to the definition of applicable
setting will ensure that the AUC program is in place across outpatient
settings in which outpatient advanced diagnostic imaging services are
furnished. IDTFs furnish services for a large number of Medicare
beneficiaries; nearly $1 billion in claims for 2.4 million
beneficiaries in 2010 (OEI-05-09-00560). An IDTF is independent of a
hospital or physician's office and diagnostic tests furnished by an
IDTF are performed by licensed, certified non-physician personnel under
appropriate physician supervision (Sec. 410.33). Like other applicable
settings, IDTFs must meet the requirements specified in Sec. 410.33 of
our regulations to be enrolled to furnish and bill for advanced
diagnostic imaging and other IDTF services. Services that may be
provided by an IDTF include, but are not limited to, magnetic resonance
imaging (MRI), ultrasound, x-rays, and sleep studies. An IDTF may be a
fixed location, a mobile entity, or an individual non-physician
practitioner, and diagnostic procedures performed by an IDTF are paid
under the PFS. IDTF services must be furnished under the appropriate
level of physician supervision as specified in Sec. 410.33(b); and all
procedures furnished by the IDTF must be ordered in writing by the
patient's treating physician or non-physician practitioner. As such, we
believe the IDTF setting is a provider-led outpatient setting
appropriate for addition to the list of applicable settings under
section 1834(q)(1)(D), and we propose to add IDTF to our definition of
applicable setting under Sec. 414.94(b) of the regulations.
We note that under the PFS, payment for many diagnostic tests
including the advanced diagnostic imaging services to which the AUC
program applies can be made either ``globally'' when the entire
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service is furnished and billed by the same entity; or payment can be
made separately for the technical component (TC) of the service and the
professional component (PC) when those portions of the service are
furnished and billed by different entities. In general, the TC for an
advanced diagnostic imaging service is the portion of the test during
which the patient is present and the image is captured. The PC is the
portion of the test that involves a physician's interpretation and
report on the captured image. For example, when a CT scan is ordered by
a patient's treating physician, the entire test (TC and PC) could be
furnished by a radiologist in their office and billed as a ``global''
service. Alternatively, the TC could be furnished and billed by an
IDTF, and the PC could be furnished and billed by a radiologist in
private practice. By adding IDTFs as an applicable setting, we believe
we would appropriately and consistently apply the AUC program across
the range of outpatient settings where applicable imaging services are
furnished.
We propose to revise the definition of applicable setting under
Sec. 414.94(b) to include an IDTF. We invite comments on this proposal
and on the possible inclusion of any other applicable setting. We
remind commenters that application of the AUC program is not only
limited to applicable settings, but also to services for which payment
is made under applicable payment systems (the physician fee schedule,
the OPPS, and the ASC payment system).
b. Consultations by Ordering Professionals
Section 1834(q)(1)(E) of the Act defines the term ``ordering
professional'' as a physician (as defined in section 1861(r)) or a
practitioner described in section 1842(b)(18)(C) who orders an
applicable imaging service. The AUC consultation requirement applies to
these ordering professionals. We are proposing that the consultation
with AUC through a qualified CDSM may be performed by clinical staff
working under the direction of the ordering professional, subject to
applicable State licensure and scope of practice law, when the
consultation is not performed personally by the ordering professional
whose NPI will be listed on the order for an advanced imaging service.
In response to the CY 2018 PFS proposed rule, we received several
public comments requesting clarification regarding who is required to
perform the consultation of AUC through a qualified CDSM. Commenters
not only sought clarification, but also provided recommendations for
requirements around this topic. Some commenters recommended that CMS
strictly interpret the statutory language and only allow the clinician
placing the order to perform the consultation and others recommended
that CMS allow others to perform the AUC consultation on behalf of the
clinician.
Section 1834(q)(4)(A)(i) of the Act requires an ordering
professional to consult with a qualified CDSM, and this was codified in
our regulations at Sec. 414.94(j). The statute does not explicitly
provide for consultations under the AUC program to be fulfilled by
other professionals, individuals or organizations on behalf of the
ordering professional; however, we continue to seek ways to minimize
the burden of this new Medicare program and understand that many
practices currently use clinical staff, working under the direction of
the ordering professional, to interact with the CDSM for AUC
consultation and subsequent ordering of advanced diagnostic imaging.
Therefore, we propose to modify paragraph Sec. 414.94(j) to specify
that additional individuals may perform the required AUC consultation.
When the AUC consultation is not performed personally by the
ordering professional, we propose the consultation may be performed by
auxiliary personnel incident to the ordering physician or non-physician
practitioner's professional service. We believe this approach is
appropriate under this program and still accomplishes the goal of
promoting the use of AUC. This proposed policy would allow the ordering
professional to exercise their discretion to delegate the performance
of this consultation. It is important to note that the ordering
professional is ultimately responsible for the consultation as their
NPI is reported by the furnishing professional on the claim for the
applicable imaging service; and that it is the ordering professional
who could be identified as an outlier ordering professional and become
subject to prior authorization based on their ordering pattern.
We propose to revise the AUC consultation requirement specified at
Sec. 414.94(j) to specify that the AUC consultation may be performed
by auxiliary personnel under the direction of the ordering professional
and incident to the ordering professional's services.
c. Reporting AUC Consultation Information
Section 1834(q)(4)(B) of the Act requires that payment for an
applicable imaging service furnished in an applicable setting and paid
for under an applicable payment system may only be made if the claim
for the service includes certain information about the AUC
consultation. As such, the statute requires that AUC consultation
information be included on any claim for an outpatient advanced
diagnostic imaging service, including those billed and paid under any
applicable payment system (the PFS, OPPS or ASC payment system). When
we initially codified the AUC consultation reporting requirement in
Sec. 414.94(k) through rulemaking in the CY 2018 PFS final rule, we
specified only that ``furnishing professionals'' must report AUC
consultation information on claims for applicable imaging services.
This led some stakeholders to believe that AUC consultation information
would be required only on practitioner claims. To better reflect the
statutory requirements of section 1834(q)(4)(B) of the Act, we are
proposing to revise our regulations to clarify that AUC consultation
information must be reported on all claims for an applicable imaging
service furnished in an applicable setting and paid for under an
applicable payment system. The revised regulation would more clearly
express the scope of advanced diagnostic imaging services that are
subject to the AUC program, that is, those furnished in an applicable
setting and paid under an applicable payment system.
The language codified in Sec. 414.94(k) uses the term furnishing
professional to describe who must report the information on the
Medicare claims. We recognize that section 1834(q)(1)(F) of the Act
specifies that a ``furnishing professional'' is a physician (as defined
in section 1861(r)) or a practitioner described in section
1842(b)(18)(C) who furnishes an applicable imaging service. However,
because section 1834(q)(4)(B) of the Act, as described above, clearly
includes all claims paid under applicable payment systems without
exclusion, we believe that the claims from both furnishing
professionals and facilities must include AUC consultation information.
In other words, we would expect this information to be included on the
practitioner's claim for the professional component of the applicable
advanced diagnostic imaging service and on the provider's or supplier's
claim for the facility portion or TC of the imaging service.
As such, we propose to revise Sec. 414.94(k) to clearly reflect
the scope of claims for which AUC consultation information must be
reported, and to clarify that the requirement to report AUC
consultation information is not limited to the furnishing professional.
[[Page 35869]]
d. Claims-Based Reporting
In the CY 2018 PFS proposed rule (82 FR 34094) we discussed using a
combination of G-codes and modifiers to report the AUC consultation
information on the Medicare claim. We received numerous public comments
objecting to this potential solution. In the 2018 PFS final rule, we
agreed with many of the commenters that additional approaches to
reporting AUC consultation information on Medicare claims should be
considered, and we learned from many commenters that reporting a unique
consultation identifier (UCI) would be a less burdensome and preferred
approach. The UCI would include all the information required under
section 1834(q)(4)(B) of the Act including an indication of AUC
adherence, non-adherence and not applicable responses. Commenters noted
that capturing a truly distinguishing UCI on the claim will allow for
direct mapping from a single AUC consultation to embedded information
within a CDSM. We indicated that we would work with stakeholders to
further explore the concept of using a UCI to satisfy the requirements
of section 1834(q)(4)(B) of the Act, which will be used for Medicare
claims processing and, ultimately, for the identification of outlier
ordering professionals, and consider developing a taxonomy for a UCI.
We had the opportunity to engage with some stakeholders over the
last 6 months and we understand that some commenters from the previous
rule continue to be in favor of a UCI, while some may have changed
their position upon further consideration.
We provide the following information to summarize alternatives we
considered. CMS had originally considered assigning a G-code for every
qualified CDSM with a code descriptor containing the name of the
qualified CDSM. The challenge to this approach arises when there is
more than one advanced imaging service on a single claim. CMS could
attribute a single G-code to all of the applicable imaging services for
the patient's clinical condition on the claim, which might be
appropriate if each AUC consultation for each service was through the
same CDSM. If a different CDSM was used for each service (for example,
when services on a single claim were ordered by more than one ordering
professional and each ordering professional used a different CDSM) then
multiple G-codes could be needed on the claim. Each G-code would appear
on the claim individually as its own line item. As a potential
solution, we considered the use of modifiers, which are appealing
because they would appear on the same line as the CPT code that
identifies the specific billed service. Therefore, information entered
onto a claim would arrive into the claims processing system paired with
the relevant AUC consultation information.
When reporting the required AUC consultation information based on
the response from a CDSM: (1) The imaging service would adhere to the
applicable AUC; (2) the imaging service would not adhere to such
criteria; or (3) such criteria were not applicable to the imaging
service ordered, three modifiers could be developed. These modifiers,
when placed on the same line with the CPT code for the advanced imaging
service would allow this information to be easily accessed in the
Medicare claims data and matched with the imaging service.
Stakeholders have made various suggestions for a taxonomy that
could be used to develop a UCI to report the required information.
Stakeholders have also considered where to place the UCI on the claim.
We understand the majority of solutions suggested by stakeholders
involving a UCI are claim-level solutions and would not allow CMS to
attribute the CDSM used or the AUC adherence status (adherent or not
adherent, or not applicable) to a specific imaging service. As such,
the approach of using a UCI would not identify whether an AUC
consultation was performed for each applicable imaging service reported
on a claim form, or be useful for purposes of identifying outlier
ordering professionals in accordance with section 1834(q)(5) of the
Act.
We have received ideas from stakeholders that are both for and
against the two approaches we have identified; and we appreciate the
stakeholders that have provided additional information or engaged us in
this discussion. Internally, we have explored the possibility of using
and feasibility of developing a UCI, and concluded that, although we
initiated this approach during the CY 2018 PFS final rule, it is not
feasible to create a uniform UCI taxonomy, determine a location of the
UCI on the claims forms, obtain the support and permission by national
bodies to use claim fields for this purpose, and solve the underlying
issue that the UCI seems limited to claim-level reporting. Using coding
structures that are already in place (such as G-codes and modifiers)
would allow CMS to establish reporting requirements prior to the start
of the program (January 1, 2020).
Since we did not finalize a proposal in the CY 2018 PFS final rule,
we propose in this rule to use established coding methods, to include
G-codes and modifiers, to report the required AUC information on
Medicare claims. This will allow the program to be implemented by
January 1, 2020. We will consider future opportunities to use a UCI and
look forward to continued engagement with and feedback from
stakeholders.
e. Significant Hardship Exception
We are proposing to revise Sec. 414.94(i)(3) of our regulations to
adjust the significant hardship exception requirements under the AUC
program. We are proposing criteria specific to the AUC program and
independent of other programs. An ordering professional experiencing
any of the following when ordering an advanced diagnostic imaging
service would not be required to consult AUC using a qualified CDSM,
and the claim for the applicable imaging service would not be required
to include AUC consultation information. The proposed criteria include:
Insufficient internet access;
EHR or CDSM vendor issues; or
Extreme and uncontrollable circumstances.
Insufficient internet access is specific to the location where an
advanced diagnostic imaging service is ordered by the ordering
professional. EHR or CDSM vendor issues may include situations where
ordering professionals experience temporary technical problems,
installation or upgrades that temporarily impede access to the CDSM,
vendors cease operations, or CMS de-qualifies a CDSM. CMS expects these
situations to generally be irregular and unusual. Extreme and
uncontrollable circumstances include disasters, natural or man-made,
that have a significant negative impact on healthcare operations, area
infrastructure or communication systems. These could include areas
where events occur that have been designated a Federal Emergency
Management Agency (FEMA) major disaster or a public health emergency
declared by the Secretary. Based on 2016 data from the Medicare EHR
Incentive Program and the 2019 payment year MIPS eligibility and
special status file, we estimate that 6,699 eligible clinicians could
submit such a request due to extreme and uncontrollable circumstances
or as a result of a decertification of an EHR, which represents less
than 1-percent of available ordering professionals.
In the CY 2017 PFS final rule, for purposes of the AUC program
significant hardship exceptions, we
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provided that those who received significant hardship exceptions in the
following categories from Sec. 495.102(d)(4) would also qualify for
significant hardship exceptions for the AUC program:
Insufficient Internet Connectivity (as specified in Sec.
495.102(d)(4)(i)).
Practicing for less than 2 years (as specified in Sec.
495.102(d)(4)(ii)).
Extreme and Uncontrollable Circumstances (as specified in
Sec. 495.102(d)(4)(iii)).
Lack of Control over the Availability of CEHRT (as
specified in Sec. 495.102(d)(4)(iv)(A)).
Lack of Face-to-Face Patient Interaction (as specified in
Sec. 495.102(d)(4)(iv)(B)).
In the CY 2018 PFS proposed rule, we proposed to amend the AUC
significant hardship exception regulation to specify that ordering
professionals who are granted reweighting of the Advancing Care
Information (ACI) performance category to zero percent of the final
score for the year under MIPS per Sec. 414.1380(c)(2) due to
circumstances that include the criteria listed in Sec.
495.102(d)(4)(i), (d)(4)(iii), and (d)(4)(iv)(A) and (B) (as outlined
in the bulleted list above) would be excepted from the AUC consultation
requirement during the same year that the re-weighting applies for
purposes of the MIPS payment adjustment. This proposal removed Sec.
495.102(d)(4)(ii), practicing for less than 2 years, as a criterion
since these clinicians are not MIPS eligible clinicians and thus would
never meet the criteria for reweighting of their MIPS ACI performance
category for the year.
In response to public comments, we did not finalize the proposed
changes to the significant hardship exceptions in the CY 2018 PFS final
rule and instead decided further evaluation was needed before moving
forward with any modifications. As we have continued to evaluate both
policy options and operational considerations for the AUC significant
hardship exception, we have concluded that the most appropriate
approach, which we consider to be more straightforward and less
burdensome than the current approach, involves establishing significant
hardship criteria and a process that is independent from other Medicare
programs. Our original intention was to design the AUC significant
hardship exception process in alignment with the process for the
Medicare EHR Incentive Program for eligible professionals, and then for
the MIPS ACI (now Promoting Interoperability) performance category.
Under section 1848(a)(7)(A) of the Act, the downward payment adjustment
for eligible professionals under the Medicare EHR Incentive Program
will end in 2018, and we are unable to continue making reference to a
regulation relating to a program that is no longer in effect. We also
note as we have in the past that the AUC program is a real-time program
with a need for real-time significant hardship exceptions. This is in
contrast to the way significant hardship exceptions are handled under
MIPS where the hardship might impact some or all of a performance
period, or might impact reporting, both of which occur well before the
MIPS payment adjustment is applied in a subsequent year. We recognize
that when a significant hardship arises, an application process to
qualify for an exception becomes a time consuming hurdle for health
care providers to navigate, and we believe that it is important to
minimize the burden involved in seeking significant hardship
exceptions. As such, we are proposing that ordering professionals would
self-attest if they are experiencing a significant hardship at the time
of placing an advanced diagnostic imaging order and such attestation be
supported with documentation of significant hardship. Ordering
professionals attesting to a significant hardship would communicate
that information, along with the AUC consultation information, to the
furnishing professional with the order and it would be reflected on the
furnishing professional's and furnishing facility's claim by appending
a HCPCS modifier. The modifier would indicate that the ordering
professional has self-attested to experiencing a significant hardship
and communicated this to the furnishing professional with the order.
Claims for advanced diagnostic imaging services that include a
significant hardship exception modifier would not be required to
include AUC consultation information.
In addition to the proposals above, we invite the public to comment
on any additional circumstances that would cause the act of consulting
AUC to be particularly difficult or challenging for the ordering
professional, and for which it may be appropriate for an ordering
professional to be granted a significant hardship exception under the
AUC program. While we understand the desire by some for significant
hardship categories unrelated to difficulty in consulting AUC through a
CDSM, we remind readers that circumstances that are not specific to AUC
consultation, such as the ordering professional being in clinical
practice for a short period of time or having limited numbers of
Medicare patients, would not impede clinicians from consulting AUC
through a CDSM as required to meet the requirements of this program.
f. Identification of Outliers
As previously mentioned, the fourth component of the AUC program
specified in section 1834(q)(5) of the Act, is the identification of
outlier ordering professionals. In our efforts to start a dialogue with
stakeholders, we would like to invite the public to submit their ideas
on a possible methodology for the identification of outlier ordering
professionals who would eventually be subject to a prior authorization
process when ordering advanced diagnostic imaging services.
Specifically, we are soliciting comments on the data elements and
thresholds that CMS should consider when identifying outliers. We also
intend to perform and use analysis to assist us in developing the
outlier methodology for the AUC program. Our existing prior
authorization programs generally do not specifically focus on outliers.
We are interested in hearing ideas from the public on how outliers
could be determined for the AUC program. Because we would be concerned
about data integrity and reliability, we do not intend to include data
from the educational and operations testing period in CY 2020 in the
analysis used to develop our outlier methodology. Since we intend to
evaluate claims data to inform our methodology we expect to address
outlier identification and prior authorization more fully in CY 2022 or
2023 rulemaking. As noted above, we expect to solicit public comment to
inform our methodology through rulemaking before finalizing our
approach.
We note that we may not provide comprehensive comment summaries and
responses to comments submitted in response to this solicitation.
Rather, we will actively consider all input as we develop the
methodology for the identification of outliers.
5. Summary
Section 1834(q) of the Act includes rapid timelines for
establishing a Medicare AUC program for advanced diagnostic imaging
services. The impact of this program is extensive as it will apply to
every physician or other practitioner who orders or furnishes advanced
diagnostic imaging services (for example, MRI, computed tomography (CT)
or positron emission tomography (PET)). This crosses almost every
medical specialty and could have a particular impact on primary care
[[Page 35871]]
physicians since their scope of practice can be quite broad.
We continue to believe the best implementation approach is one that
is diligent, maximizes the opportunity for public comment and
stakeholder engagement, and allows for adequate advance notice to
physicians and practitioners, beneficiaries, AUC developers, and CDSM
developers. It is for these reasons we propose to continue a stepwise
approach, adopted through notice and comment rulemaking.
In summary, we are proposing policies to modify existing
requirements and criteria and to provide further clarification on
implementation of the AUC program. We include a proposal to add IDTFs
to the definition of applicable settings under this program. We also
include proposals regarding who beyond the ordering professional may
consult AUC through a qualified CDSM to meet the statutory requirements
for the AUC program, as well as a proposal to more clearly include all
entities required to report AUC consultation information on the claim.
Finally, we propose to modify the significant hardship exception
criteria and process under Sec. 414.94(i)(3) to be specific to the AUC
program and independent of other Medicare programs. We are also
requesting public comment on other circumstances that could be
considered significant hardships, posing particular real-time
difficulty or challenge to the ordering professional in consulting AUC.
We invite the public to submit comments on these proposals, as well as
provide comment on potential methods for, and issues related to,
mechanisms for claims-based reporting and identifying outlier ordering
professionals.
We will continue to post information on our website for this
program, accessible at www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Appropriate-Use-Criteria-Program/index.html.
E. Medicaid Promoting Interoperability Program Requirements for
Eligible Professionals (EPs)
1. Background
Sections 1903(a)(3)(F) and 1903(t) of the Act provide the statutory
basis for the incentive payments made to Medicaid EPs and eligible
hospitals for the adoption, implementation, upgrade, and meaningful use
of CEHRT. We have implemented these statutory provisions in prior
rulemakings to establish the Medicaid Promoting Interoperability
Programs.
Under sections 1848(o)(2)(A)(iii) and 1903(t)(6)(C)(i)(II) of the
Act, and the definition of ``meaningful EHR user'' in regulations at
Sec. 495.4, one of the requirements of being a meaningful EHR user is
to successfully report the clinical quality measures selected by CMS to
CMS or a state, as applicable, in the form and manner specified by CMS
or the state, as applicable. Section 1848(o)(2)(B)(iii) of the Act
requires that in selecting electronic clinical quality measures (eCQMs)
for EPs to report under the Promoting Interoperability Program, and in
establishing the form and manner of reporting, the Secretary shall seek
to avoid redundant or duplicative reporting otherwise required. We have
taken steps to align various quality reporting and payment programs
that include the submission of eCQMs.
In the ``Medicare Program; Hospital Inpatient Prospective Payment
Systems for Acute Care Hospitals and the Long-Term Care Hospital
Prospective Payment System and Policy Changes and Fiscal Year 2018
Rates; Quality Reporting Requirements for Specific Providers; Medicare
and Medicaid Electronic Health Record (EHR) Incentive Program
Requirements for Eligible Hospitals, Critical Access Hospitals, and
Eligible Professionals; Provider-Based Status of Indian Health Service
and Tribal Facilities and Organizations; Costs Reporting and Provider
Requirements; Agreement Termination Notices'' final rule (82 FR 37990,
38487) (hereafter referred to as the ``FY 2018 IPPS/LTCH PPS final
rule''), we established that, for 2017, Medicaid EPs would be required
to report on any six eCQMs that are relevant to the EP's scope of
practice. In proposing and finalizing that change, we indicated that it
is our intention to align eCQM requirements for Medicaid EPs with the
requirements of Medicare quality improvement programs, to the extent
practicable.
2. eCQM Reporting Requirements for EPs Under the Medicaid Promoting
Interoperability Program for 2019
CMS annually reviews and revises the list of eCQMs for each MIPS
performance year to reflect updated clinical standards and guidelines.
In section III.H.3.h.(2)(b)(i) of this proposed rule, we are proposing
to amend the list of available eCQMs for the CY 2019 performance
period. To keep eCQM specifications current and minimize complexity, we
propose to align the eCQMs available for Medicaid EPs in 2019 with
those available for MIPS eligible clinicians for the CY 2019
performance period. Specifically, we propose that the eCQMs available
for Medicaid EPs in 2019 would consist of the list of quality measures
available under the eCQM collection type on the final list of quality
measures established under MIPS for the CY 2019 performance period.
We believe that this proposal would be responsive to stakeholder
feedback supporting quality measure alignment between MIPS and the
Medicaid Promoting Interoperability Program for EPs, and that it would
encourage EP participation in the Medicaid Promoting Interoperability
Program by allowing those that are also MIPS eligible clinicians the
ability to report the same eCQMs as they report for MIPS in 2019. In
addition, we believe that aligning the eCQMs available in each program
would ensure the most uniform application of up-to-date clinical
standards and guidelines possible.
We anticipate that this proposal would reduce burden for Medicaid
EPs by aligning the requirements for multiple reporting programs, and
that the system changes required for EPs to implement this change would
not be significant, particularly in light of our belief that many EPs
will report eCQMs to meet the quality performance category of MIPS and
therefore should be prepared to report on the available eCQMs for 2019.
We expect that this proposal would have only a minimal impact on
states, by requiring minor adjustments to state systems for 2019 to
maintain current eCQM lists and specifications.
We also request comments on whether in future years of the Medicaid
Promoting Interoperability Program beyond 2019, we should include all
e-specified measures from the core set of quality measures for Medicaid
and the Children's Health Insurance Program (CHIP) (the Child Core Set)
and the core set of health care quality measures for adults enrolled in
Medicaid (Adult Core Set) (hereinafter together referred to as ``Core
Sets'') as additional options for Medicaid EPs. Sections 1139A and
1139B of the Act require the Secretary to identify and publish core
sets of health care quality measures for child Medicaid and CHIP
beneficiaries and adult Medicaid beneficiaries. These measure sets are
required by statute to be updated annually and are voluntarily reported
by states to CMS. These core sets comprise measures that specifically
focus on populations served by the Medicaid and CHIP programs and are
of particular importance to their care. Several of these Core Set
measures are included in the MIPS eCQM list, but some are not. We
believe that including as eCQM reporting options for Medicaid
[[Page 35872]]
EPs the e-specified measures from the Core Sets that are not also on
the MIPS eCQM list would increase EP utilization of these measures and
provide states with better data to report. At this time, the only
measure within the Core Sets that would not be available as an option
for Medicaid EPs in 2019 (because it is not on the MIPS eCQM list) is
NQF-1360, ``Audiological Diagnosis No Later Than 3 Months of Age.''
However, as these Core Sets are updated annually, there may be other
eCQMs that could be included in future years.
For 2019, we propose that Medicaid EPs would report on any six
eCQMs that are relevant to the EP's scope of practice, regardless of
whether they report via attestation or electronically. After we removed
the NQS domain requirements for EPs' 2017 eCQM submissions in the FY
2018 IPPS/LTCH PPS final rule, we have found that allowing EPs to
report on any six quality measures that are relevant to their practice
has increased EPs' flexibility to report pertinent data. In addition,
this policy would generally align with the MIPS data submission
requirement for eligible clinicians using the eCQM collection type for
the quality performance category, which is established at Sec.
414.1335(a)(1). MIPS eligible clinicians who elect to submit eCQMs must
submit data on at least six quality measures, including at least one
outcome measure (or, if an applicable outcome measure is not available,
one other high priority measure). We refer readers to Sec.
414.1335(a)(2) and (3) for the data submission criteria that apply to
individual MIPS eligible clinicians and groups who elect to submit data
for other collection types.
We also propose that for 2019 the Medicaid Promoting
Interoperability Program would adopt the MIPS requirement that EPs
report on at least one outcome measure (or, if an applicable outcome
measure is not available or relevant, one other high priority measure).
We also request comments on how high priority measures should be
identified for Medicaid EPs. We propose to use all three of the
following methods to identify which of the available measures are high
priority measures, but invite comments on other possibilities.
1. We would use the same set of high priority measures for EPs
participating in the Medicaid Promoting Interoperability Program that
the MIPS program has identified for eligible clinicians. We note that
in section III.H., we are proposing to amend Sec. 414.1305 to revise
the definition of high priority measure for purposes of MIPS to mean an
outcome (including intermediate-outcome and patient-reported outcome),
appropriate use, patient safety, efficiency, patient experience, care
coordination, or opioid-related quality measure, beginning with the
2021 MIPS payment year.
2. For 2019, we would also identify as high priority measures the
available eCQMs that are included in the previous year's Core Sets and
that are also included on the MIPS list of eCQMs. Because the Core Sets
are released at the beginning of each year, it would not be possible to
update the list of high-priority eCQMs with those added to the current
year's Core Sets. CMS has already identified the measures included in
the Core Sets as ones that specifically focus on populations served by
the Medicaid and CHIP programs and are particularly important to their
care. The eCQMs that would be available for EPs to report in 2019, that
are both part of the Core Sets and on the MIPS list of eCQMs, and that
would be considered high priority measures under our proposal are:
CMS2, ``Preventive Care and Screening: Screening for Depression and
Follow-Up Plan''; CMS4, ``Initiation and Engagement of Alcohol and
Other Drug Dependence Treatment''; CMS122, ``Diabetes: Hemoglobin A1c
(HbA1c) Poor Control (>9%)''; CMS125, ``Breast Cancer Screening'';
CMS128, ``Anti-depressant Medication Management''; CMS136, ``Follow-Up
Care for Children Prescribed ADHD Medication (ADD)''; CMS153,
``Chlamydia Screening for Women''; CMS155, ``Weight Assessment and
Counseling for Nutrition and Physical Activity for Children and
Adolescents''; and CMS165, ``Controlling High Blood Pressure.''
3. We would also give each state the flexibility to identify which
of the available eCQMs selected by CMS are high priority measures for
EPs in that state, with review and approval from CMS, through their
State Medicaid HIT Plans (SMHP), similar to the flexibility granted
states to modify the definition of Meaningful Use at Sec. 495.332(f).
This would give states the ability to identify as high priority those
measures that align with their state health goals or other programs
within the state. We proposed to amend Sec. 495.332(f) to provide for
this state flexibility to identify high priority measures.
We propose that any eCQMs identified via any of these mechanisms be
considered to be high priority measures for EPs participating in the
Medicaid Promoting Interoperability Program for 2019. We invite
comments on whether all three of these methods should be utilized (as
proposed) or whether there are reasons to instead use a subset of these
methods, or only one of them.
We also propose that the eCQM reporting period for EPs in the
Medicaid Promoting Interoperability Program would be a full CY in 2019
for EPs who have demonstrated meaningful use in a prior year, in order
to align with the corresponding performance period in MIPS for the
quality performance category. We continue to align Medicaid Promoting
Interoperability Program requirements with requirements for other CMS
quality programs, such as MIPS, to the extent practicable, to reduce
the burden of reporting different data for separate programs. In
addition, we have found that clinical quality data from an entire year
reporting period is significantly more useful than partial year data
for quality measurement and improvement because it gives states a
fuller picture of a health care provider's care and patient outcomes.
The eCQM reporting period for EPs demonstrating meaningful use for the
first time, which was established in the final rule entitled ``Medicare
and Medicaid Programs; Electronic Health Record Incentive Program--
Stage 3 and Modifications to Meaningful Use in 2015 Through 2017'' (80
FR 62762) (hereafter referred to as ``Stage 3 final rule''), would
remain any continuous 90-day period (80 FR 62892).
We will adjust future years' requirements for reporting eCQMs in
the Medicaid Promoting Interoperability Program as necessary, through
rulemaking, and will continue to align the quality reporting
requirements, as logical and feasible, to minimize EP burden.
We invite public comment on these proposals.
3. Proposed Revisions to the EHR Reporting Period and eCQM Reporting
Period in 2021 for EPs Participating in the Medicaid Promoting
Interoperability Program
In the July 28, 2010 final rule titled ``Medicare and Medicaid
Programs; Electronic Health Record Incentive Program'' at 75 FR 44319,
we established that, in accordance with section 1903(t)(4)(A)(iii) of
the Act, in no case may any Medicaid EP receive an incentive after 2021
(see Sec. 495.310(a)(2)(v)). Therefore, December 31, 2021 is the last
date that states could make Medicaid Promoting Interoperability Program
payments to Medicaid EPs (other than pursuant to a successful appeal
related to 2021 or a prior year).
For states to make payments by that deadline, there must be
sufficient time after EHR and eCQM reporting periods
[[Page 35873]]
end for EPs to attest to states, for states to conduct their prepayment
processes, and for states to issue payments. Therefore, we propose to
amend Sec. 495.4 to provide that the EHR reporting period in 2021 for
all EPs in the Medicaid Promoting Interoperability Program would be a
minimum of any continuous 90-day period within CY 2021, provided that
the end date for this period falls before October 31, 2021, to help
ensure that the state can issue all Medicaid Promoting Interoperability
Program payments on or before December 31, 2021. Similarly, we propose
to change the eCQM reporting period in 2021 for EPs in the Medicaid
Promoting Interoperability Program to a minimum of any continuous 90-
day period within CY 2021, provided that the end date for this period
falls before October 31, 2021, to help ensure that the state can issue
all Medicaid Promoting Interoperability Program payments on or before
December 31, 2021.
We understand that the October 31, 2021 date might not provide some
states with sufficient time to process payments by December 31, 2021.
We believe that states are best positioned to determine the last
possible date in CY 2021 by which the EHR or eCQM reporting periods for
Medicaid EPs must end, and the deadline for receiving EP attestations,
so that the state is able to issue all payments by December 31, 2021.
Therefore, we propose to allow states the flexibility to set
alternative, earlier final deadlines for EHR or eCQM reporting periods
for Medicaid EPs in CY 2021, with prior approval from us, through their
State Medicaid HIT Plan (SMHP). If a state establishes an alternative,
earlier date within CY 2021 by which all EHR or eCQM reporting periods
in CY 2021 must end, Medicaid EPs in that state would continue to have
a reporting period of a minimum of any continuous 90-day period within
CY 2021. The end date for the reporting period would have to occur
before the day of attestation, which must occur prior to the final
deadline for attestations established by their state. We proposed to
amend Sec. 495.332(f) to provide for this state flexibility to
identify an alternative date by which all EHR reporting periods or eCQM
reporting periods for Medicaid EPs in CY 2021 must end.
We believe there is no reason why a state would need to set a date
by which EHR reporting periods and eCQM reporting periods must end for
Medicaid EPs that is earlier than the day before that state's
attestation deadline for EPs. Doing so would restrict EPs' ability to
select EHR and eCQM reporting periods. Therefore, we propose that any
alternative deadline for CY 2021 EHR and eCQM reporting periods set by
a state may not be any earlier than the day prior to the attestation
deadline for Medicaid EPs attesting to that state.
We invite public comment on this proposal.
While we are not making any proposals regarding eligible hospitals
in this proposed rule, we acknowledge that there will be a similar
issue if there are still hospitals eligible to receive Medicaid
Promoting Interoperability Program payments in 2021, including
Medicaid-only eligible hospitals as well as ``dually-eligible''
eligible hospitals and critical access hospitals (CAHs) (those that are
eligible for an incentive payment under Medicare for meaningful use of
CEHRT and/or subject to the Medicare payment reduction for failing to
demonstrate meaningful use of CEHRT, and are also eligible to earn a
Medicaid incentive payment for meaningful use of CEHRT). However, based
on attestation data and information from states' SMHPs regarding the
number of years states disburse Medicaid Promoting Interoperability
Program payments to hospitals, we believe that there will be no
hospitals eligible to receive Medicaid Promoting Interoperability
Program payments in 2021 due to the requirement that, after 2016,
eligible hospitals cannot receive a Medicaid Promoting Interoperability
Program payment unless they have received such a payment in the prior
fiscal year. At this time, we believe that there are no hospitals that
will be able to receive incentive payments in 2020 or 2021. We invite
comments and suggestions on whether this belief is accurate, and if
not, how we could address the issue in a manner that limits the burden
on hospitals and states. We are not proposing any specific policy in
this rule, but, if necessary, we expect to address the issue in a
future proposed rule that is more specifically related to hospital
payment.
4. Proposed Revisions to Stage 3 Meaningful Use Measures for Medicaid
EPs
a. Proposed Change to Objective 6 (Coordination of Care Through Patient
Engagement)
In the Stage 3 final rule, we adopted a phased approach under Stage
3 for EP Objective 6 (Coordination of care through patient engagement),
Measure 1 (View, Download, or Transmit) and Measure 2 (Secure
Electronic Messaging). This phased approach established a 5 percent
threshold for both measures 1 and 2 of this objective for an EHR
reporting period in 2017. (80 FR 62848 through 62849) In the same rule,
we established that the threshold for Measure 1 would rise to 10
percent, beginning with the EHR reporting period in 2018, and that the
threshold for Measure 2 would rise to 25 percent, beginning with the
EHR reporting period in 2018 We stated that we would continue to
monitor performance on these measures to determine if any further
adjustment was needed. In the FY 2018 IPPS/LTCH PPS final rule (82 FR
38493), we established a policy allowing EPs, eligible hospitals, and
CAHs to use either 2014 Edition or 2015 Edition CEHRT, or a combination
of 2014 Edition and 2015 Edition CEHRT, for an EHR reporting period in
CY 2018, and depending on which Edition(s) they use, to attest to the
Modified Stage 2 objectives and measures or the Stage 3 objectives and
measures. In doing so, we also delayed the rise of the Objective 6
Measure 1 and Measure 2 thresholds until 2019.
Based on feedback we have received, we understand that these two
measures are the largest barrier to successfully demonstrating
meaningful use, especially in rural areas and at safety net clinics.
Stakeholders have reported a variety of causes that have resulted in
lower patient participation than was anticipated when the Stage 3 final
rule was issued. The data that we have collected via states for
Medicaid EPs and at CMS from Medicare EPs for previous program years
supports this feedback. The primary issue is that the view, download,
transmit measure requires a positive action by patients, which cannot
be controlled by an EP. Medicaid populations that are at the greatest
risk have lower levels of internet access, internet literacy and health
literacy than the general population. While the Secure Electronic
Messaging measure does not require patient action, only that the EP
send a secure message, we have received feedback that this
functionality is not highly utilized by patients. While we encourage
EPs to continue to reach out to patients via secure messaging to engage
them in their health care between office visits, it is not productive
for EPs to send messages to patients who are unlikely to see them or
take action. Retaining the current threshold of 5 percent for both
measures would continue to incentivize EPs to engage patients in their
own care without raising the requirements to unattainable thresholds
for EPs who serve vulnerable Medicaid patients. Therefore, we propose
to amend Sec. 495.24(d)(6)(i) such that the thresholds
[[Page 35874]]
for Measure 1 (View, Download, or Transmit) and Measure 2 (Secure
Electronic Messaging) of Meaningful Use Stage 3 EP Objective 6
(Coordination of care through patient engagement) would remain 5
percent for 2019 and subsequent years.
We invite comments on this proposal.
b. Proposed Change to the Syndromic Surveillance Reporting Measure
In the Stage 3 final rule, we established that the syndromic
surveillance reporting measure for EPs was limited to those who
practice in urgent care settings (80 FR 62866 through 62870). Since
then, we have received feedback from states and public health agencies
that while many are unable to accept non-emergency or non-urgent care
ambulatory syndromic surveillance data electronically, some public
health agencies can and do want to receive data from health care
providers in non-urgent care settings. We believe that public health
agencies that set the requirements for data submission to public health
registries are in a better position to judge which health care
providers can contribute useful data.
Therefore, we propose to amend Sec. 495.24(d)(8)(i)(B)(2), EP
Objective 8 (Public health and clinical data registry reporting),
Measure 2 (Syndromic surveillance reporting measure), to amend the
language restricting the use of syndromic surveillance reporting for
meaningful use only to EPs practicing in an urgent care setting. We
propose to include any EP defined by the state or local public health
agency as a provider who can submit syndromic surveillance data. This
change would not alter the exclusion for this measure at Sec.
495.25(d)(8)(i)(C)(2)(i), for EPs who are not in a category of health
care providers from which ambulatory syndromic surveillance data is
collected by their jurisdiction's syndromic surveillance system, as
defined by the state or local public health agency. Furthermore, this
does not create any requirements for syndromic surveillance registries
to include all EPs. Additionally, under the specifications for the 2015
Edition of CEHRT for syndromic surveillance, it is possible that an EP
could own CEHRT and submit syndromic surveillance in a format that is
not accepted by the local jurisdiction. In this case, the EP may take
an exclusion for syndromic surveillance.
We invite comments on this proposal.
F. Medicare Shared Savings Program
As required under section 1899 of the Act, we established the
Medicare Shared Savings Program (Shared Savings Program) to facilitate
coordination and cooperation among health care providers to improve the
quality of care for Medicare Fee-For-Service (FFS) beneficiaries and
reduce the rate of growth in expenditures under Medicare Parts A and B.
Eligible groups of providers and suppliers, including physicians,
hospitals, and other health care providers, may participate in the
Shared Savings Program by forming or participating in an Accountable
Care Organization (ACO). The final rule establishing the Shared Savings
Program appeared in the November 2, 2011 Federal Register (Medicare
Program; Medicare Shared Savings Program: Accountable Care
Organizations; Final Rule (76 FR 67802) (hereinafter referred to as the
``November 2011 final rule''). A subsequent major update to the program
rules appeared in the June 9, 2015 Federal Register (Medicare Program;
Medicare Shared Savings Program: Accountable Care Organizations; Final
Rule (80 FR 32692) (hereinafter referred to as the ``June 2015 final
rule'')). The final rule entitled, ``Medicare Program; Medicare Shared
Savings Program; Accountable Care Organizations--Revised Benchmark
Rebasing Methodology, Facilitating Transition to Performance-Based
Risk, and Administrative Finality of Financial Calculations,'' which
addressed changes related to the program's financial benchmark
methodology, appeared in the June 10, 2016 Federal Register (81 FR
37950) (hereinafter referred to as the ``June 2016 final rule'').
We have also made use of the annual calendar year (CY) Physician
Fee Schedule (PFS) rules to address quality reporting for the Shared
Savings Program and certain other issues. In the CY 2018 PFS final rule
(82 FR 53209 through 53226), we finalized revisions to several
different policies under the Shared Savings Program, including the
assignment methodology, quality measure validation audit process, use
of the skilled nursing facility (SNF) 3-day waiver, and handling of
demonstration payments for purposes financial reconciliation and
establishing historical benchmarks. In addition, in the CY 2017 Quality
Payment Program final rule (81 FR 77255 through 77260) and the CY 2018
Quality Payment Program final rule (82 FR 53688 through 53706), we
finalized policies related to the Alternative Payment Model (APM)
scoring standard under the Merit-Based Incentive Payment System (MIPS),
which reduces the reporting burden for MIPS eligible clinicians who
participate in MIPS APMs, such as the Shared Savings Program, by: (1)
Using the CAHPS for ACOs survey and the ACO reported CMS Web Interface
quality data for purposes of assessing quality performance in the
Shared Savings Program and to score the MIPS quality performance
category for these eligible clinicians; (2) automatically awarding MIPS
eligible clinicians participating in Shared Savings Program ACOs a
minimum of one-half of the total points in the MIPS improvement
activities performance category; (3) requiring ACO participants to
report Advancing Care Information (ACI) data at the group practice
level or solo practitioner level; and (4) not assessing MIPS eligible
clinicians on the MIPS cost performance category because, through their
participation in the ACO, they are already being assessed on cost and
utilization under the Shared Savings Program.
As a general summary, we are proposing the following changes to the
quality performance measures that will be used to assess quality
performance under the Shared Savings Program for performance year 2019
and subsequent years:
Changes to Patient Experience of Care Survey measures.
Changes to CMS Web Interface and Claims-Based measures.
1. Quality Measurement
a. Background
Section 1899(b)(3)(C) of the Act states that the Secretary shall
establish quality performance standards to assess the quality of care
furnished by ACOs and seek to improve the quality of care furnished by
ACOs over time by specifying higher standards, new measures, or both.
In the November 2011 final rule, we established a quality performance
standard consisting of 33 measures across four domains, including
patient experience of care, care coordination/patient safety,
preventive health, and at-risk population (76 FR 67872 through 67891).
Since the Shared Savings Program was established, we have updated the
measures that comprise the quality performance standard for the Shared
Savings Program through the annual rulemaking in the CY 2015, 2016, and
2017 PFS final rules (79 FR 67907 through 67920, 80 FR 71263 through
71268, and 81 FR 80484 through 80489, respectively).
As we stated in the November 2011 final rule establishing the
Shared Savings Program (76 FR 67872), our principal goal in selecting
quality measures for ACOs has been to identify
[[Page 35875]]
measures of success in the delivery of high-quality health care at the
individual and population levels, with a focus on outcomes.
For performance year 2018, 31 quality measures are used to
determine ACO quality performance (81 FR 80488 and 80489). Quality
measures are submitted by the ACO through the CMS Web Interface,
calculated by CMS from administrative and claims data, and collected
via a patient experience of care survey referred to as the Consumer
Assessment of Healthcare Provider and Systems (CAHPS) for ACOs Survey.
The CAHPS for ACOs survey is based on the Clinician and Group Consumer
Assessment of Healthcare Providers and Systems (CG-CAHPS) Survey and
includes additional, program specific questions that are not part of
the CG-CAHPS. The CG-CAHPS survey is maintained, and periodically
updated, by the Agency for Healthcare Research and Quality (AHRQ).
The quality measures collected through the CMS Web Interface in
2015 and 2016 were used to determine whether eligible professionals
participating in an ACO would avoid the PQRS and automatic Physician
Value-Based Payment Modifier (Value Modifier) downward payment
adjustments for 2017 and 2018 and to determine if ACO participants were
eligible for upward, neutral or downward adjustments based on quality
measure performance under the Value Modifier. Beginning with the 2017
performance period, which impacts payments in 2019, PQRS and the Value
Modifier were replaced by the MIPS. Eligible clinicians who are
participating in an ACO and subject to MIPS (MIPS eligible clinicians)
will be scored under the alternative payment model (APM) scoring
standard under MIPS (81 FR 77260). These MIPS eligible clinicians
include any eligible clinicians who are participating in an ACO in a
track of the Shared Savings Program that is an Advanced APM, but who do
not become Qualifying APM Participants (QPs) as specified in Sec.
414.1425, and are not otherwise excluded from MIPS. Beginning with the
2017 reporting period, measures collected through the CMS Web Interface
will be used to determine the MIPS quality performance category score
for MIPS eligible clinicians participating in a Medicare Shared Savings
Program ACO. Starting with the 2018 performance period, the quality
performance category under the MIPS APM Scoring Standard for MIPS
eligible clinicians participating in a Shared Savings Program ACO will
include measures collected through the CMS Web Interface and the CAHPS
for ACOs survey measures.
The CAHPS for ACOs Survey includes the core questions contained in
the CG-CAHPS, plus additional questions to measure access to and use of
specialist care, experience with care coordination, patient involvement
in decision-making, experiences with a health care team, health
promotion and patient education, patient functional status, and general
health. From 2014 through 2017, ACOs had the option to use a short
version of the survey (8 Summary Survey Measures (SSMs) used in
assessing quality performance, 1 SSM scored for informational purposes)
or a longer version of the survey (8 SSMs used in determining quality
performance and 4 SSMs scored for informational purposes). Although not
all measures in the longer version of the survey were used in
determining the ACO's quality score, the measure performance rate
information could be used by the ACO in its quality improvement
efforts. For 2018, CMS will only offer one version of the CAHPS for
ACOs survey. Eight SSMs will be used in quality determination and two
SSMs will be scored for informational purposes. There were no changes
to the scored measure set between the 2017 and 2018 surveys: The 2018
survey is a streamlined version of the survey that assesses the same
content areas required in 2017, using fewer survey items.
The 2018 CAHPS for ACOs survey incorporates updates made by AHRQ to
the Clinician and Group (CG) CAHPS survey that were based on feedback
from survey users and stakeholders as well as analyses of multiple data
sets. In the ``Notice of Proposed Changes for the Consumer Assessment
of Healthcare Providers and Systems (CAHPS) Clinician & Group Survey''
published in the January 21, 2015 Federal Register (80 FR 2938-2939),
AHRQ solicited public comment on proposed updates to produce the CAHPS
Clinician & Group Survey v. 3.0. Based on analyses of multiple data
sets and comments received from the public, AHRQ, released the CAHPS
Clinician & Group Survey v. 3.0. The 2018 CAHPS for ACOs survey
includes language refinements and core SSM item changes that align with
the CAHPS Clinician & Group Survey v. 3.0.
Additional information on the CG-CAHPS survey update is available
on the AHRQ website at https://www.ahrq.gov/sites/default/files/wysiwyg/cahps/surveys-guidance/cg/about/proposed-changes-cahps-c&g-survey2015.pdf.
In addition to incorporating changes based on the AHRQ survey
update, CMS removed all items included in the SSMs, Helping You to Take
Medications as Directed and Between Visit Communication. These were
optional SSMs that were not part of the scored measures. The update
resulted in reducing the number of questions from 80 to 58 questions.
Accordingly, the CAHPS for ACOs SSMs that contribute to the ACO
performance score for performance year 2018, as finalized in the CY
2017 PFS final rule (81 FR 80488) are: Getting Timely Care,
Appointments & Information; How Well Your Providers Communicate;
Patients' Rating of Provider; Access to Specialists; Health Promotion
and Education; Shared Decision Making; Health Status & Functional
Status; and Stewardship of Patient Resources. In addition, the core
survey includes SSMs on Care Coordination and Courteous & Helpful
Office Staff. However, because these measures are not included in the
Shared Savings Program quality measure set for 2018, scores for these
measures will be provided to ACOs for informational purposes only and
will not be used in determining the ACOs' quality scores.
b. Proposals for Changes to the CAHPS Measure Set
To enhance the Patient/Caregiver Experience domain and align with
MIPS (82 FR 54163), we are proposing to begin scoring the 2 SSMs that
are currently collected with the administration of the CAHPS for ACOs
survey and shared with the ACOs for informational purposes only. Under
this proposal, we would add the following CAHPS for ACOs SSMs that are
already collected and provided to ACOs for informational purposes to
the quality measure set for the Shared Savings Program as ACO-45,
CAHPS: Courteous and Helpful Office Staff, and ACO-46: CAHPS: Care
Coordination. These measures would be scored and included in the ACO
quality determination starting in 2019. Both of these SSMs are
currently designated by AHRQ as CG CAHPS core measures.
The Courteous and Helpful Office Staff SSM, which would be added as
ACO-45, asks about the helpfulness, courtesy and respectfulness of
office staff. This SSM has been a CG-CAHPS core measure in the previous
two versions of the CG-CAHPS survey, but was previously provided for
informational purposes only and not included in the ACO quality score
determination. We are also proposing to add the SSM, CAHPS: Care
Coordination to the CAHPS for ACOs
[[Page 35876]]
measures used in ACO quality score determination as ACO-46. The Care
Coordination SSM asks questions about provider access to beneficiary
information and provider follow-up. This SSM was designated a core
measure in the most recent version of the CG-CAHPS survey.
Inclusion of these measures in the quality measure set that is used
to assess the quality performance of ACOs under the Shared Savings
Program would place greater emphasis on outcome measures and the voice
of the patient and provide ACOs with an additional incentive to act
upon opportunities for improved care coordination and communication,
and would align with the MIPS measure set finalized in the CY 2018
Quality Payment Program final rule (82 FR 54163). Care Coordination and
patient and caregiver engagement are goals of the Shared Savings
Program. The Care Coordination SSM emphasizes the care coordination
goal, while the Courteous and Helpful Office Staff SSM supports patient
engagement as it addresses a topic that has been identified as
important to beneficiaries in testing. For performance year 2016, the
mean performance rates across all ACOs for these two measures, which
were not included in the ACO quality score determination, were 87.18
for the Care Coordination SSM and 92.12 for Courteous and Helpful
Office Staff SSM.
Consistent with Sec. 425.502(a)(4), regarding the scoring of newly
introduced quality measures, we propose that these additional SSMs
would be pay-for-reporting for all ACOs for 2 years (performance years
2019 and 2020). The measures would then phase into pay-for-performance
for ACOs in their first agreement period in the program according to
the schedule in Table 25 beginning in performance year 2021. We seek
comment on this proposed change to the quality measure set.
Additionally, we seek comment on potentially converting the Health
and Functional Status SSM (ACO-7) to pay-for-performance in the future.
The Health and Functional Status SSM is currently pay-for-reporting for
all years. We have not scored this measure because the scores on the
Health and Functional Status SSM may reflect the underlying health of
beneficiaries seen by ACO providers/suppliers as opposed to the quality
of the care provided by the ACO. We are also considering possible
options for enhancing collection of Health and Functional Status data.
One option would be to change our data collection procedures to collect
data from the same ACO assigned beneficiaries over time. This change
could allow for measurement of changes that occurred while
beneficiaries were receiving care from ACO providers/suppliers. We are
seeking stakeholder feedback on this approach or other recommendations
regarding the potential inclusion of a functional status measure in the
assessment of ACO quality performance in the future.
c. Proposed Changes to the CMS Web Interface and Claims-Based Quality
Measure Sets
In developing these proposals, we considered the agency's efforts
to streamline quality measures, reduce regulatory burden and promote
innovation as part of the agency's Meaningful Measures initiative (See
CMS Press Release, CMS Administrator Verma Announces New Meaningful
Measures Initiative and Addresses Regulatory Reform; Promotes
Innovation at LAN Summit, October 30, 2017, available at https://www.cms.gov/Newsroom/MediaReleaseDatabase/Press-releases/2017-Press-releases-items/2017-10-30.html). Under the Meaningful Measures
initiative, CMS has committed to assessing only those core issues that
are most vital to providing high-quality care and improving patient
outcomes, with the aim of focusing on outcome-based measures, reducing
unnecessary burden on providers, and putting patients first. In
considering the quality reporting requirements under the Shared Savings
Program, we have also considered the quality reporting requirements
under other initiatives, such as the MIPS and Million Hearts
Initiative, and consulted with the measures community to ensure that
the specifications for the measures used under the Shared Savings
Program are up-to-date with current clinical guidelines, focus on
outcomes over process, reflect agency and program priorities, and
reduce reporting burden.
Since the Shared Savings Program was first established in 2012, we
have not only updated the quality measure set to reduce reporting
burden, but also to focus on more meaningful, outcome-based measures.
The most recent updates to the Shared Savings Program quality measure
set were made in the CY 2017 PFS final rule (81 FR 80484 through 80489)
to adopt the ACO measure recommendations made by the Core Quality
Measures Collaborative, a multi-stakeholder group with the goal of
aligning quality measures for reporting across public and private
initiatives to reduce provider reporting burden. Currently, more than
half of the 31 Shared Savings Program quality measures are outcome-
based, including:
Patient-reported outcome measures collected through the
CAHPS for ACOs Survey that strengthen patient and caregiver experience.
Outcome measures supporting effective communication and
care coordination, such as unplanned admission and readmission
measures.
Intermediate outcome measures that address the effective
treatment of chronic disease, such as hemoglobin A1c control for
patients with diabetes.
In this rule, we are proposing to reduce the total number of
measures in the Shared Savings Program quality measure set. These
proposals are intended to reduce the burden on ACOs and their
participating providers and suppliers by lowering the number of
measures they are required to report through the CMS Web Interface and
on which they are assessed through the use of claims data. Reducing the
number of measures on which ACOs are measured would reduce the number
of performance metrics that they are required to track and eliminate
redundancies between measures that target similar populations. The
proposed reduction in the number of measures would enable ACOs to
better utilize their resources toward improving patient care. These
proposals further reduce burden by aligning with the proposed changes
to the CMS Web Interface measures that are reported under MIPS as
discussed in Tables A, C, and D of Appendix 1: Proposed MIPS Quality
Measures of this proposed rule. We recognize that ACOs and their
participating providers and suppliers dedicate resources to performing
well on our quality metrics, and we believe that reducing the number of
metrics and aligning them across programs would allow them to more
effectively target those resources toward improving patient care. We
are proposing to reduce the number of measures by minimizing measure
overlap and eliminating several process measures. The proposal to
remove process measures also aligns with our proposal to reduce the
number of process measures within the MIPS measure set as discussed in
section III.H.b.iii of this proposed rule and would support the CMS
goal of moving toward outcome-based measurement.
We are proposing to retire the following claims-based quality
measures, which have a high degree of overlap with other measures that
would remain in the measure set:
ACO-35--Skilled Nursing Facility 30-Day All-Cause
Readmission Measure (SNFRM).
ACO-36--All-Cause Unplanned Admissions for Patients with
Diabetes.
[[Page 35877]]
ACO-37--All-Cause Unplanned Admission for Patients with
Heart Failure.
Within the claims-based quality measures, overlap exists between
measures with respect to the population being measured (the
denominator), because a single admission may be counted in the
numerator for multiple measures. For example, ACO-35 addresses
unplanned readmissions from a SNF, and the vast majority of these SNF
readmissions are also captured in the numerator of ACO-8 Risk-
Standardized All Condition Readmission. Similarly, ACO-36 and ACO-37
address unplanned admissions for patients with diabetes and heart
failure and most of these admissions are captured in the numerator of
ACO-38 Risk-Standardized Acute Admission Rates for Patients with
Multiple Chronic Conditions (please note that the measure name has been
updated to align with changes made by the measure steward). Therefore,
to reduce redundancies within the Shared Savings Program measure set,
we propose to remove ACO-35, ACO-36, and ACO-37 from the measure set.
However, because these measures are claims-based measures and therefore
do not impose any reporting burden on ACOs, we intend to continue to
provide information to ACOs on their performance on these measures for
use in their quality improvement activities through a new quarterly
claims-based quality outcome report that ACOs will begin receiving in
2018.
Although we are proposing to retire ACO-35 (SNFRM) from the set of
quality measures that are scored for the Shared Savings Program, we
recognize the value of measuring the quality of care furnished to
Medicare beneficiaries in SNFs. Therefore, we are seeking comment on
the possibility of adding the Skilled Nursing Facility Quality
Reporting Program (SNFQRP) measure ``Potentially Preventable 30-Day
Post-Discharge Readmission Measure for Skilled Nursing Facilities'' to
the Shared Savings Program quality measure set through future
rulemaking. This measure differs from ACO-35 (Skilled Nursing Facility
30-Day All-Cause Readmission Measure), which we are proposing to remove
above, as the SNFQRP measure looks only at unplanned, potentially
preventable readmissions for Medicare Fee-For-Service beneficiaries
within 30 days of discharge to a lower level of care from a SNF, while
ACO-35 assesses readmissions from a SNF, regardless of cause, that
occur within 30 days following discharge from a hospital. As a result,
the SNFQRP measure would have less overlap with ACO-8 (Risk-
Standardized All Cause Readmission measure) than does ACO-35 (SNFRM),
because the two measures' readmission windows differ. Specifically, the
readmission window for the SNFQRP measure is 30 days following
discharge from a SNF, while the readmission window for ACO-8 is 30 days
following discharge from a hospital.
We are also proposing to retire claims-based measure ACO-44 (Use of
Imaging Studies for Low Back Pain), as this measure is restricted to
individuals 18-50 years of age, which results in low denominator rates
under the Shared Savings Program, meaning that the measure is not a
valuable reflection of the beneficiaries cared for by Shared Savings
Program ACOs. As a result, although this measure was originally added
to the Shared Savings Program quality measure set in order to align
with the Core Quality Measures Collaborative, we no longer believe ACO-
44 is a meaningful measure that should be retained in the Shared
Savings Program quality measure set. The deletion of this measure would
also align ACO quality measurement with the MIPS requirements as this
measure was removed for purposes of reporting under the MIPS program in
the CY 2018 Quality Payment Program final rule (82 FR 54159). However,
in recognition of the value in providing feedback to providers on
potential overuse of diagnostic procedures, we intend to continue to
provide ACOs feedback on performance on this measure as part of the new
quarterly claims based quality report.
We welcome public comment on our proposal to retire these 4 claims-
based measures from the quality measure set.
Further, we seek to align with changes made to the CMS Web
Interface measures under the Quality Payment Program. In the 2017 PFS
final rule, we stated we do not believe it is beneficial to propose CMS
Web interface measures for ACO quality reporting separately (81 FR
80499). Therefore, in order to avoid confusion and duplicative
rulemaking, we adopted a policy that any future changes to the CMS Web
interface measures would be proposed and finalized through rulemaking
for the Quality Payment Program, and that such changes would be
applicable to ACO quality reporting under the Shared Savings Program.
In accordance with the policy adopted in the CY 2017 PFS final rule (81
FR 80501), we are not making any specific proposals related to changes
in CMS Web Interface measures reported under the Shared Savings
Program. Rather, we refer readers to Tables A, C, and D of Appendix 1:
Proposed MIPS Quality Measures of this proposed rule for a complete
discussion of the proposed changes to the CMS Web Interface measures.
If the proposed changes are finalized, ACOs would no longer be
responsible for reporting the following measures for purposes of the
Shared Savings Program starting with reporting for performance year
2019:
ACO-12 (NQF #0097) Medication Reconciliation Post-
Discharge.
ACO-13 (NQF #0101) Falls: Screening for Future Fall Risk.
ACO-15 (NQF #0043) Pneumonia Vaccination Status for Older
Adults.
ACO-16 (NQF #0421) Preventive Care and Screening: Body
Mass Index (BMI) Screening and Follow Up.
ACO-41 (NQF #0055) Diabetes: Eye Exam.
ACO-30 (NQF #0068) Ischemic Vascular Disease (IVD): Use of
Aspirin or another Antithrombotic.
We note that ACO-41 is one measure within a two-component diabetes
composite that is currently scored as one measure. The proposed removal
of ACO-41 means that ACO-27 Diabetes Hemoglobin A1c (HbA1c) Poor
Control (>9%) would now be assessed as an individual measure. If the
proposed changes are finalized as proposed, Table 26 shows the maximum
possible points that may be earned by an ACO in each domain and overall
in performance year 2019 and in subsequent performance years.
Additionally, we note that we are proposing to add the following
measure to the CMS Web Interface for purposes of the Quality Payment
Program:
ACO-47 (NQF #0101) Falls: Screening, Risk-Assessment, and
Plan of Care to Prevent Future Falls.
If this proposal is finalized, consistent with our policy of
adopting changes to the CMS Web Interface Measures through rulemaking
for the Quality Payment Program, Shared Savings Program ACOs would be
responsible for reporting this measure starting in performance year
2019.
Table 25 shows the proposed Shared Savings Program quality measure
set for performance year 2019 and subsequent performance years.
[[Page 35878]]
Table 25--Proposed Measure Set for Use in Establishing the Shared Savings Program Quality Performance Standard, Starting With Performance Year 2019
--------------------------------------------------------------------------------------------------------------------------------------------------------
Pay for performance phase-
in R--Reporting P--
Domain ACO measure Measure title New measure NQF #/measure steward Method of data Performance
No. submission --------------------------
PY1 PY2 PY3
--------------------------------------------------------------------------------------------------------------------------------------------------------
AIM: Better Care for Individuals
--------------------------------------------------------------------------------------------------------------------------------------------------------
Patient/Caregiver Experience... ACO-1 CAHPS: Getting ............ NQF N/A AHRQ Survey............ R P P
Timely Care,
Appointments, and
Information.
ACO-2 CAHPS: How Well ............ NQF N/A AHRQ Survey............ R P P
Your Providers
Communicate.
ACO-3 CAHPS: Patients' ............ NQF N/A AHRQ Survey............ R P P
Rating of
Provider.
ACO-4 CAHPS: Access to ............ NQF #N/A CMS/AHRQ Survey............ R P P
Specialists.
ACO-5 CAHPS: Health ............ NQF #N/A AHRQ Survey............ R P P
Promotion and
Education.
ACO-6 CAHPS: Shared ............ NQF #N/A AHRQ Survey............ R P P
Decision Making.
ACO-7 CAHPS: Health ............ NQF #N/A AHRQ Survey............ R R R
Status/Functional
Status.
ACO-34 CAHPS: Stewardship ............ NQF #N/A AHRQ Survey............ R P P
of Patient
Resources.
ACO-45 CAHPS: Courteous \1\ X NQF #N/A AHRQ Survey............ R R P
and Helpful
Office Staff.
ACO-46 CAHPS: Care \1\ X NQF #N/A AHRQ Survey............ R R P
Coordination.
Care Coordination/Patient ACO-8 Risk-Standardized, ............ Adapted NQF #1789 CMS Claims............ R R P
Safety. All Condition
Readmission.
ACO-38 Risk-Standardized ............ NQF#2888 CMS Claims............ R R P
Acute Admission
Rates for
Patients with
Multiple Chronic
Conditions.
ACO-43 Ambulatory ............ AHRQ Claims............ R P P
Sensitive
Condition Acute
Composite (AHRQ
Prevention
Quality Indicator
(PQI) #91)
(version with
additional Risk
Adjustment) \2\.
ACO-47 Falls: Screening, ............ NQF #0101 NCQA CMS Web Interface. R R P
Risk-Assessment,
and Plan of Care
to Prevent Future
Falls.
ACO-11 Use of certified ............ NQF #N/A CMS Quality Payment R P P
EHR technology. Program Advancing
Care Information.
--------------------------------------------------------------------------------------------------------------------------------------------------------
AIM: Better Health for Populations
--------------------------------------------------------------------------------------------------------------------------------------------------------
Preventive Health.............. ACO-14 Preventive Care ............ NQF #0041 AMA-PCPI CMS Web Interface. R P P
and Screening:
Influenza
Immunization.
ACO-17 Preventive Care ............ NQF #0028 AMA-PCPI CMS Web Interface. R P P
and Screening:
Tobacco Use:
Screening and
Cessation
Intervention.
ACO-18 Preventive Care ............ NQF #0418 CMS CMS Web Interface. R P P
and Screening:
Screening for
Depression and
Follow-up Plan.
ACO-19 Colorectal Cancer ............ NQF #0034 NCQA CMS Web Interface. R R P
Screening.
ACO-20 Breast Cancer ............ NQF #2372 NCQA CMS Web Interface. R R P
Screening.
ACO-42 Statin Therapy for ............ NQF #N/A CMS CMS Web Interface. R R R
the Prevention
and Treatment of
Cardiovascular
Disease.
Clinical Care for At Risk ACO-40 Depression ............ NQF #0710 MNCM CMS Web Interface. R R R
Population--Depression. Remission at
Twelve Months.
Clinical Care for At Risk ACO-27 Diabetes ............ NQF #0059 NCQA CMS Web Interface. R P P
Population--Diabetes. Hemoglobin A1c
(HbA1c) Poor
Control (>9%).
Clinical Care for At Risk ACO-28 Hypertension : ............ NQF #0018 NCQA CMS Web Interface. R P P
Population--Hypertension. Controlling High
Blood Pressure.
--------------------------------------------------------------------------------------------------------------------------------------------------------
\1\ Measures that are currently collected as part of the administration of the CAHPS for ACO survey, but will be considered new measures for purposes of
the pay for performance phase-in.
\2\ The language in parentheses has been added for clarity and no changes have been made to the measure.
We are proposing to eliminate 10 measures and to add one measure to
the Shared Savings Program quality measure set. This would result in 24
measures for which ACOs would be held accountable. With these proposed
measure changes, the 4 domains would include the following numbers of
quality measures (See Table 26):
Patient/Caregiver Experience of Care--10 measures.
Care Coordination/Patient Safety--5 measures, including
the double-weighted EHR measure (ACO-11).
Preventive Health--6 measures.
At Risk Populations--3 measures.
Table 26 provides a summary of the number of measures by domain and
the total points and domain weights that would be used for scoring
purposes under the changes to the quality measure set proposed in this
proposed rule.
[[Page 35879]]
Table 26--Number of Measures and Total Points for Each Domain Within the Shared Savings Program Quality
Performance Standard, Starting With Performance Year 2019
----------------------------------------------------------------------------------------------------------------
Number of
Domain individual Total measures for Total possible Domain weight
measures scoring purposes points (%)
----------------------------------------------------------------------------------------------------------------
Patient/Caregiver Experience.......... 10 10 individual survey 20 25
module measures.
Care Coordination/Patient Safety...... 5 5 measures, including 12 25
double-weighted EHR
measure.
Preventive Health..................... 6 6 measures.............. 12 25
At-Risk Population.................... 3 3 individual measures... 6 25
-------------------------------------------------------------------------
Total in all Domains.............. 24 24...................... 50 100
----------------------------------------------------------------------------------------------------------------
G. Physician Self-Referral Law
1. Background
Section 1877 of the Act, also known as the physician self-referral
law: (1) Prohibits a physician from making referrals for certain
designated health services (DHS) payable by Medicare to an entity with
which he or she (or an immediate family member) has a financial
relationship (ownership or compensation), unless an exception applies;
and (2) prohibits the entity from filing claims with Medicare (or
billing another individual, entity, or third party payer) for those
referred services. The statute establishes a number of specific
exceptions, and grants the Secretary the authority to create regulatory
exceptions for financial relationships that pose no risk of program or
patient abuse. Additionally, the statute mandates refunding any amount
collected under a bill for an item or service furnished under a
prohibited referral. Finally, the statute imposes reporting
requirements and provides for sanctions, including civil monetary
penalty provisions.
Section 50404 of the Bipartisan Budget Act of 2018 (Pub. L. 115-
123, enacted February 9, 2018) added provisions to section 1877(h)(1)
of the Act pertaining to the writing and signature requirements in
certain compensation arrangement exceptions to the statute's referral
and billing prohibitions. Although we believe that the newly enacted
provisions in section 1877(h)(1) of the Act are principally intended
merely to codify in statute existing CMS policy and regulations with
respect to compliance with the writing and signature requirements, we
are proposing revisions to our regulations to address any actual or
perceived difference between the statutory and regulatory language, to
codify in regulation our longstanding policy regarding satisfaction of
the writing requirement found in many of the exceptions to the
physician self-referral law, and to make the Bipartisan Budget Act of
2018 policies applicable to compensation arrangement exceptions issued
using the Secretary's authority in section 1877(b)(4) of the Act.
In the CY 2016 PFS final rule with comment period (80 FR 70885), we
revised Sec. 411.357(a)(7), (b)(6), and (d)(1)(vii) to permit a lease
arrangement or personal service arrangement to continue indefinitely
beyond the stated expiration of the written documentation describing
the arrangement under certain circumstances. Section 50404 of the
Bipartisan Budget Act of 2018 added substantively identical holdover
provisions to section 1877(e) of the Act. Because the new statutory
holdover provisions effectively mirror the existing regulatory
provisions, we do not believe it is necessary to revise Sec.
411.357(a)(7), (b)(6), and (d)(1)(vii) as a result of these statutory
revisions.
2. Special Rules on Compensation Arrangements (Section 1877(h)(1)(E) of
the Act)
Many of the exceptions for compensation arrangements in Sec.
411.357 require that the arrangements are set out in writing and signed
by the parties. (See Sec. 411.357(a)(1), (b)(1), (d)(1)(i), (e)(1)(i),
(e)(4)(i), (l)(1), (p)(2), (q) (incorporating the requirement contained
in Sec. 1001.952(f)(4)), (r)(2)(ii), (t)(1)(ii) or (t)(2)(iii) (both
incorporating the requirements contained in Sec. 411.357(e)(1)(i)),
(v)(7), (w)(7), (x)(1)(i), and (y)(1).) \7\ As described above, section
50404 of the Bipartisan Budget Act of 2018 amended section 1877 of the
Act with respect to the writing and signature requirements in the
statutory compensation arrangement exceptions. As detailed below, we
are proposing a new special rule on compensation arrangements at Sec.
411.354(e) and proposing to amend existing Sec. 411.353(g) to codify
the statutory provisions in our regulations.
---------------------------------------------------------------------------
\7\ We note that, where the writing requirement appears in the
statutory and regulatory exceptions, we interpret it uniformly,
regardless of any minor differences in the language of the
requirement. See 80 FR 71315. Similarly, we interpret the signature
requirement uniformly where it appears, regardless of any minor
differences in the language of the statutory and regulatory
exceptions.
---------------------------------------------------------------------------
a. Writing Requirement (Sec. 411.354(e))
In the CY 2016 PFS final rule with comment period, we stated CMS'
longstanding policy that the writing requirement in various
compensation arrangement exceptions in Sec. 411.357 can be satisfied
by ``a collection of documents, including contemporaneous documents
evidencing the course of conduct between the parties'' (80 FR 71315).
Our guidance on the writing requirement appeared in the preamble of the
CY 2016 PFS final rule with comment period but was not codified in
regulations. Section 50404 of the Bipartisan Budget Act of 2018 added
subparagraph D, ``Written Requirement Clarified,'' to section
1877(h)(1) of the Act. Section 1877(h)(1)(D) of the Act provides that,
in the case of any requirement in section 1877 of the Act for a
compensation arrangement to be in writing, such requirement shall be
satisfied by such means as determined by the Secretary, including by a
collection of documents, including contemporaneous documents evidencing
the course of conduct between the parties involved.
In light of the recently added statutory provision at section
1877(h)(1)(D) of the Act, we are proposing to add a special rule on
compensation arrangements at Sec. 411.354(e). Proposed Sec.
411.354(e) provides that, in the case of any requirement in 42 CFR part
411, subpart J, for a compensation arrangement to be in writing, the
writing requirement may be satisfied by a collection of documents,
including contemporaneous documents evidencing the course of conduct
between the parties. The special rule at Sec. 411.357(e) codifies our
existing policy on the writing requirement, as previously articulated
in the CY 2016 PFS final rule with comment period. (See 80 FR 71314 et
seq.)
[[Page 35880]]
b. Special Rule for Certain Arrangements Involving Temporary
Noncompliance With Signature Requirements (Sec. 411.353(g))
Many of the exceptions for compensation arrangements in Sec.
411.357 require that the arrangement (that is, the written
documentation evidencing the arrangement) is signed by the parties to
the arrangement. Under our existing special rule for certain
arrangements involving temporary noncompliance with signature
requirements at Sec. 411.353(g)(1), an entity that has a compensation
arrangement with a physician that satisfies all the requirements of an
applicable exception in Sec. 411.355, Sec. 411.356 or Sec. 411.357
except the signature requirement may submit a claim and receive payment
for a designated health service referred by the physician, provided
that: (1) The parties obtain the required signature(s) within 90
consecutive calendar days immediately following the date on which the
compensation arrangement became noncompliant (without regard to whether
any referrals occur or compensation is paid during such 90-day period);
and (2) the compensation arrangement otherwise complies with all
criteria of the applicable exception. Existing Sec. 411.353(g)(1)
specifies the paragraphs where the applicable signature requirements
are found and existing Sec. 411.353(g)(2) limits an entity's use of
the special rule at Sec. 411.353(g)(1) to only once every 3 years with
respect to the same referring physician.
Section 50404 of the Bipartisan Budget Act of 2018 added
subparagraph E, ``Signature Requirement,'' to section 1877(h)(1) of the
Act. Section 1877(h)(1)(E) of the Act provides that, in the case of any
requirement in section 1877 of the Act for a compensation arrangement
to be in writing and signed by the parties, the signature requirement
is satisfied if: (1) Not later than 90 consecutive calendar days
immediately following the date on which the compensation arrangement
became noncompliant, the parties obtain the required signatures; and
(2) the compensation arrangement otherwise complies with all criteria
of the applicable exception. Notably, under the newly added section
1877(h)(1)(E) of the Act, an applicable signature requirement is not
limited to specific exceptions and entities are not limited in their
use of the rule to only once every 3 years with respect to the same
referring physician. In addition, section 1877(h)(1)(E) of the Act does
not include a reference to the occurrence of referrals or the payment
of compensation during the 90-day period when the signature requirement
is not met.
To conform the regulations with the recently added statutory
provision at section 1877(h)(1)(E) of the Act, we are proposing to
amend existing Sec. 411.353(g) by: (1) Revising the reference at Sec.
411.353(g)(1) to specific exceptions and signature requirements; (2)
deleting the reference at Sec. 411.353(g)(1) to the occurrence of
referrals or the payment of compensation during the 90-day period when
the signature requirement is not met; and (3) deleting the limitation
at Sec. 411.353(g)(2). In the alternative, we are proposing to delete
Sec. 411.353(g) in its entirety and codify in proposed Sec.
411.354(e) the special rule for signature requirements in section
1877(h)(1)(E). We seek comments regarding the best approach for
codifying in regulation this provision of the Bipartisan Budget Act of
2018.
Finally, we note that the effective date of section 50404 of the
Bipartisan Budget Act was February 9, 2018. Thus, beginning February 9,
2018, parties who meet the requirements of section 1877(h)(1)(E) of the
Act, including parties who otherwise would have been barred from
relying on the special rule for certain arrangements involving
temporary noncompliance with signature requirements at Sec.
411.353(g)(1) because of the 3-year limitation at Sec. 411.353(g)(2),
may avail themselves of the new statutory provision at section
1877(h)(1)(E) of the Act.
H. CY 2019 Updates to the Quality Payment Program
1. Executive Summary
a. Overview
This proposed rule would make payment and policy changes to the
Quality Payment Program. The Medicare Access and CHIP Reauthorization
Act of 2015 (MACRA) (Pub. L. 114-10, enacted April 16, 2015) amended
title XVIII of the Act to repeal the Medicare sustainable growth rate
(SGR) formula, to reauthorize the Children's Health Insurance Program,
and to strengthen Medicare access by improving physician and other
clinician payments and making other improvements. The MACRA advances a
forward-looking, coordinated framework for clinicians to successfully
take part in the Quality Payment Program that rewards value in one of
two ways:
The Merit-based Incentive Payment System (MIPS).
Advanced Alternative Payment Models (Advanced APMs).
As we move into the third year of the Quality Payment Program, we
have taken all stakeholder input into consideration including
recommendations made by the Medicare Payment Advisory Commission
(MedPAC), an independent congressional agency established by the
Balanced Budget Act of 1997 (Pub. L. 105-33) to advise the U.S.
Congress on issues affecting the Medicare program, including payment
policies under Medicare, the factors affecting expenditures for the
efficient provision of services, and the relationship of payment
policies to access and quality of care for Medicare beneficiaries. We
will continue to implement the Quality Payment Program as required,
smoothing the transition where possible and offering targeted
educational resources for program participants. A few examples of how
we are working to address MedPAC's concerns are evident in our work
around burden reduction and reshaping our focus of interoperability.
Additionally, we heard the concern about process-based measures, and we
are continuing to move towards the development and use of more outcome
measures by way of removing process measures that are topped out and
funding new quality measure development, as required by section 102 of
MACRA. Additionally, we are also developing new episode-based cost
measures, with stakeholder feedback, for potential inclusion in the
cost performance category beginning in 2019. CMS acknowledges that the
Quality Payment Program is a large shift for many clinicians and
practices, and thus, we will continue to implement the program
gradually with targeted educational resources, public trainings, and
technical assistance for those who qualify. With MIPS, eligible
clinicians now report under one program, which replaces three separate
legacy programs. The Quality Payment Program takes a comprehensive
approach to payment. Instead of basing payment only on a series of fee-
for-service billing codes, the Quality Payment Program adds
consideration of quality through a set of evidence-based measures and
clinical practice improvement activities that were primarily developed
by clinicians.
As a priority for Quality Payment Program Year 3, we are committed
to reducing clinician burden, implementing the Meaningful Measures
Initiative, promoting interoperability, continuing our support of small
and rural practices, empowering patients through the Patients Over
Paperwork initiative, and promoting price transparency.
[[Page 35881]]
Reducing Clinician Burden
We are committed to reducing clinician burden by simplifying and
reducing burden for participating clinicians. Examples include:
Implementing the Meaningful Measures Initiative, which is
a framework that applies a series of cross-cutting criteria to keep the
most meaningful measures with the least amount of burden and greatest
impact on patient outcomes;
Promoting advances in interoperability; and
Establishing an automatic extreme and uncontrollable
circumstances policy for MIPS eligible clinicians.
Improving Patient Outcomes and Reducing Burden Through Meaningful
Measures
Regulatory reform and reducing regulatory burden are high
priorities for us. To reduce the regulatory burden on the healthcare
industry, lower health care costs, and enhance patient care, in October
2017, we launched the Meaningful Measures Initiative.\8\ This
initiative is one component of our agency-wide Patients Over Paperwork
Initiative,\9\ which is aimed at evaluating and streamlining
regulations with a goal to reduce unnecessary cost and burden, increase
efficiencies, and improve beneficiary experience. The Meaningful
Measures Initiative is aimed at identifying the highest priority areas
for quality measurement and quality improvement to assess the core
quality of care issues that are most vital to advancing our work to
improve patient outcomes. The Meaningful Measures Initiative represents
a new approach to quality measures that fosters operational
efficiencies and will reduce costs, including the collection and
reporting burden, while producing quality measurement that is more
focused on meaningful outcomes.
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\8\ Meaningful Measures web page: https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/QualityInitiativesGenInfo/MMF/General-info-Sub-Page.html.
\9\ See Remarks by Administrator Seema Verma at the Health Care
Payment Learning and Action Network (LAN) Fall Summit, as prepared
for delivery on October 30, 2017, https://www.cms.gov/Newsroom/MediaReleaseDatabase/Fact-sheets/2017-Fact-Sheet-items/2017-10-30.html.
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The Meaningful Measures Framework has the following objectives:
Address high-impact measure areas that safeguard public
health;
Patient-centered and meaningful to patients;
Outcome-based where possible;
Fulfill each program's statutory requirements;
Minimize the level of burden for health care providers
(for example, through a preference for EHR-based measures where
possible, such as electronic clinical quality measures);
Significant opportunity for improvement;
Address measure needs for population based payment through
alternative payment models; and
Align across programs and/or with other payers.
To achieve these objectives, we have identified 19 Meaningful
Measures areas and mapped them to six overarching quality priorities as
shown in Table 27.
Table 27--Meaningful Measures Framework Domains and Measure Areas
------------------------------------------------------------------------
Quality priority Meaningful measure area
------------------------------------------------------------------------
Making Care Safer by Reducing Harm Healthcare-Associated
Caused in the Delivery of Care. Infections.
Preventable Healthcare Harm.
Strengthen Person and Family Engagement Care is Personalized and
as Partners in Their Care. Aligned with Patient's Goals.
End of Life Care according to
Preferences.
Patient's Experience of Care.
Patient Reported Functional
Outcomes.
Promote Effective Communication and Medication Management.
Coordination of Care. Admissions and Readmissions to
Hospitals.
Transfer of Health Information
and Interoperability.
Promote Effective Prevention and Preventive Care.
Treatment of Chronic Disease. Management of Chronic
Conditions.
Prevention, Treatment, and
Management of Mental Health.
Prevention and Treatment of
Opioid and Substance Use
Disorders.
Risk Adjusted Mortality.
Work with Communities to Promote Best Equity of Care.
Practices of Healthy Living. Community Engagement.
Make Care Affordable................... Appropriate Use of Healthcare.
Patient-focused Episode of
Care.
Risk Adjusted Total Cost of
Care.
------------------------------------------------------------------------
By including Meaningful Measures in our programs, we believe that
we can also address the following cross-cutting measure criteria:
Eliminating disparities;
Tracking measurable outcomes and impact;
Safeguarding public health;
Achieving cost savings;
Improving access for rural communities; and
Reducing burden.
We believe that the Meaningful Measures Initiative will improve
outcomes for patients, their families, and health care providers while
reducing burden and costs for clinicians and providers and promoting
operational efficiencies.
In the quality performance category, clinicians have the
flexibility to select and report the measures that matter most to their
practice and patients. However, we have received feedback that some
clinicians find the performance requirements confusing, and the program
makes it difficult for them to choose measures that are meaningful to
their practices and have more direct benefit to beneficiaries. For the
2019 MIPS performance period, we are proposing the following updates:
(1) Adding 10 new MIPS quality measures that include 4 patient reported
outcome measures, 7 high priority measures, 1 measure that replaces an
existing measure, and 2 other measures on important clinical topics in
the Meaningful Measures framework; and (2) removing 34 quality
measures.
In addition to having the right measures, we want to ensure that
the collection of information is valuable to clinicians and worth the
cost and burden of collecting the information. In
[[Page 35882]]
section III.H.3.h.(2)(b)(iv) of this proposed rule, we are requesting
comments on a tiered scoring system for quality measures where measures
would be awarded points based on their value. We are also seeking
comment on what patient reported outcome measures produce better
outcomes and request accompanying supporting evidence that the measures
do, in fact, improve outcomes.
Promoting Interoperability Performance Category
As required by MACRA, the Quality Payment Program includes a MIPS
performance category that focuses on meaningful use of certified EHR
technology, referred to in the CY 2017 and CY 2018 Quality Payment
Program rules as the ``advancing care information'' performance
category. As part of our approach to promoting and prioritizing
interoperability of healthcare data, in Quality Payment Program Year 2,
we changed the name of the performance category to the Promoting
Interoperability performance category.
We have prioritized interoperability, which we define as health
information technology that enables the secure exchange of electronic
health information with, and use of electronic health information from,
other health information technology without special effort on the part
of the user; allows for complete access, exchange, and use of all
electronically accessible health information for authorized use under
applicable law; and does not constitute information blocking as defined
by the 21st Century Cures Act (Pub. L. 114-255, enacted December 13,
2016). We are committed to working with the Office of the National
Coordinator for Health IT (ONC) on implementation of the
interoperability provisions of the 21st Century Cures Act to have
seamless but secure exchange of health information for clinicians and
patients, ultimately enabling Medicare beneficiaries to get their
claims information electronically. In addition, we are prioritizing
quality measures and improvement activities that lead to
interoperability.
To further CMS' commitment to implementing interoperability, at the
2018 Healthcare Information and Management Systems Society (HIMSS)
conference, CMS Administrator Seema Verma announced the launching of
the MyHealthEData initiative.\10\ This initiative aims to empower
patients by ensuring that they control their healthcare data and can
decide how their data is going to be used, all while keeping that
information safe and secure. The overall government-wide initiative is
led by the White House Office of American Innovation with participation
from HHS--including its CMS, ONC, and the National Institutes of Health
(NIH)--as well as the U.S. Department of Veterans Affairs (VA).
MyHealthEData aims to break down the barriers that prevent patients
from having electronic access and true control of their own health
records from the device or application of their choice. This effort
will approach the issue of healthcare data from the patient's
perspective.
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\10\ https://www.cms.gov/Newsroom/MediaReleaseDatabase/Fact-sheets/2018-Fact-sheets-items/2018-03-06.html.
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For the Promoting Interoperability performance category, we require
MIPS eligible clinicians to use 2015 Edition certified EHR technology
beginning with the 2019 MIPS performance period to make it easier for:
Patients to access their data.
Patient information to be shared between doctors and other
health care providers.
Continuing To Support Small and Rural Practices
We understand that the Quality Payment Program is a big change for
clinicians, especially for those in small and rural practices. We
intend to continue to offer tailored flexibilities to help these
clinicians to participate in the program. For example, we propose to
retain a small practice bonus under MIPS by moving it to the quality
performance category. We will also continue to support small and rural
practices by offering free and customized resources available within
local communities, including direct, one-on-one support from the Small,
Underserved, and Rural Support Initiative along with our other no-cost
technical assistance.
Further, we note that we are proposing to amend our regulatory text
to allow small practices to continue using the Medicare Part B claims
collection type. We are also proposing to revise the regulatory text to
allow a small practice to submit quality data for covered professional
services through the Medicare Part B claims submission type for the
quality performance category, as discussed further in section
III.H.3.h. of this proposed rule. Finally, small practices may continue
to choose to participate in MIPS as a virtual group, as discussed in
section III.H.3. of this proposed rule.
Empowering Patients Through the Patients Over Paperwork Initiative
Our Patients Over Paperwork initiative establishes an internal
process to evaluate and streamline regulations with a goal to reduce
unnecessary burden, to increase efficiencies, and to improve the
beneficiary experience.\11\ This administration is dedicated to putting
patients first, empowering consumers of healthcare to have the
information they need to be engaged and active decision-makers in their
care. As a result of this consumer empowerment, clinicians will gain
competitive advantage by delivering coordinated, high-value quality
care.
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\11\ Patients Over Paperwork web page available at https://www.cms.gov/Outreach-and-Education/Outreach/Partnerships/PatientsOverPaperwork.html.
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The proposals for the Quality Payment Program in this proposed rule
seek to promote competition and to empower patients. We are
consistently listening, and we are committed to using data-driven
insights, increasingly aligned and meaningful quality measures, and
technology that empowers patients and clinicians to make decisions
about their healthcare.
In conjunction with development of the Patients Over Paperwork
initiative, we are making progress toward developing a patient-centered
portfolio of measures for the Quality Payment Program, including 7 new
outcome measures included on the 2017 CMS Measures Under Consideration
List,\12\ 5 of which are directly applicable to the prioritized
specialties of general medicine/crosscutting and orthopedic surgery.
Finally, on March 2, 2018, CMS announced a funding opportunity for $30
million in grants to be awarded for quality measure development. The
funding opportunity is aimed at external stakeholders with insight into
clinician and patient perspectives on quality measurement and areas for
improvement to advance quality measures for the Quality Payment
Program.\13\
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\12\ Centers for Medicare & Medicaid Services. List of Measures
Under Consideration for December 1, 2017. Baltimore, MD: US
Department of Health and Human Services; 2017. https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/QualityMeasures/Downloads/Measures-under-Consideration-Listfor2017.pdf. Accessed May 4, 2018.
\13\ Centers for Medicare & Medicaid Services. Medicare Access
and CHIP Reauthorization Act of 2015 (MACRA) Funding Opportunity:
Measure Development for the Quality Payment Program. Baltimore, MD:
US Department of Health and Human Services; 2018. https://blog.cms.gov/2018/03/02/medicare-access-and-chipreauthorization-act-of-2015-macra-funding-opportunity/. Accessed May 4, 2018.
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[[Page 35883]]
Promoting Price Transparency
Through the Executive Order Promoting Healthcare Choice and
Competition Across the United States (E.O. 13813, 82 FR 48385 (Oct. 12,
2017)), the President prioritized changing the rate of growth of
healthcare spending to foster competition in healthcare markets,
resulting in the American people receiving better value for their
investment in healthcare. To support these goals, we are helping
patients control their health data and make it easier to take their
data with them as they move in and out of the healthcare system. This
will let patients make informed choices about their care, leading to
more competition and lower costs.
b. Summary of the Major Provisions
(1) Quality Payment Program Year 3
We believe the third year of the Quality Payment Program should
build upon the foundation that has been established in the first 2
years, which provides a trajectory for clinicians moving to a
performance-based payment system. This trajectory provides clinicians
the ability to participate in the program through two pathways: MIPS
and Advanced APMs.
(2) Payment Adjustments
As discussed in section VII.F.8. of this proposed rule, for the
2021 MIPS payment year and based on Advanced APM participation during
the 2019 MIPS performance period, we estimate that between 160,000 and
215,000 clinicians will become Qualifying APM Participants (QP). As a
QP, an eligible clinician is exempt from the MIPS reporting
requirements and payment adjustment, and qualifies for a lump sum
incentive payment based on 5 percent of their aggregate payment amounts
for covered professional services for the prior year. We estimate that
the total lump sum APM incentive payments will be approximately $600-
800 million for the 2021 Quality Payment Program payment year.
For MIPS, we have posted a blog that provides preliminary
participation information for the first year of MIPS.\14\ However, due
to time constraints, we are unable to incorporate and analyze the
performance and participation data from the first year of MIPS for the
estimates in this proposed rule. Therefore, under the policies proposed
in this proposed rule, we based our estimates for the 2019 MIPS
performance period/2021 MIPS payment year on historical 2016 PQRS and
Medicare and Medicaid EHR Incentive Program data. We estimate that
approximately 650,000 clinicians would be MIPS eligible clinicians in
the 2019 MIPS performance period. This number will depend on a number
of factors, including the number of eligible clinicians excluded from
MIPS based on their status as QPs or Partial QPs, the number that
report as groups, and the number that elect to opt-in to MIPS. In the
2021 MIPS payment year, MIPS payment adjustments, which only apply to
covered professional services, will be applied based on MIPS eligible
clinicians' performance on specified measures and activities within
four integrated performance categories. We estimate that MIPS payment
adjustments will be approximately equally distributed between negative
MIPS payment adjustments ($372 million) and positive MIPS payment
adjustments ($372 million) to MIPS eligible clinicians, as required by
the statute to ensure budget neutrality. Positive MIPS payment
adjustments will also include up to an additional $500 million for
exceptional performance to MIPS eligible clinicians whose final score
meets or exceeds the proposed additional performance threshold of 80
points. However, the distribution will change based on the final
population of MIPS eligible clinicians for the 2021 MIPS payment year
and the distribution of final scores under the program. We anticipate
that we will be able to update these estimates with the data from the
first year of MIPS in the CY 2019 Quality Payment Program final rule.
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\14\ https://blog.cms.gov/2018/05/31/quality-payment-program-exceeds-year-1-participation-goal/.
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2. Definitions
At Sec. 414.1305, subpart O--
We define the following terms:
++ Ambulatory Surgical Center (ASC)-based MIPS eligible clinician.
++ Collection type.
++ Health IT vendor.
++ MIPS determination period.
++ Submission type.
++ Submitter type.
++ Third party intermediary.
We revise the definitions of the following terms:
++ High priority measure.
++ Hospital-based MIPS eligible clinician
++ Low-volume threshold.
++ MIPS eligible clinician.
++ Non-patient facing MIPS eligible clinician.
++ Qualified Clinical Data Registry (QCDR).
++ Qualifying APM Participant (QP).
++ Small practices.
These terms and definitions are discussed in detail in relevant
sections of this proposed rule.
3. MIPS Program Details
a. MIPS Eligible Clinicians
Under Sec. 414.1305, a MIPS eligible clinician, as identified by a
unique billing TIN and NPI combination used to assess performance, is
defined as any of the following (excluding those identified at Sec.
414.1310(b)): A physician (as defined in section 1861(r) of the Act); a
physician assistant, nurse practitioner, and clinical nurse specialist
(as such terms are defined in section 1861(aa)(5) of the Act); a
certified registered nurse anesthetist (as defined in section
1861(bb)(2) of the Act); and a group that includes such clinicians.
Section 1848(q)(1)(C)(II) of the Act provides the Secretary with
discretion, beginning with the 2021 MIPS payment year, to specify
additional eligible clinicians (as defined in section 1848(k)(3)(B) of
the Act) as MIPS eligible clinicians. Such clinicians may include
physical therapists, occupational therapists, or qualified speech-
language pathologists; qualified audiologists (as defined in section
1861(ll)(3)(B) of the Act); certified nurse-midwives (as defined in
section 1861(gg)(2) of the Act); clinical social workers (as defined in
section 1861(hh)(1) of the Act); clinical psychologists (as defined by
the Secretary for purposes of section 1861(ii) of the Act); and
registered dietitians or nutrition professionals.
We received feedback from non-physician associations representing
each type of additional eligible clinician through listening sessions
and meetings with various stakeholder entities and through public
comments discussed in the CY 2017 Quality Payment Program final rule
(81 FR 77038). Commenters generally supported the specification of such
clinicians as MIPS eligible clinicians beginning with the 2021 MIPS
payment year.
To assess whether these additional eligible clinicians could
successfully participate in MIPS, we evaluated whether there would be
sufficient measures and activities applicable and available for each of
the additional eligible clinician types. We focused our analysis on the
quality and improvement activities performance categories because these
performance categories require submission of data. We did not focus on
the Promoting Interoperability performance category because there is
extensive analysis regarding who can participate under the current
exclusion criteria. In addition,
[[Page 35884]]
in section III.H.3.i.(2)(b) of this proposed rule, we are proposing to
automatically assign a zero percent weighting for the Promoting
Interoperability performance category for these new types of MIPS
eligible clinicians. In addition, we did not focus on the cost
performance category because we are only able to assess cost
performance for a subset of eligible clinicians--those who are
currently eligible as a result of not meeting any of the current
exclusion criteria. So the impact of the cost performance category for
these additional eligible clinicians will continue to be considered but
is currently not a decisive factor. From our analysis, we found that
improvement activities would generally be applicable and available for
each of the additional eligible clinician types. However, for the
quality performance category, we found that not all of the additional
eligible clinician types would have sufficient MIPS quality measures
applicable and available. As discussed in section III.H.3.h.(2)(b)(iii)
of this proposed rule, for the quality performance category, we are
proposing to remove several MIPS quality measures. If those measures
are finalized for removal, we anticipate that qualified speech-language
pathologists, qualified audiologists, certified nurse-midwives, and
registered dietitians or nutrition professionals would each have less
than 6 MIPS quality measures applicable and available to them. However,
if the quality measures are not finalized for removal, we will reassess
whether these eligible clinicians would have an adequate amount of MIPS
quality measures available to them. If we find that these additional
clinicians do have at least 6 MIPS quality measures available to them,
then we propose to include them in the MIPS eligible clinician
definition. We are focusing on the quality performance category because
as discussed above, the quality and improvement activities performance
categories require submission of data. We believe there would generally
be applicable and available improvement activities for each of the
additional eligible clinician types, but that not all of the additional
eligible clinician types would have sufficient MIPS quality measures
applicable and available if the proposed MIPS quality measures are
removed from the program. We did find QCDR measures approved for the CY
2018 performance period that are either high priority and/or outcome
measures that, if approved for the CY 2019 performance period, may be
applicable to these additional eligible clinicians. However, this would
necessitate that they utilize a QCDR in order to be successful in MIPS.
Further, we have heard some concerns from the non-physician
associations, through written correspondence, that since their
clinicians would be joining the program 2 years after its inception, we
should consider several ramp-up policies in order to facilitate an
efficient integration of these clinicians into MIPS. We note that the
MIPS program is still ramping up, and we will continue to increase the
performance threshold to ensure a gradual and incremental transition to
the performance threshold until Quality Payment Program Year 6.
Therefore, if specified as MIPS eligible clinicians beginning with the
2021 MIPS payment year, the additional eligible clinicians would have 4
years in the program in order to ramp up. Conversely, if specified as
MIPS eligible clinicians beginning in a future year, they would be
afforded less time to ramp up the closer the program gets to Quality
Payment Program Year 6.
Therefore, we request comments on our proposal to amend Sec.
414.1305 to modify the definition of a MIPS eligible clinician, as
identified by a unique billing TIN and NPI combination used to assess
performance, to mean any of the following (excluding those identified
at Sec. 414.1310(b)): A physician (as defined in section 1861(r) of
the Act); a physician assistant, nurse practitioner, and clinical nurse
specialist (as such terms are defined in section 1861(aa)(5) of the
Act); a certified registered nurse anesthetist (as defined in section
1861(bb)(2) of the Act); beginning with the 2021 MIPS payment year, a
physical therapist, occupational therapist, clinical social worker (as
defined in section 1861(hh)(1) of the Act), and clinical psychologist
(as defined by the Secretary for purposes of section 1861(ii) of the
Act); and a group that includes such clinicians. Alternatively, we
propose that if the quality measures proposed for removal are not
finalized, then we would include additional eligible clinician types in
the definition of a MIPS eligible clinician beginning with the 2021
MIPS payment year (specifically, qualified speech-language
pathologists, qualified audiologists, certified nurse-midwives, and
registered dietitians or nutrition professionals), provided that we
determine that each applicable eligible clinician type would have at
least 6 MIPS quality measures available to them. In addition, we are
requesting comments on: (1) Specifying qualified speech-language
pathologists, qualified audiologists, certified nurse-midwives, and
registered dietitians or nutrition professionals as MIPS eligible
clinicians beginning with the 2021 MIPS payment year; and (2) delaying
the specification of one or more additional eligible clinician types as
MIPS eligible clinicians until a future MIPS payment year.
b. MIPS Determination Period
Currently, MIPS uses various determination periods to identify
certain MIPS eligible clinicians for consideration for certain
applicable policies. For example, the low-volume threshold, non-patient
facing, small practice, hospital-based, and ambulatory surgical center
(ASC)-based determinations are on the same timeline with slight
differences in the claims run-out policies, whereas the facility-based
determinations has a slightly different determination period. The
virtual group eligibility determination requires a separate election
process. We are proposing in this rule to add a virtual group
eligibility determination period beginning in CY 2020 as discussed in
section III.H.3.f.(2)(a) of this proposed rule. In addition, the rural
and health professional shortage area (HPSA) determinations do not
utilize a determination period.
Under Sec. 414.1305, the low-volume threshold determination period
is described as a 24-month assessment period consisting of an initial
12-month segment that spans from the last 4 months of the calendar year
2 years prior to the performance period through the first 8 months of
the calendar year preceding the performance period, and a second 12-
month segment that spans from the last 4 months of the calendar year 1
year prior to the performance period through the first 8 months of the
calendar year performance period. An individual eligible clinician or
group that is identified as not exceeding the low-volume threshold
during the initial 12-month segment will continue to be excluded under
Sec. 414.1310(b)(1)(iii) for the applicable year regardless of the
results of the second 12-month segment analysis. For the 2020 MIPS
payment year and future years, each segment of the low-volume threshold
determination period includes a 30-day claims run out.
Under Sec. 414.1305, the non-patient facing determination period
is described as a 24-month assessment period consisting of an initial
12-month segment that spans from the last 4 months of the calendar year
2 years prior to the performance period through the first 8 months of
the calendar year preceding the performance period and a second 12-
month segment that spans from the last 4 months of the calendar year 1
year prior to the performance
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period through the first 8 months of the calendar year performance
period. An individual eligible MIPS clinician, group, or virtual group
that is identified as non-patient facing during the initial 12-month
segment will continue to be considered non-patient facing for the
applicable year regardless of the results of the second 12-month
segment analysis. For the 2020 MIPS payment year and future years, each
segment of the non-patient facing determination period includes a 30-
day claims run out.
In the CY 2018 Quality Payment Program final rule (82 FR 53581), we
finalized that for the small practice size determination period, we
would utilize a 12-month assessment period, which consists of an
analysis of claims data that spans from the last 4 months of a calendar
year 2 years prior to the performance period followed by the first 8
months of the next calendar year and includes a 30-day claims run out.
In the CY 2017 Quality Payment Program final rule (81 FR 77238
through 77240), we finalized that to identify a MIPS eligible clinician
as hospital-based we would use claims with dates of service between
September 1 of the calendar year 2 years preceding the performance
period through August 31 of the calendar year preceding the performance
period, but in the event it is not operationally feasible to use claims
from this time period, we would use a 12-month period as close as
practicable to this time period.
In the CY 2018 Quality Payment Program final rule (82 FR 53684
through 53685), we finalized that to identify a MIPS eligible clinician
as ASC-based, we would use claims with dates of service between
September 1 of the calendar year 2 years preceding the performance
period through August 31 of the calendar year preceding the performance
period, but in the event it is not operationally feasible to use claims
from this time period, we would use a 12-month period as close as
practicable to this time period.
In the CY 2018 Quality Payment Program final rule (82 FR 53760), we
discussed, but did not finalize, our proposal or the alternative option
for how an individual clinician or group would elect to use and be
identified as using facility-based measurement for the MIPS program.
Because we were not offering facility-based measurement until the 2019
MIPS performance period, we did not need to finalize either of these
for the 2018 MIPS performance period. However, in section
III.H.3.i.(1)(d) of this proposed rule, we are proposing to amend Sec.
414.1380(e)(2)(i)(A) to specify a criterion for a clinician to be
eligible for facility-based measurement. Specifically, that is, the
clinician furnishes 75 percent or more of his or her covered
professional services in sites of service identified by the place of
service codes used in the HIPAA standard transaction as an inpatient
hospital, on-campus outpatient hospital, or emergency room setting
based on claims for a 12-month segment beginning on October 1 of the
calendar year 2 years prior to the applicable performance period and
ending on September 30 of the calendar year preceding the applicable
performance period with a 30-days claims run out. We are not proposing
to utilize the MIPS determination period for purposes of the facility-
based determination because for the facility-based determination, we
are only using the first segment of the MIPS determination period. We
are using the first segment because the performance period for measures
in the hospital value-based purchasing program overlapped in part with
that determination period. If we were to use the second segment, we
could not be assured that the clinician actually worked in the hospital
on which their MIPS score would be based during that time. We believe
this approach provides clarity and