Medicare finalized its 2019 PFS

AOA scores big wins in Medicare’s 2019 PFS rulemaking

Medicare's 2019 Physician Fee Schedule (PFS) is out and the final verdict is in: The AOA left its mark on key policy considerations that affect optometry and secured a resounding affirmation of comprehensive eye examinations.

At a time when our detractors oppose us at every opportunity and every level, AOA's cogent and patient-care focused advocacy efforts rise above the fray and prevail.

Published by the Centers for Medicare & Medicaid Services (CMS) on Nov. 1, the final rule updates payment polices, rates and quality provisions for services furnished under the PFS come Jan. 1, 2019, and reportedly reflects the administration's efforts to improve accessibility, quality, affordability and innovation. Those efforts manifested as broad changes to telehealth coverage, evaluation and management (E/M) services and Merit-based Incentive Payment System (MIPS) program measures. 

In July, CMS proposed several new and significant policy changes for calendar year (CY) 2019 that would impact how doctors of optometry and other physicians must furnish care and practice. The AOA immediately responded by engaging in a series of meetings with CMS officials and crafting detailed public comments that argued for very specific policy adjustments, many of which are reflected in the final rule. 

Samuel D. Pierce, O.D., AOA president, says the final rule is clear evidence of AOA's power to advance optometry's priorities. 

"At a time when our detractors oppose us at every opportunity and every level, AOA's cogent and patient-care-focused advocacy efforts rise above the fray and prevail," Dr. Pierce says. "CMS made decisions that were right for the practice of health care and right for the care of our patients."

CMS stands behind comprehensive eye exams

 Year three of the Quality Payment Program (QPP) known as MIPS will see some changes to the quality measures that eligible providers must report, as well as who may participate. While CMS focused on removing low-value, low-priority quality measures in favor of those with a greater impact on health outcomes, it effectively doubled down on the importance of comprehensive eye examinations

Last year, the AOA offered CMS an innovative policy recommendation that would create a MIPS improvement activity to encourage greater patient education efforts nationwide about in-person, comprehensive eye exams. The CMS embraced this recommendation and finalized it for the CY 2019 Performance Period, and thereafter. 

Specifically, CMS notes that in order for providers to receive credit for this activity, MIPS-eligible clinicians must provide literature or facilitate conversations about the topic "using resources such as the Think About Your Eyes campaign, and/or referring patients to resources providing no-cost eye exams ... such as the American Optometric Association's VISION USA." Now, for CY 2019, any doctor type who educates patients on the value of comprehensive eye exams can earn this MIPS improvement activity credit. 

However, the proposal was initially met with opposition. During the regulatory process, CMS received comments from the American Academy of Ophthalmology (AAO) that urged CMS against finalizing the proposal. The AAO commented that "the proposed activity description is very likely to lead to increases in unnecessary expenditures both for public programs and for low-income patients." 

CMS patently rejected the AAO's comment and responded by indicating "since comprehensive eye exams are relatively low-cost interventions and early detection of conditions that can be identified through an eye exam may reduce more costly treatment later, we believe this improvement activity will not unnecessarily increase expenditures for public programs and the target population." Overall, CMS noted the improvement activity "will have a positive impact on patient care and promote health equity." 

Additionally, CMS finalized changes in CY 2019 that will allow doctors to opt into MIPS, as long as they meet one of the low-volume threshold requirements; added a new low-volume threshold of 200 services annually; and eliminated claims-based reporting of quality measures for larger practices, but smaller practices—under 15 doctors—can still report quality measures via claims. 

Informing telehealth policy 

Medicare continues to prize technology and health IT innovation as it moves toward greater acceptance of telehealth and remote patient monitoring in this final rule. Beyond expanded reimbursement for remote patient-monitoring services, CMS also established a new HCPCS code for virtual check-ins with the CY 2019 update that initially drew concerns from other health groups when first proposed. 

For its part, AOA relied on its telehealth policy when submitting public comments on CMS' telehealth changes to ensure safeguards for the doctor-patient relationship—and CMS took note. The AOA argued for stringent tailoring of telehealth "check-in visits," namely that physicians must obtain consent prior to performing telehealth services and that telehealth check-in visits must only be available for use by established patients after a doctor-patient relationship had been developed, and CMS agreed.  

The final rule contains both these provisions, and regarding check-in visits, CMS added that such codes could only be reported by those that can furnish E/M services. Furthermore, when the AOA argued that CMS should not be overly prescriptive in the types of technology used for each visit, CMS noted: 

"We are persuaded by the comments advising us not to be overly prescriptive about the technology that is used, and are finalizing allowing audio-only, real-time telephone interactions in addition to synchronous, two-way audio interactions that are enhanced with video or other kinds of transmission." 

Separately, CMS also addressed usage of store-and-forward telehealth technology. Again, the AOA argued on behalf of an established doctor-patient relationship and telehealth usage only with express patient consent. In its final rule, CMS recognized separate payment for store-and-forward telehealth when used to determine if an office visit is necessary, but only permissible for established patients. So, too, CMS agreed that patient consent is required in the medical record for each billed service for the HCPCS code.  

Emphasizing efficiency with E/M visits 

In keeping with CMS' stated desire to reduce administrative burdens and improve the accuracy of payments for E/M visits, the final rule implements several changes to documentation polices for the immediate future (CYs 2019-2020), as well as documentation, coding and payment changes in the years ahead (CY 2021). Here's what CMS finalized for CY 2019:

  • Elimination of the requirement to document the medical necessity of a home visit in lieu of an office visit.
  • For established patient visits, practitioners may document what has changed since the last visit-or pertinent items that have not changed—when relevant information is already in the medical record, and need not re-record the defined list of required elements if practitioners review the prior information and no update is warranted.
  • For E/M visits, practitioners need not re-enter the patient's chief complaint and history that has already been entered by ancillary staff or the beneficiary. Practitioners may simply indicate the medical record has been reviewed and verified.  

In CY 2021, CMS finalized changes to policies regarding documentation for E/M visit levels as well as implementation of add-on codes for "extended visits" with patients and those that "describe additional resources inherent in visits for primary care and particular kinds of non-procedural specialized medical care." 

On the whole, the AOA supported CMS' efforts to reduce unnecessary documentation but argued that more time was needed to consider such significant payment changes that would completely alter reimbursement for E/M services in 2019. In the final rule, CMS noted that practitioners should continue using either 1995 or 1997 versions of E/M guidelines while it begins discussions on a refined coding and payment structure for E/M visits for 2021. 

The AOA also opposed CMS' proposal to reduce payment by 50 percent for the "least expensive procedure or visit that the same physician (or a physician in the same group practice) furnished on the same day as a separately identifiable E/M visit." Additionally, the AOA supported the add-on code for primary care E/M visits and will continue to argue that doctors of optometry providing primary care should be able to report this code. 

Click here to review the 2019 Medicare PFS in the Federal Register, and click here to review CMS' fact sheet.  

November 8, 2018

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