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Exploring the CMS final rule for MACRA and 2019 Physician Fee Schedule

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Adding payment options for virtual services and a subset of changes to the Medicare Shared Savings Program for Accountable Care Organizations (ACOs) are two of the updates included in the final rule released by the Centers for Medicare & Medicaid Services (CMS) on November 1, 2018. The final rule includes updates to payment policies, payment rates, and quality provisions for services furnished under the Medicare Physician Fee Schedule (PFS) on or after January 1, 2019.

Many of the updates relate to communication technology, telemedicine, and virtual check-ins. One of the new payment provisions is listed under the category of “Modernizing Medicare Physician Payment by Recognizing Communication Technology-Based Services.” CMS is finalizing proposals to pay separately for two newly defined physicians’ services provided using communication technology:

  • Brief communication technology-based service, e.g. virtual check-in (HCPCS code G2012)
  • Remote evaluation of recorded video and/or images submitted by an established patient (HCPCS code G2010)

In a move toward making healthcare more efficient and more convenient, these payment provisions would mean that healthcare providers would be paid for “the brief communication technology-based service when the patient checks in with the practitioner via telephone or other telecommunications device to decide whether an office visit or other service is needed.”

Recognizing the value of telemedicine in the continuing efforts to reduce opioid addiction, CMS is also implementing a provision that removes the originating site geographic requirements from the Substance Use-Disorder Prevention that Promotes Opioid Recovery and Treatment (SUPPORT) for Patients and Communities Act, adding the home of the patient as a permissible originating site for telehealth services furnished for purposes of treatment of a substance use disorder or a co-occurring mental health disorder for services furnished on or after July 1, 2019.

In regard to ACOs, the CMS final rule addresses a number of changes, including:

  • A voluntary 6-month extension for existing ACOs whose participation agreements expire on December 31, 2018, and the methodology for determining financial and quality performance for this 6-month performance year from January 1, 2019, through June 30, 2019.
  • Allowing beneficiaries who voluntarily align to a Nurse Practitioner, Physician Assistant, Certified Nurse Specialist, or a physician with a specialty not used in assignment to be prospectively assigned to an ACO if the clinician they align with is participating in an ACO, as provided for in the Bipartisan Budget Act of 2018.
  • Revising the definition of primary care services used in beneficiary assignment.
  • Providing relief for ACOs and their clinicians impacted by extreme and uncontrollable circumstances in 2018 and subsequent years.
  • Reducing the Shared Savings Program core quality measure set by eight measures; and promoting interoperability among ACO providers and suppliers by adding a new CEHRT threshold criterion to determine ACOs’ eligibility for program participation and retiring the current Shared Savings Program quality measure on the percentage of eligible clinicians using CEHRT.

The final rule spans 2,378-pages; however, CMS has published a fact sheet on “Final Policy, Payment, and Quality Provisions Changes to the Medicare Physician Fee Schedule for Calendar Year 2019,” providing a list of the updates and changes to the PFS for calendar year (CY) 2019.