Keeping Up With The 2019 Physician Fee Schedule Updates

Keeping Up With The 2019 Physician Fee Schedule Updates


Effective from January 1, 2019, the Medicare Physician Fee Schedule has become a significant driving force of change and updates going forward until 2021. CMS has implemented various changes with the primary aim of maximizing the accessibility, affordability, and quality of patient care in the industry. The rule has paved the way for multiple alterations in the documentation, payment policies, and provisions together with accepting reasonable proposals related to the use of G-codes, modifiers, and various other provisions.

In the present year, the Final Rule has furnished numerous changes under Medicare Physicians Fee Schedule (MPFS) including the revisions in the Quality Payment Program (QPP), which was independently published in the previous year. This is markedly the first time where CMS decided to jointly publish the PFS and QPP proposed rule, including payment regulation of the final regulations.

An Overview

A physician fee is an inclusive list of the entire fee scheduled required to be reimbursed to the providers on the bases of Fee-for-Service basis. These services consist of patient visits, diagnostic tests, therapy visits, surgical procedure, etc. CMS releases the Fee Schedule lists annually for physicians, nurse practitioners, physician assistants, therapists, ambulance services, clinical services, laboratory services, clinical laboratory services, and durable medical equipment, prosthetics, orthotics, and supplies.

The determined decision by CMS to make the changes in PFS and QPP in reference to the agenda of maximizing patient care has modernized the healthcare organizations. With upfront changes in the documentation requirements to changes in the payment policies, CMS has to steer clear the way for a modernized and technology-based healthcare environment. The final rule is comprehensive, concise, and apt for the impending requirement as per the medical associations and individual physicians.

The PFS Final rule has majorly benefitted the clinicians by reducing the administrative cost by $843 million for the next decade, creating a sanguine impact on the financial health of the industry.

What changed under the Final Rule?

1.   The significant decision of separate payment of Virtual Services

While continuing its inaugural streak, CMS has created three new codes for telecommunication services. Under this, physicians will be paid for their services whenever a patient checks-in virtually to avail the services. These new HCPCS codes are:

  • HCPCS Code G2012 – for the non-face-to-face but brief appointments via communications technology – these are the virtual check-ins which can only be utilized by an established patient to communicate with his/her patient. CMS has established these codes to reimburse and reward the providers who can save superfluous healthcare finances and increases patient care by merely consulting the patient virtually. If the virtual service originates from a related E/M service, then CMS has proposed not to bill it separately but bundled.


  • HCPCS G2010 – for remote evaluation of patients by submitting photos and videos – This is an independent service which has eliminated the possibility of an E/M office visit seven days before the service to be provided or any service or procedure provided within the next 24 hours after the available appointment. To make the process more efficient, CMS had finalized the consent process to be available in the form of verbal, written, or any electronic confirmation. Valerie McCleary, MS RHIA, a Health Information Management Professional, has conducted various session regarding the recent updates, revisions, and changes by CMS in the field of Virtual Reality and telemedicine.

Moreover, through these codes, physicians have been provided with the facility of following up with the patient via audio/ video communication, text messages, email, or any patient portal communication system.

2.    2019 Physician Fee Schedule Telehealth

CMS has also made several changes to the Telehealth services by making it more geographically viable to the patients living in remote areas.  The decision to remove the originating site geographic requirements and to add the home of an individual as a permissible originating site a geographic condition has also stirred many pots.

On or after July 01, 2019, CMS has decided to implement a provision for the Substance Use-Disorder Prevention that Promotes Opioid Recovery and Treatment (SUPPORT) as a Patient and Communities Act. By applying a provision of the SUPPORT Law, CMS is making it available for the Substance Use Disorder (SUD) or co-occurring Mental Health Disorder patients to get access to the telehealth service from home only.

3.    E/M Updates - The Long-Awaited Overhaul

The last E/M changes or overhaul was over 20 years ago. It has been more than two decades that CMS has initiated any changes in the medical record documentation guidelines. The evaluation and management documentation requirements are now seeing the daylight of change in the year 2019, affecting the process until 2021. For this matter, CMS has proposed these major changes in the E/M codes 99210-99215 so that excessive and dispensable burden of documentation can be eliminated from the physician’s daily cycle – making him focus on patient care, prominently. But are you updated with the 2019 E/M Guidelines?

These guidelines are a key factor in the aspects of HIPAA Audits, documentation, reimbursement, etc. It has become the need of the hour to be kept posted with the CMS updates and guidelines if one aims at attaining proper reimbursements or passing an audit – impeccably.

As of today various changes have and will come into effects in 2019, and many document-related changes have been postponed till 2021 as posted by CMS. 

According to CMS, the key criterion behind making these adjustments were history, examination, and medical decision making. The much-talked-about overhauls are:

  1. If a medical examination or visit has already taken place between the patient and the physician, then instead of re-entering the medical records and information, the practitioner can simply check it as reviewed and verified. This applies to all the new as well as established patients.
  2. CMS has removed the need to document medical necessity regarding home visits instead of office visits – To eliminate E/M visit complexities, it has been put forward that practitioners are not required to record a home visit instead of an office visit.
  3. In case of office/outpatient visits of an established patient, CMS has issued that if relevant information is already entered in the medical records, physicians don’t need to re-enter any record and instead they can give attention to the documentation aspect of it and can make changes to the items which may or may not have changed in the current visit.

4.   QPP Changes

The Medicare Access and CHIP Reauthorization’s (MACRA) QPP has also seen numerous changes for the current year 2019 as well as payment changes till the year 2021. Under QPP, the key value-based payment programs – The Merit-Based Incentive Payment System (MIPS) and Alternative Payment Models (APMs) – have witnessed the overhaul first hand.

Increased Clinical Eligibility

  • The implementation has changed the inclusiveness in the MIPS by expanding the eligibility of the physicians to a number of new clinicians previously excluded – easing up the providers’ burdens and creating new ways for low-volume provides.
  • The new option of ‘opt-in process’ is crafted to help the low-volume providers in order to assist certain providers which have less volume of patients to still participate in the Merit-Based Incentive Payment System.

The Fee schedule has covered Medicare rates as well as numerous policies under Part B together with QPP covering the payment adjustment under MIPS or participation in the APM. The 2378 page Final Rule has indicated various changes in the performance threshold by altering various provisions from the previous year QPP proposed rule.

5.   Reduced Burden Of The ACO

CMS has also made sure to focus on the deliverability of the medical services to the patients at a lower cost. This, in action, converted in the changes made under the Medicare’s Accountable Care Organization (ACO) by reducing the number of core quality measure.

 In order to restructure the Medicare Shared Savings Program (MSSP), the proposed rule also has a time-sensitive provision. Participants whose agreement ended on December 31, 2019, had been given a 6-month extension period starting from January 1.

6.   Off-Campus Outpatient Department

CMS remained neutral in the payment policies under the final rule. Any Non-excepted Off-campus hospital department built after November 2, 2015, will be paid 40% of the 2019 Outpatient Prospective Payment System (OPPS). The 2019 OPPS Final Rule has also been separately released by CMS where it has cut down the drug acquisition through the 340B program.  According to CMS, the PFS Relatively Adjuster is a means to ignite a healthy relationship between hospitals and physicians practices.

2019 has become the year of overhauls, revisions, and updates in the healthcare industry. The latest updates have been so that the after-affect has a reach till 2021. To be updated and on track with your practice, SymposiumGo organizes various webinars by the industry’s most experienced speakers and experts. Get yourself a webinar – be it a Live, Recorded, or an On-demand – and update your medical practice with the latest changes to change your gears and step on to the next level of career.