1. Highlights of the 2019 IPPS, OPPS* and PFS* Rules
23rd Annual Mississippi Rural health conference
November 2, 2018
* Proposed Rule as of 10/28/2018

2. What do they all have in common?
Seek to Reduce Medicare Beneficiary’s cost share and provide convenience
Reduced co-insurance amounts
Pricing transparency
Seek to control or eliminate over-utilization and duplicative services
Site Neutrality
Reimbursement Reductions
Changes to MS-DRG, APC and PFS
Focus on care management and coordination of care
Expanded CPT/HCPCS® codes
Reimbursement increases
Continue to advance health information technology for patient care and quality measures
Remote services
Smaller set of measures

3. 2019 IPPS Final Rule
August 2, 2018
CMS-1694-F

4. Who does it affect?
The 2019 IPPS Final Rule affects approximately 3,330 Acute Care Hospitals and approximately LTCHs.
The changes apply to discharges occurring on or after October 1, 2018.

5. Interoperability
The Medicare and Medicaid Promoting Interoperability Programs replace the EHR Incentive Programs for eligible hospitals, CAHS, and eligible professionals.
A minimum 90 day continuous reporting period in calendar year 2019 and 2020.
A smaller set of measures which CMS intends to use to create a less burdensome and more flexible structure.
E-prescribing measures related to opioids and controlled substances. Drug monitoring programs optional in CY 2019.
Beginning with CY 2019, providers are required to use EHR products with 2015 CEHRT.

6. Pricing Transparency
For CY 2019, CMS will require hospitals to make available to the public a list of their standard charges via the internet in a machine readable format. The information should be updated annually or more often if appropriate.
Recommendations (not rule) to ensure that patients know what their out-of-pocket cost will be including information on out-of-network services/professional fees.

7. Reduction in Quality Measures
Under Inpatient Quality Reporting, Value-Based Purchasing, Hospital Acquired Conditions, and Readmission Reduction programs, the number of total measures will be reduced.
Capped out measures
Redundant or Duplicative Measures
Remove Measures for which the cost of reporting outweighed the benefit of the measure.
Focus on patient care measures
18 measures to be removed and 25 measures will be de- duplicated.
Streamline and equalize reporting for the “report cards”.

8. Payment Rates under IPPS
Payment Component
Adjustment
Hospital Market Basket Adjustment
+ 2.90%
Productivity Adjustments
- 1.85%
Legislative Adjustment
+ .50%
ACA Adjustment
- .75%
Net Increase*
+1.85%
* For General Acute Hospitals under IPPS that have successfully participate in IQR and meaningful use EHR.

9. Wage Index
“CMS looks forward to continuing to work on geographic payment disparities, particularly for rural hospitals, to the extent permitted by law and appreciates responses to our request for public input on this issue. By allowing for the imputed wage index floor to expire for all urban states, CMS has begun the process of making geographic payments more equitable.” ---CMS IPPS Fact Sheet

10. Uncompensated Care Payments
Estimated increase of $1.5 Billion for FY 2019 compared to FY 2018.
75% of what would have been paid as disproportionate share hospital payment adjusted for the change in rate of uninsured patients and other factors.
Expect increased audits of Worksheet S-10 data.
Possible changes in the instructions for Worksheet S-10.

11. MS-DRG Changes 11 MS-DRGs have been removed (DELETED)
18 MS-DRGs have been created (NEW)
Approximately 76% of MS-DRGs had either a plus/minus 5% change or no change at all in weight.
Approximately 24% of MS-DRGS had either a plus/minus > 5% up to greater than 10% in weight.
Many of the most significant weight changes were for diagnoses with procedures that would not be performed in rural hospitals.

12. 2019 OPPS Rule*
*Proposed, Not Final

13. New CPT® Codes for 2019 335 Code Changes
The American Medical Association, who owns the code set, has made code changes in the new 2019 CPT edition. The changes reflect the CPT Editorial Panel and the health care community’s combined annual effort to capture and describe the latest scientific and technological advances in medical, surgical and diagnostic services.
335 Code Changes
Implementation of January 1, 2019
CMS urged to accept the code changes
Changes to CMS specific G codes. (have all resources)
CPT® Codes are the property of the AMA.

14. OPPS Rate Increase
CMS proposed increasing the OPPS rates by percent in The agency arrived at its proposed rate increase through the following updates: a positive 2.8 percent market basket update, a negative 0.8 percentage point update for a productivity adjustment and a negative percentage point adjustment for cuts under the ACA.

15. Site Neutral Reimbursement
Under the proposed rule, CMS would make payments for clinic visits site-neutral by reducing the payment rate for hospital outpatient clinic visits provided at off-campus provider-based departments to 40 percent of the OPPS rate. The clinic visit is the most common service billed under the OPPS, and CMS estimates the payment proposal would save the Medicare program and Medicare recipients a combined $760 million in 2019.
This change is projected to reduce OPPS payments by percent, which would largely offset the 1.25 percent payment rate increase under the proposed rule.

16. Site Neutrality and Patient Cost Share
“For an individual Medicare beneficiary, current Medicare payment for the clinic visit is approximately $116 with $23 being the average beneficiary copayment. The proposal to adjust this payment to the PFS equivalent rate would reduce the OPPS payment rate for the clinic visit by the PFS relativity adjuster of 40 percent to an amount of $46 and a beneficiary copayment of $9, thus saving beneficiaries an average of $14 each time they visit an off-campus department.”
CMS Fact Sheet:

17. 340 B Drug Reimbursement
 CMS scaled back the 340B drug discount program in 2018, and the agency proposed additional cuts for next year.
On Jan. 1, 2018, CMS began paying hospitals 22.5 percent less than the average sales price for drugs purchased through the 340B program. That's compared to the previous payment rate of average sales price plus 6 percent.
Under the proposed rule, CMS would extend the average sales price minus 22.5 percent payment rate to 340B drugs provided at nonexcepted off-campus provider-based departments.
CMS also proposed to pay for separately payable biosimilars acquired under the 340B program at the average sales price minus 22.5 percent of the biosimilar's own ASP, rather than ASP minus 22.5 percent of the reference product's ASP.

18. Changes in Quality Reporting
For 2019, CMS proposed removing one measure from the Hospital Quality Reporting Program beginning with the payment determination and removing nine other measures beginning with the 2021 payment determination.
"The proposals to remove these measures are consistent with the CMS' commitment to using a smaller set of more meaningful measures and focusing on patient-centered outcomes measures, while taking into account opportunities to reduce paperwork and reporting burden on providers," CMS said in the fact sheet for the proposed rule.

19. 2019 PFS Rule
Proposed Changes

20. RVU Conversion Factor
“With the budget neutrality adjustment to account for changes in RVUs, all required by law, the proposed 2019 PFS conversion factor is $36.05, a slight increase above the PFS conversion factor of $35.99.” –CMS Fact Sheet

21. Patients Over Paperwork?
“...we propose to apply a minimum documentation standard where Medicare would require information to support a level 2 CPT visit code for history, exam and/or medical decision-making in cases where practitioners choose to use the current framework, or, as proposed, medical decision-making to document E/M level 2 through 5 visits. In cases where practitioners choose to use time to document E/M visits, we propose to require practitioners 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.
Practitioners could choose to document additional information for clinical, legal, operational or other purposes, and we anticipate that for those reasons, they would continue generally to document medical record information consistent with the level of care furnished.”
changes-medicare-physician-fee-schedule-calendar-year-3

22. Proposed New Patient E & M Reimbursement

23. Proposed Established Patient E & M Reimbursement

24. Primary Care Add-on Code
Proposes an add-on HCPCS G-code.
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.

25. Other Proposed Changes
Add-On Codes for Podiatric Visits
Add-On Codes for Prolonged Face-to-Face Visits
An Technical Modification to Practice Expense Methodology
Allow multiple visits to providers of the same specialty and same group on the same date of service
Reduce duplicative documentation for teaching physicians
Remove the requirement to document medical necessity of home visits.

26. Reduction in Reimbursement for E & M & separately identifiable office procedure
“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.”

27. New & Revised E & M Codes Interprofessional consult codes
99451: 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 minutes or more of medical consultative time.
99452: Interprofessional telephone/Internet/electronic health record referral service[s] provided by a treating/requesting physician or other qualified health care professional, 30 minutes.
For 2019, CMS is proposing to pay for the consultation codes that would reimburse a treating or consulting physician when collaborating on a patient’s treatment plan. The proposed 2019 Medicare physician fee schedule that it would unbundle four current codes — — that pay a consulting physician for providing a report to the treating physician in addition to the two new codes.

28. New & Revised E & M Codes Chronic Care Management
Since CCM code debuted, nurses and ancillary staff could perform the work under general supervision. In 2019, you can report the new code – – when the physician or non-physician provider personally performs the work or the work is performed incident-to.
The 2019 CPT code book describes the difference between the two codes: “Code is reported when, during the calendar month, at least 20 minutes of clinical staff time is spent in care management activities.
Code is reported when 30 minutes of physician or other qualified health care professional personal time is spent in care management activities.”

29. Virtual Check-In/Remote Evaluation
HCPCS Code GVCI1: Brief Communication Technology-based Service, e.g. Virtual Check-in, performed by physician.
HCPCS Code GRAS1: Remote Evaluation of Recorded Video and/or Images Submitted by the Patient (Pre-recorded, store & forward).
“Practitioners could be separately paid for the Brief Communication Technology-based Service when they check in with beneficiaries via telephone or other telecommunications device to decide whether an office visit or other service is needed. This would increase efficiency for practitioners and convenience for beneficiaries.”

30. More about Brief Communication/Technology-Based Services
Separately billable when not related to an office visit within 7 days or resulting in a visit within 24 hours or soonest available appointment.
Separately billable for RHC/FQHCs if the communication does not result in an encounter; included in all-inclusive PPS rate if an encounter results.
A new and unique G Code would be created for RHC/FQHCs. Deductible and Coinsurance would apply.

31. PT/OT Outpatient Services
Functional Status Reporting to be discontinued for outpatient services beginning January 1, 2019
Two new modifiers to be created to designate PTA and OTA services. These services to be paid at 85% of PFS. Modifiers not needed on claims until January 1, The modifiers will be used in conjunction with existing therapy modifiers and services will be subject to therapy caps.

32. QPP/MIPS/MACRA
The quality measures will focus more on the measures which most impact patient care and away from measures which have been capped out or are more burdensome to report than the expected benefit of the measure.

33. Empowering Rural Health
Contact Info:
Patty Harper, RHIA, CHT-PW, CHT-IM
ICD-10-CM/PCS Trainer ( )
Empowering Rural Health