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Stephanie Pellitt

, National Council for Behavioral Health

CMS Proposes Overhaul of Medicare Billing Standards

July 19, 2018 | Medicare | Quality | Comments
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Last week, the Centers for Medicare and Medicaid Services (CMS) released its proposed rules for the 2019 Medicare Physician Fee Schedule (MPFS) and Quality Payment Program (QPP). The proposed rules update payment rates and key policies applicable to physicians and other professionals under Medicare. Among the key changes, the proposed rule would reduce billing documentation requirements, expand telehealth options and potentially create a bundled payment for the care and management of substance use disorders (SUD) in Medicare.

The MPFS dictates Medicare rates and policies under Medicare Part B, while the QPP rule offers changes for two key value-based payment programs created under Medicare Access and CHIP Reauthorization Act of 2015 (MACRA): the Merit-Based Incentive Payment System (MIPS) and Alternative Payment Models (APMs).

Comments on the proposed rules are due by Sept. 10th, 2018. Highlights of the proposed rule changes are provided below.


  • Telehealth: The rule proposes paying physicians for their time spent reaching out to patients over the phone or through other telecommunication devices to determine if an in-person visit is necessary. Additionally, physicians could receive payment for brief, virtual check-ins and evaluation of patient-submitted photos.
  • Evaluation and Management (E&M) Coding: Instead of requiring practitioners to use existing standards to decide the level of E&M code for outpatient, office-based medical reporting and documentation, CMS proposes allowing practitioners to select the visit’s level based on either time spent face-to-face with the billing practitioner or the level of medical decision-making; practitioners can also select to continue using existing selection standards. Documentation requirements would also be changed to require only documentation that matches a lower-level E&M code (regardless of the complexity of service reported) and eliminate a series of varying Medicare payment rates in favor of a single payment level.
  • Bundled SUD Payment Rate: CMS is requesting feedback on the creation of a new Medicare bundled payment for the care and management of substance use disorders to aid efforts addressing the opioid crisis.
  • In-Home Visits: The rule would eliminate the requirement for physicians to justify the medical necessity of home visits.
  • Same-Day Services: The rule would also eliminate a policy that prevents payment for same-day visits with multiple practitioners in the same specialty within a group practice.


  • Volume Threshold Criteria: The rule would raise the low-volume threshold, exempting more clinicians from MIPS participation. The new criteria includes: incurring $90,000 or less in allowed charges under Medicare Part B; treating 200 or fewer Part B enrollees who are paid for through the Medicare physician fee schedule; or offering 200 or fewer covered services. Clinicians meeting any one of the three criteria would be exempt from MIPS participation.
  • MIPS Opt-In: The rule would create an opt-in option for clinicians with a low volume of Medicare Part B enrollees or reimbursements to participate in MIPS if they meet or exceed any one of the criteria described above.
  • Scoring Methods and Performance Categories: The proposed rule revamps the performance categories, including quality measures. CMS proposes dropping 34 quality measures that the agency has deemed ineffective, while adding 10 quality measures including four measures based on patients’ reporting of their outcomes. These changes largely do not affect behavioral health measures, with the exception of the proposed elimination of a measure that looks at screening for alcohol or substance use in patients with depression and/or bipolar disorder.
  • Electronic Health Records (EHRs): Emphasizing the importance of greater information sharing and interoperability, CMS is proposing to require MIPS eligible clinicians to use 2015 edition certified EHRs beginning next year.
  • Medicare Advantage Demonstration: The rule would allow Medicare Advantage plans to qualify as an alternative payment model through a demonstration program called the Medicare Advantage Qualifying Payment Arrangement Incentive (MAQI).

The National Council for Mental Wellbeing will be submitting comments in response to the proposed rules. Stay tuned to the Capitol Connector for future analysis on how these rules could impact behavioral health.