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Stephanie Pellitt

, National Council for Behavioral Health

CMS Finalizes Changes to Medicare Physician Payment and Quality Policies

November 8, 2018 | Medicare | Quality | Comments
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Last week, the Centers for Medicare and Medicaid Services (CMS) released its final rule for the 2019 payment year under Medicare. The rule finalizes policies around reducing provider burden, increasing electronic health record (EHR) interoperability, and coverage expansions for telehealth, virtual care, and substance use disorder treatment. Notably, CMS decided to modify its original proposal to significantly change the payment and documentation requirements for traditional outpatient, office-based visits by modifying some elements to address concerns raised by provider groups like the National Council and other stakeholders.


Included in its 2,000-page decision, CMS made changes to the Evaluation and Management (E/M) codes, the set of codes used by physicians and other practitioners to report common office and other visits. Over the summer, CMS had proposed fairly significant changes to the payment and documentation requirements for traditional outpatient, office-based visits. It had proposed modifying not only the decision protocol for code selection and its accompanying documentation requirements, but also collapsing the reimbursement structure such that instead of having five distinct reimbursement amounts depending on complexity (for levels 1 through 5), CMS would pay for only Level 1 and then a single blended rate for Levels 2 through 5.

 However, in the final rule, CMS partially responded to concerns from community stakeholders, including the National Council, that the proposed payment system could have adverse and unintended consequences for delivery of specialty services to highly complex patients, especially if it were to be implemented in the timeline proposed and the data available. In response, CMS’s final rule reflects a decision to move forward with some elements pertaining to documentation, while delaying implementation of payment changes until 2021. For a detailed timeline of these changes and guidance for providers, click here.

Additional information about E/M changes can be found in this letter from CMS to clinicians outlining how the agency is reducing burden through reform of documentation and coding requirements.

Other provisions included in the rule are:

Medicare Promoting Interoperability Program: Emphasizing the importance of greater information sharing and interoperability, CMS finalized its proposal to require Merit-Based Incentive Payment System (MIPS) eligible clinicians to use 2015 edition certified EHRs beginning next year.

Telehealth Opioid Use Disorders: The rule implements a provision from the SUPPORT for Patients and Communities Act (H.R. 6) which removes the originating site geographic requirements and adds the home of an individual 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.

Telehealth and Virtual Care: CMS also for the first time will provide access to “virtual” care. The rule allows Medicare to pay providers for new communication technology-based services, such as brief check-ins between patients and practitioners, and pay separately for evaluation of remote pre-recorded images and/or video. CMS is also expanding the list of Medicare-covered telehealth services.

Medicare OTP Access: CMS invited feedback on another provision of the SUPPORT for Patients and Communities Act that establishes a new Medicare benefit category for opioid use disorder treatment services furnished by opioid treatment programs (OTP) under Medicare Part B, beginning on or after January 1, 2020. The public has 60 days to provide information regarding services furnished by OTPs, payments for these services, and additional conditions for Medicare participation for OTPs that stakeholders believe may be useful for CMS to consider for future rulemaking to implement this category.

SUD Bundled Payment: In the proposed rule, CMS invited comments on a possible proposal for a bundled episode of care for management and counseling treatment for substance use disorders (SUD). In official comments to CMS, the National Council expressed strong support for this proposal, while raising larger issues of access to SUD treatment for Medicare beneficiaries. In the final rule, CMS stated that it received many comments with detailed information that it is continuing to review and expects these to help inform future rulemaking.