On November 1, 2018, the Centers for Medicare & Medicaid Services (CMS) issued a final rule that 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.
Conversion Factor
- With the budget neutrality adjustment to account for changes in Relative Value Units (RVUs), all required by law, the final 2019 PFS conversion factor is $36.04, a slight increase above the 2018 PFS conversion factor of $35.99.
Discontinuation of Functional Status Reporting (G-Code) Requirements for Outpatient
- The data from the functional reporting system was to be used to aid CMS in recommending changes and reforming of Medicare payment for outpatient therapy services that were subject to the statutory therapy caps. Going forward, the functional status reporting data that would be collected may be even less purposeful because the Bipartisan Budget Act of 2018 repealed the therapy caps while imposing protections to ensure therapy services are furnished when appropriate. As a result, CMS has finalized the proposal to discontinue the functional status reporting requirements for services furnished on or after January 1, 2019.
Outpatient Physical Therapy and Occupational Therapy Services Furnished by Assistants
- The Bipartisan Budget Act of 2018 requires payment for services furnished in whole or in part by a therapy assistant at 85 percent of the applicable Part B payment amount for the service effective January 1, 2022. In order to implement this payment reduction, the law requires CMS to establish a new modifier by January 1, 2019 and detail plans to accomplish this in the final rule.
- CMS is finalizing our proposal to establish two new payment modifiers – one for Physical Therapy Assistants (PTAs) and another for Occupational Therapy Assistants (OTAs) – when services are furnished in whole, or in part by a PTA or OTA. These will be used alongside of the current PT and OT modifiers, instead of replacing them. CMS is also finalizing a de minimis standard under which a service is furnished in whole or in part by a PTA or OTA when more than 10 percent of the service is furnished by the PTA or OTA, instead of the proposed definition that applied when a PTA or OTA furnished any minute of a therapeutic service. The new therapy modifiers for services furnished by PTAs and OTAs are not required on claims until January 1, 2020.
KX Modifier Attestation Amount
- The amount at which the KX modifier must be attached to the claim so that the therapist is attesting that therapy is medically necessary is $2,040.
Medicare Telehealth Services
- Finalized the addition of the following codes to the list of telehealth services:
- HCPCS codes G0513 and G0514 (Prolonged preventive service(s)
- CMS is also finalizing policies to implement telehealth services related to beneficiaries with end-stage renal disease (ESRD) receiving home dialysis and beneficiaries with acute stroke effective January 1, 2019. CMS is also finalizing policies to add mobile stroke units as originating sites and not to apply originating site type or geographic requirements for telehealth services furnished for purposes of diagnosis, evaluation, or treatment of symptoms of an acute stroke.
The following payment provisions are also included in the
Final Rule
, please review
Fact Sheet
for more information:
- Streamlining Evaluation and Management Payment and Reducing Clinician Burden
- Modernizing Medicare Physician Payment by Recognizing Communication Technology-Based Services
- Comment Solicitation on Creating a Bundled Episode of Care for Management and Counseling Treatment for Substance Use Disorders
- Telehealth Services for the Treatment of Opioid Use Disorder and Other Substance Use Disorders
- Providing Practice Flexibility for Radiologist Assistants
- Practice Expense (PE): Market-Basket Supply and Equipment Pricing Update
- Payment Rates for Non-Exempt Off-Campus Provider Based Hospital Departments
- Clinical Laboratory Fee Schedule
- Ambulance Fee Schedule Payments
- Wholesale Acquisition Cost-Based Payment for Part B Drugs
- Medicare Shared Savings Program Accountable Care Organizations
- Appropriate Use Criteria for Advanced Diagnostic Imaging
