top of page
  • Writer's pictureClaire Freeman, BS, CPC

Proposed Changes to Medicare PFS 2019

CMS published their Proposed Policy, Payment, and Quality Provisions Changes to the Medicare Fee Schedule for Calendar Year 2019 on July 12th, 2018. This is not the typical annual change proposal with an increase in the fee schedule or sequestration, CPT coding updates, or other updates that we come to know. This year's proposal has big changes in the way providers will be paid, document notes, and more updates to the new Quality Payment Program (QPP), probably more commonly known as the MACRA/MIPS.

Streamlining Evaluation and Management (E/M) Payment and Documentation Requirements

CMS is proposing to reduce the current approximate 10 levels (5 New Patient levels and 5 Established Patient levels), to 2 levels: 1) New Patient, and 2) Established Patient. It looks like the CPT codes will not be deleted, rather all E/M for New Patients (and the same for Established Patients) will be paid the same amount. CMS states:

to expand current options by allowing practitioners to use time as the governing factor in selecting visit level and documenting the E/M visit, regardless of whether counseling or care coordination dominate the visit;
to expand current options regarding the documentation of history and exam, to allow practitioners to focus their documentation on what has changed since the last visit or on pertinent items that have not changed, rather than re-documenting information, provided they review and update the previous information; and
to allow practitioners to simply review and verify certain information in the medical record that is entered by ancillary staff or the beneficiary, rather than re-entering it. 

If CMS finalizes the proposal, then the next big question is what are the amounts to be paid? Medicare has stated the proposed 2019 PFS conversion factor is $36.05. Using the average RVUs from released 12/18/17, effective 01/01/2018, and using the proposed conversion factor, a New Patient Reimbursement would be approximately $92.00 (Facility) or $122.00 (Non Facility), and Established Patient would be $56.00 (Facility) or $80.00 (Non Facility). To be clear, CMS has not published the methodology of the proposed single blended payment rate within their Fact Sheet. So these numbers are probably inaccurate, but does give insight into the proposed change.

Other proposed changes include:

  • New HCPC codes for a 'Virtual Check-In' and Evaluation of a Recorded Video and/or Image submitted by a patient.

  • Discontinuation of the Outpatient Therapy Functional Status Information

  • New modifiers for Physical Therapy/Occupational Therapy - to help determine who provided the treatment (Physical Therapy Assistant or Occupational Therapy Assistant vs Licensed Physical Therapist or Licensed Occupational Therapist)

  • New HCPCS codes for telehealth prolonged preventive services

  • Changes to the Clinical Laboratory Fee Schedule

  • Changes to Ambulance Fee Schedule

  • Changes to the Quality Payment Program (QPP)

For more information check out the Fact Sheet published by CMS: FACT SHEET: PROPOSED CHANGES TO MEDICARE PHYSICIAN FEE SCHEDULE 2019

39 views0 comments

Recent Posts

See All


bottom of page