United Healthcare has recently announced a policy change. Effective January 1, 2023, UHC will no longer cover home- and self-administered subcutaneous allergen immunotherapy. The AAOA, in conjunction with AAOHNS, is working to try to reverse this policy change. In the meantime,…
Brief Update on the Final CY 2019 Physician Fee Schedule
On November 1, the Centers for Medicare and Medicaid Services released the final Physician Fee Schedule (PFS) detailing policies related to Medicare physician payment and the Quality Payment Program (QPP). A brief summary of key provisions for AAOA members follows:
Direct Practice Expense Inputs
The Protecting Access to Medicare Act (PAMA) authorized the Secretary of the Department of Health and Human Services to conduct a market research study to update direct practice expense (PE) inputs for supply and equipment pricing. CMS finalized its proposal to phase in the new direct PE input pricing from this study over a 4 year period to ease the transition to these new prices. However, in response to public comments including those from AAOA in coalition with the American College of Allergy, Asthma & Immunology, the Advocacy Council of the American College of Allergy, Asthma & Immunology, and the American Academy of Allergy, Asthma & Immunology, they are finalizing pricing for approximately 60 supply and equipment codes in CY 2019, including 3 antigen supply codes. The final supply values follow.
|Description||CY 2018 Price||Proposed
CY 2019 Price
CY 2019 Price
(pollen, mite, mold, cat)
|SH010||antigen, venom, tri-vespid||$44.050||$51.320||$60.240|
E/M Documentation and Payment Policy
For 2019, CMS originally proposed significant changes to evaluation and management (E/M) payment and documentation requirements, including a single payment for level 2-5 office visits for both new and established patients. The agency responded to the overwhelming negative stakeholder response to its proposal by significantly revising its final policy.
CMS will not implement any payment changes until January 1, 2021 which will allow the agency to further refine these policies based on stakeholder input. If the payment changes outlined in this final rule go into effect in 2021, CMS estimates allergy/immunology E/M reimbursement will be held harmless while otolaryngology will see a 5 percent increase.
On January 1, 2019, CMS will implement the following documentation changes:
- The requirement to document medical necessity of furnishing visits in the home rather than office will be eliminated.
- Physicians will no longer be required to re-record elements of history and physical exam when there is evidence that the information has been reviewed and updated. In addition,
- Physicians must only document that they reviewed and verified information regarding chief complaint and history that is already recorded by ancillary staff or the patient.
For CY 2019 and 2020, the current coding and payment structure for E/M outpatient visits will remain in place, and providers should continue to use either the 1995 or 1997 versions of the E/M guidelines.
Beginning in 2021, CMS will pay a single rate for E/M outpatient visit levels 2, 3, and 4 (one for established and another for new patients) and will only require level 2 documentation based on the current guidelines, medical decision making, or time for these visits. The agency chose to not finalize the inclusion of level 5 visits in the single payment rate, to better account for the care and needs of particularly complex patients. CMS did finalize its policies to create complexity add-on which applies to allergy/immunology services and extended service codes that can be billed with all level 2-4 new and established outpatient visits. To see an impact of these payment changes, CMS created a matrix available here. The agency did not finalize its proposal to create a single practice expense (PE) value for E/M services because of the unintended negative consequences it had on the indirect PE for certain specialties, including allergy. In response to stakeholder feedback, CMS also discarded its proposal to apply a multiple procedure payment reduction when a procedure and E/M service using modifier -25 are billed together.