On July 12, 2018, the Centers for Medicare & Medicaid Services (CMS) released the proposed Medicare Physician Fee Schedule Rule for 2019, which includes substantial Medicare payment reductions for allergy-immunology. In particular, CMS has proposed updating supplies and equipment pricing, and the re-pricing of antigens would have a significant impact on allergy and immunology payments, with an estimated 6% reduction for the specialty. We believe this is based on flawed information, and we will be working with our membership to collect documentation on the real cost of antigens.
CMS estimates that this cut will be offset to some extent by other proposed changes, which are anticipated to increase Medicare payments by 1%, resulting in an overall anticipated 5% reduction in Medicare payment. The most important of these other changes relate to payment for evaluation and management (E&M) services. CMS is proposing to collapse payment for office and outpatient visits, such that new patient office visits (99202-99205) would be paid at $135 and established office visits (99212-99215) would be paid at $93, regardless of level of complexity. CMS is proposing to implement a 50% multiple procedure reduction to the lower paid of an E&M service and a procedure billed on the same date of service. In addition, a new code would be created to provide an add-on payment of approximately $9 applicable to office visits provided by specialties (including allergy/immunology) for whom E&M visit codes make up a large percentage of total allowed charges and who primarily bill level 4 and level 5 visits.
Under CMS’ 2019 proposal, existing documentation guidelines also would be changed. Under the proposal, physicians could select the level of E&M code based on the 1995 or 1997 documentation guidelines; the complexity of medical decision-making; or physician time. Documentation for history and exam will focus on interval history since last visit. Physicians will be allowed to review and verify certain information in the medical record entered by ancillary staff or the beneficiary, rather than re-entering the information.
CMS is also proposing a number of changes to the merit-based incentive payment system (MIPS) program. Many allergists are already exempt from the program under the current low-volume threshold, which CMS proposes to retain. CMS is also proposing to add a third criteria under which physicians providing fewer than 200 covered professional services to Part B patients would be exempt from the program.
The Advocacy Council may be reaching out to you to help us reverse these proposed payment reductions. Stay tuned for further information.
Links to the fact sheets that CMS has posted on the major components of the rule may be found at: