How will the 2019 Medicare Fee Schedule changes affect your practice?

When the 2019 Medicare Fee Schedule was first proposed last year, there were two critical issues for allergy:

  1. A potential reduction in the reimbursement for CPT 95165 – allergen immunotherapy.
  2. The consolidation of evaluation and management (E&M) services.

The good news for allergists? Both were successfully resolved, thanks to the work of the College’s Advocacy Council and many of our other medical association partners.

Allergen immunotherapy reimbursement

The proposed rule included a more than 10% reduction in reimbursement for CPT code 95165 – allergen immunotherapy – and additional decreases phased-in over the next four years.

The College’s Advocacy Council, along with the American Academy of Allergy, Asthma and Immunology (AAAAI), met with The Centers for Medicare and Medicaid Services (CMS) in August to address the proposed cuts. We proved that CMS’ contractor used incorrect data in calculating the costs of antigen used in allergen immunotherapy. After receiving a joint comment letter from the Advocacy Council, AAAAI, and the American Academy of Otolaryngic Allergy, CMS recalculated the costs with correct data. The result was an 8% increase in reimbursement for allergen immunotherapy in 2019 ($14.42, up from $13.32 per dose), with additional increases through 2022.

E&M services

CMS had proposed consolidation of E&M level 2-5 visits into a single reimbursement amount. This revision would have caused unintended consequences throughout the fee schedule, reducing allergy reimbursement up to 15% for some services.

The Advocacy Council, along with most of the medical community, opposed this change. Because of this resoundingly negative reaction, CMS agreed to postpone the consolidation until 2021. More importantly, CMS withdrew the aspects of the proposal which would have resulted in the across-the-board allergy cuts. They also agreed to exclude level 5 visits from future consolidation proposals.

The American Medical Association, joined by the Advocacy Council and many other medical organizations, has been spearheading the charge to work with CMS in developing revisions to the E&M structure that address CMS’ interest in consolidation and simplification. It’s still a work in progress, and the final result will likely be quite different from the current plan for 2021.

Other changes include:

  • An increase in reimbursement (9-12%) for venom immunotherapy codes (95145-95149) phased in over four years.
  • An increase in the conversion factor of 0.14%.
  • A decrease in reimbursement for CPT 95004. This is the second year of a two-year phase-in resulting from a revaluation of this code in 2017.
  • An estimated 1% overall decrease in allergy reimbursement from Medicare.
  • The deletion of multiple procedure payment reduction from the rule.
  • The reduction of documentation burdens: 
    • Beginning in 2019, for established patients, history and physical documentation need to only focus on what has changed since the last visit.
    • For new and established patients, the physician only needs to review and verify information already entered by clinical staff.
    • Teaching physicians may document their involvement in a service through their own notes or those of the residents or nurses. 
  • Additional prolonged service codes. These can be billed when the E&M service lasts 30 minutes longer than the time for the underlying E&M service (CPT code 99354, 99355). This is compared with other prolonged service codes which require at least 60 minutes of additional time.
  • New CPT codes for interprofessional consults and virtual check-ins, covered in a previous Advocacy Insider article.
  • Three new CPT codes for remote physiologic monitoring. These can be used to report remote monitoring of physiologic parameters such as weight, blood pressure, pulse oximetry, and respiratory flow rate during a 30-day period using an FDA-approved medical device. The service must be ordered by a physician or other qualified health care professional and should not be reported if monitoring is less than 16 days. The new codes are 99453, 99454 and 99457. Reimbursement ranges from about $20 to $64.

It is important to note that the Medicare 20% co-payment applies to all the telehealth and technology-based communication services and patient consent is required. Consent can be verbal but should be documented in the medical record. If you plan to bill for these codes, think through how you’ll handle these issues in advance.

For more info to help your practice in the coming year, we recently reviewed the changes to the Merit-Based Incentive Payment System for 2019.

Advocacy Issue: 
Billing, Coding & Payments