From the desk of the EMD: CMS giveth and CMS taketh away – reimbursement in 2019

July 30, 2018

Just as we get some good news on the compounding issue from USP, our friends at the Centers for Medicare and Medicaid Services (CMS) may be causing the allergist misery in 2019.  First some good news from CMS. Administrator, Seema Verma, announced the contraction of our office-based E&M codes from five to two. This would reduce the amount of documentation and paperwork for physicians and save 51 hours of clinic time per doctor per year. Let’s face it, that sounds terrific. The plan is to keep Level 1, which is primarily used for non-physician services, and Levels 2-5 would be incorporated into one code with one reimbursement rate. For new patients, that rate is about $135, and for established patients $93, with specialties like allergy/immunology getting an additional $14 with each visit based on a new complexity G code. An analysis by the AMA suggests that our specialty would see a 13% increase in reimbursement for new and return patient visits compared to 2017.  This is great for the allergist, but unfortunately this is where the good news stops.

Along with collapsing the E&M codes, CMS has recommended a multiple payment procedure reduction (MPPR) of 50%. This will institute a payment reduction of 50%, applied to the lower paid of two services, when physicians report an E&M service and a procedure on a single day. In other words, if you do allergy skin testing the same day as the new patient evaluation, you will only be reimbursed for the skin testing at 50% of the Medicare rate. You may be saying “that is just for the Medicare population. I don’t see many Medicare patients, so it won’t affect me.” Well, you would be wrong, as private insurers frequently follow Medicare’s lead.

Do I have any more good news for you? Unfortunately, no. For the proposed 2019 fee schedule from CMS, many of our most frequent CPT codes will take a big hit. Here are just a few examples: 95004, percutaneous allergy skin tests, go from $5.40 in 2018 to $4.33 in 2019. That’s a plunge of almost 20%. 95115, immunotherapy (one injection), falls by $0.71, which is an almost 8% drop. Here is another one - 95076, ingestion challenge test for first 120 minutes, decreases over 10% from $122.01 in 2018 to $109.23 next year. 95165, antigen therapy services (multi-dose vial) decreases by over 10% from $13.32 to $11.90 in 2019. A few codes, like ones for spirometry and costs for venom, do show a small increase in reimbursement in 2019. It’s easy to see that these payment reductions, along with the proposed MPPR of 50%, could lead to financial calamity for us in allergy. When CMS looked at the impact of all their changes on allergy/immunology, their data came up with a 5% decrease in total Medicare reimbursement. I am concerned that the decline could be worse.

Now that I have completely depressed you, what can be done? The College is aware of the impact that these changes would have on every practicing allergist and our patients. The College’s Advocacy Council and our Washington consultants are partnering with the Academy in developing a joint strategy to reverse these massive cuts which undervalue our services. CMS will be taking comments on the proposed changes through Sept. 10.  Rest assured that everything that can be done will be done to support the allergy community in preventing changes which are detrimental to our practice.

Michael Blaiss, MD, FACAAI, Executive Medical Director