Nov. 15, 2018

Issue Spotlight

CMS moves on E/M: 3 things physicians should know

There were major victories for physicians in the 2019 Medicare physician fee schedule final rule, particularly when it comes to payment for evaluation-and-management (E/M) services. But with the document running nearly 2,400 pages, it could be difficult to sort them out. So here are three things physicians need to know about next year's fee schedule from the Centers for Medicare & Medicaid Services (CMS).

1. CMS has postponed the E/M coding "collapse" for at least two years. CMS will postpone its proposal to collapse payment rates for four E/M office visit services into a single blended rate. The AMA advised CMS that the proposal could create unintended consequences for specialties that treat the sickest patients and for physicians who provide comprehensive primary care. In revising E/M payments, CMS also announced it would take into consideration the recommendations of the AMA-convened Current Procedural Terminology (CPT®)/Relative Value Scale Update Committee (RUC) Workgroup. The group has already held five conference calls and one in-person meeting.

More than 200 individuals have participated in each meeting, including CMS staff, medical officers and contractors.

The workgroup has used a formal survey mechanism to solicited feedback throughout the process to ensure that maximum input is acquired to achieve consensus. More than 60 national specialty societies have responded to these surveys.

"The panel members have deep expertise in defining and valuing codes, and as members of various specialties, they all use the office visit codes to describe and bill for services provided to Medicare patients," said AMA President Barbara L. McAneny, MD. "The group is analyzing these issues and plans to offer solutions to be provided to CMS for future implementation."

The workgroup is also working to build consensus around modernizing the office and outpatient E/M CPT codes to simplify the documentation requirements and better focus code selection around medical decision-making and physician time. "The two-year delay in implementation will provide the opportunity for us to respond to the work done by the AMA and the CPT Editorial Panel, as well as other stakeholders," CMS said in the final rule. "We will consider any changes that are made to CPT coding for E/M services, and recommendations regarding appropriate valuation of new or revised codes, through our annual rulemaking process."

2. Proposed same-day-service pay cut will not be implemented. CMS has dropped its proposal to chop in half payments for office visits that occur on the same day as a procedure furnished by the same physician or another physician in the same practice. Also dropped from consideration is a proposal to create a new indirect practice expense category for office visits. This proposal would have resulted in large changes in payments for some specialties—including a greater than 10 percent pay cut for chemotherapy services.

3. New documentation rules cut physician administrative burden. CMS followed suggestions provided by the AMA and some 170 other medical groups in a letter sent to CMS Administrator Seema Verma. Specifically, physicians will not have to redocument elements of a patient's medical history and physical exam. Instead, documentation will focus on patients' medical history during the interval since the previous visit. Also gone is a requirement that physicians redocument information recorded by their staff or by the patient. In addition, a requirement to document the medical necessity of furnishing a home visit rather than an office visit has been eliminated.

"With physicians facing excessive documentation requirements in their practices, it is a relief to see that the administration not only understands the problem of regulatory burden but is taking concrete steps to address it," Dr. McAneny said. "Patients are likely to see the effect as their physicians will have more time to spend with them and be able to more quickly locate relevant information in medical records."

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National Update

2019 Medicare final rules include QPP changes and advance digital medicine

CMS released combined final rules establishing 2019 Medicare Physician Fee Schedule (PFS) and Quality Payment Program (QPP) policies. CMS set the 2019 PFS conversion factor at $36.0391 and the anesthesia conversion factor is $22.2730. Read the AMA's summary.

Due to AMA advocacy efforts, CMS embraced digital medicine in the PFS. The agency expanded access to medical care using telecommunications technology, including virtual check-ins, and established separate payment for interprofessional internet consultations. CMS also lifted restrictions for certain telehealth services, such as home dialysis treatment, and added the patient's home as a permissible originating site for telehealth services furnished to treat substance-use disorders or co-occurring mental health disorders, effective July 1.

CMS finalized its proposal to reduce add-on payments for new Part B drugs from 6 percent to 3 percent (before sequestration) until the drug has sufficient data to move to reimbursement based on Average Sales Price (ASP). ASP can typically be determined after the first quarter the drug is on the market.

Pursuant to extensive AMA Advocacy, CMS postponed payment changes to E/M services until 2021, giving the AMA-convened E/M workgroup time to recommend a better solution. Read more about the E/M changes in the issue spotlight feature of this week's Advocacy Update.

The agency maintained reduced reporting requirements for small practices in the Merit-based Incentive Payment System (MIPS). CMS overhauled the Promoting Interoperability (formerly, Advancing Care Information) category to move away from the pass/fail scoring system and eliminated many measures, including ones that were outside the physician's control, such as whether a patient viewed their records. The agency also created an opt-in option for physicians who fall below the low-volume threshold to participate in MIPS and earn an incentive or receive a penalty.

CMS agreed not to increase the financial risk requirement for alternative payment models (APMs), currently set at 8 percent of revenues, for at least the next six years. In response to AMA advocacy aimed at helping physicians who practice in areas with an above-average proportion of patients in Medicare Advantage plans, CMS waived MIPS reporting and payment adjustments for physicians participating in Medicare Advantage APMs, effective in 2018.

Quality Payment Program leads to positive incentive payments

CMS has released new information showing that 93 percent of clinicians eligible for MIPS in its first year, 2017, will receive positive incentive payments in 2019, with about three quarters of them qualifying for an "exceptional" performance bonus. In addition, nearly 100,000 clinicians who participated in advanced APMs in 2017 will receive a five percent lump sum bonus payment in 2019.

Physicians in small and rural practices also scored well in the first year of MIPS. Although the mean MIPS score in 2017 for small and rural practices was about 45, compared to 74 for large practices, 28 percent of rural and 30 percent of small practices earned a positive incentive payment in 2017. An additional 65 percent of small practices and 44 percent of rural practices qualified for an exceptional performance bonus.

Highlights from the 2018 AMA Interim Meeting

This year’s AMA Interim Meeting addressed a wide range of clinical practice, payment, public health topics and more, including:

  • Physicians again forcefully spoke out on gun-violence policy
  • Sex ed should include age-appropriate content on bullying, consent
  • AMA moves to protect income-based loan repayment programs
  • Vaping is an epidemic and the FDA must act
  • Front-of-package labels on food products need transparency
  • Eight ways to promote affordable access to high-value care

Read more at AMA Wire®.

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State Update

Medical societies urge New York governor to sign parity legislation

The AMA and American Psychiatric Association joined the Medical Society of the State of New York (MSSNY) and the NYS Psychiatric Association in sending a letter urging New York Gov. Andrew Cuomo to sign legislation, Assembly Bill 3694-C that will improve compliance with federal and state mental health and substance-use disorder (SUD) parity laws.

The medical societies emphasized that mental health and SUD  parity laws have been the law of New York—and every other state—for at least 10 years, but health insurance company compliance continues to lag. Assembly Bill 3694-C will provide important data to better compare requirements for accessing benefits that are applied to mental health and SUD treatment and coverage as compared with those applied to medical/surgical benefits. The compliance report, particularly if made available to key stakeholders and open for public inspection to patient advocates, will help regulators and others identify where appropriate oversight and enforcement are necessary.

For information, please contact MSSNY's Moe Auster.

Pennsylvania supports 6th edition of the Guides to the Evaluation of Permanent Impairment

The sixth edition of the AMA Guides to the Evaluation of Permanent Impairment will now be used in Pennsylvania following enactment of House Bill 1840. The bill was made necessary when the Pennsylvania Supreme Court held that the delegation of authority to the AMA on the Guides was unconstitutional. To rectify the confusion, HB 1840 amended current law to specifically include the AMA Guides to the Evaluation of Permanent Impairment, sixth edition (second printing April 2009).

Saving time and lives by increased access to MAT in Pennsylvania

"There was no reason for the delay," said Dr. Gallagher. "She simply wanted to get into a methadone clinic as quickly as possible for herself and her baby." 

Once he and his staff finally got through to someone who could approve a prior-authorization request, it took only a few minutes, and Dr. Gallagher could then immediately arrange for the specialized care. "I'm pleased to report that mom did well in treatment, and she delivered a healthy baby," he said.

Dr. Gallagher's situation is all-too familiar for physicians in Pennsylvania and across the nation. They spend countless hours on senseless prior-authorization requests that are almost always approved. Not only do prior-authorization requirements cause unnecessary delays that negatively impact patient care, they also force medical staff and physicians to sink time into making phone calls to insurance companies during business hours, taking time away from patients.

But that is about to change in Pennsylvania, as it did recently in Maryland. Gov. Tom Wolf secured an agreement in October with the seven largest health insurance companies in the Commonwealth that removes prior authorization for methadone, naltrexone and at least one form of buprenorphine. In addition, the agreement requires the medications to be on a health plan's lowest cost-sharing tier.

"As we fight the opioid crisis, our focus should be on removing barriers to treatment wherever they may exist and helping people battling addiction get the treatment they need," said Pennsylvania Human Services Department Secretary Teresa Miller. "When someone decides they are ready for treatment, time is critical. Time spent waiting for a service authorization makes it more difficult for the individual who initiates treatment to remain engaged in treatment."

The agreement, the first in the nation, was helped by sustained advocacy by the AMA and Pennsylvania Medical Society (PAMED). Dr. Gallagher chairs PAMED's opioid task force.

The process to remove prior authorization for medication-assisted treatment (MAT) began over a year ago when Governor Wolf called a meeting in the state capitol that included physicians, health insurance companies and other stakeholders. Dr. Gallagher advocated for the need to streamline the approval process so that patients could begin treatment faster, calling on the insurance company representatives to explain why prior authorization for MAT was necessary. The AMA Opioid Task Force has worked with PAMED and many other medical societies to call for a removal of prior authorization for MAT.

"The insurance companies wouldn't answer my questions, they kept dodging," Dr. Gallagher said. "So, Attorney General (Josh) Shapiro said, 'Let's get back to Dr. Gallagher's question, you're not giving him an answer, why are we doing this?' And we got no good answers, so we kept up the pressure and discussions with the governor and his administration to follow up and eventually we won."

The AMA and PAMED continue to engage with Pennsylvania policymakers to monitor implementation of the agreement. Contact the AMA Advocacy Resource Center to learn how to take action.

"We have long advocated for the removal of prior authorization and other barriers to increase access to MAT for substance-use disorders," said AMA President-elect Patrice A. Harris, MD, MA. "The leadership shown by the governor and his administration to reach this agreement should act as a call for all states to demonstrate that they support patients' access to care over needless administrative burdens."

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Judicial Update

State tries to seize $275 million from medical liability fund

The Pennsylvania physician liability insurer of last resort is facing its third fight to stop the state from seizing hundreds of millions of dollars intended to pay potential claims and instead using it to close a budget gap.

At stake is more than $275 million held by the Pennsylvania Professional Liability Joint Underwriting Association (JUA). In 2016, the state attempted to expropriate $200 million and send it directly to offset its perennial budget shortfall. State officials argued then that the association's money was an unneeded surplus.

This time, in what critics charge is a disingenuous bureaucratic maneuver, Pennsylvania wants control of all of money. Instead of demanding the money outright, the General Assembly passed a new law placing the association under control of a board of political appointees who will be free to direct the money wherever they wish.

"The farmer has tapped the proverbial fox to guard the henhouse," observes a friend-of-the-court brief filed on behalf of the JUA by the Pennsylvania Medical Society and the Litigation Center of the American Medical Association and State Medical Societies. They have joined the case to protect the fund from what they say is a transparent bid to grab the cash.

"The defendants have already showed their hand, having tried twice before in the last two years to legislate the transfer of JUA funds to the Commonwealth. The defendants intend to divert the JUA's alleged 'excess' funds to the state's funds."

Read more at AMA Wire.

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Other News

Extortion scam targeting DEA registrants

The Drug Enforcement Administration (DEA) has learned that registrants are receiving telephone calls and emails by criminals identifying themselves as DEA employees or other law enforcement personnel. The criminals have masked their telephone number on caller ID by showing the DEA Registration Support 1-800 number. A DEA employee would not contact a registrant and demand money or threaten to suspend a registrant's DEA registration. Physicians who are contacted by a person purporting to work for DEA and seeking money or threatening to suspend their DEA registration can submit information through the DEA Diversion Control Division's "Extortion Scam Online Reporting" webpage.

For information contact:
Locate DEA Field Office -
Registration Service Center - 1-800-882-9539
Email -

How to reduce the impact of attempted cyberattacks

Even though Cybersecurity Awareness Month has passed, it is important that physicians and health systems continue to review their practices' cyber hygiene year-round. Research from the AMA has identified that over 80 percent of all physicians experience a cyberattack—around half are a result of malicious email or viruses. HHS has released a set of basic cybersecurity safeguards that physicians and their business associates can deploy to greatly reduce the impact of attempted cyberattacks. By reviewing these important safeguards, physician practices can better understand the effect of encryption, good email habits and secure computer networking.

Advocacy in action: See the latest results

Learn about where the AMA stands on top issues and key achievements in 2018 by reading the latest "Advocacy in action" dashboard. From fighting prior authorization to pushing for regulatory relief, to advocating for drug-pricing transparency, the AMA has had the backs of patients and physicians throughout its advocacy this year—and there is more to come. See what else the AMA is working on, hear how members are moving medicine through their advocacy and send feedback to

Download the AMA's guide to physician advocacy

Want to be a better physician advocate? Download the Physicians' Guide to Advocacy, which explains how to cultivate relationships on Capitol Hill as well as:

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Upcoming Events

Register now for both 2019 advocacy conferences

Registration is now open for the 2019 AMA State Advocacy Summit (formerly the State Legislative Strategy Conference) and the National Advocacy Conference. Register for both events today and get 20 percent off. SAS will be held Jan. 10-12 in Scottsdale, Arizona, and NAC will be held Feb. 11-13 at the Grand Hyatt in Washington, D.C.

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