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New CMS 2019 proposed rule could impact GI practice

The new rule includes several significant policy and payment changes that will impact gastroenterologists. AGA will continue to monitor the latest action on these changes and will let you know how to take action. 

This communication offers a topline summary of the most important proposed changes to the payment rates and policies for services paid under the Medicare Physician Fee Schedule (PFS). The PFS proposed rule appeared in the Federal Register and can be downloaded here.

Key proposals:

    • Major evaluation and management (E/M) changes aimed at reducing physician burden impact coding and reimbursement. 
    • Esophagogastroduodenoscopy (EGD) and colonoscopy codes identified by an outside party as potentially misvalued. 
    • Weight of the cost performance category under the Quality Payment Program (QPP) increases from 10 to 15 percent.
    • CMS proposes adding a GI-specific cost measure for screening/surveillance colonoscopy.
    • QPP performance threshold increases from 15 to 30 points.

AGA, ACG and ASGE are currently reviewing the details of the proposed rules and will be providing joint comments.

CMS will accept comments until Sept. 10, 2018, and will respond to comments in a final rule to be issued on or around Nov. 1, 2018. We will keep you updated as we learn more.

Medicare Physician Payment
    • 2019 proposed conversion factor: The proposed 2019 PFS conversion factor is $36.05, an increase of .03 percent from the 2018 PFS conversion factor of $35.99. Click here to review 2019 MPFS proposed Relative Value Units (RVUs) for GI services.
    • Reforming E/M Payment: CMS proposes a major new reimbursement methodology for E/M services effective Jan. 1, 2019. Under the proposal, new patient level 2-5 (99202-99205) and established patient level 2-5 (99212-99215) services would receive one blended payment. 

The table below reflects the proposed rates.


CPT 2018 Final Work RVUs 2019 Proposed Work RVUs 2081 Final Non-Facility Payment 2019 Proposed Non-Facility Payment
New Patient Office Visit
99201 0.48 0.48 $45 $44
99202 0.93 1.90 $76 $135
99203 1.42 1.90 $110 $135
99204 2.43 1.90 $167 $135
99205 3.17 1.90 $211 $135
Established Patient Office Visit
99211 0.18 0.18 $22 $24
99212 0.48 1.22 $45 $93
99213 0.97 1.22 $74 $93
99214 1.5 1.22 $109 $93
99215 2.11 1.22 $148 $93


* Note: despite some discrepancy in calculations, these tables were taken directly from the proposed rule.


CMS proposes changing how physicians document office/outpatient E/M visits instead of applying the current 1995 or 1997 E/M documentation guidelines. Proposed changes include allowing practitioners to:

    • Use time as the governing factor in selecting visit level and documenting the E/M visit, regardless of whether counseling or care coordination dominate the visit. 
    • Focus their documentation on what has changed since the last visit or on pertinent items that have not changed, rather than re-documenting information, provided they review and update the previous information. 
    • Simply review and verify certain information in the medical record that is entered by ancillary staff or the beneficiary, rather than re-entering it. 

The agency is soliciting comment on how documentation guidelines for medical decision-making might be changed in future years. 

Finally, CMS is proposing several new G codes as E/M add-on services for primary care services, specialty professionals and prolonged services.

    • Misvalued code initiative: CMS received a public nomination of several high-volume codes to be reviewed under the potentially misvalued code initiative, including two GI services: 45385 (Colonoscopy with lesion removal) and 43239 (EGD biopsy single/multiple). The submitter suggested that the services identified have a systemic overvaluation of work RVUs. The societies will work in a unified manner to be certain that the GI codes identified are indeed properly valued.
Public Nominations Due to Overvaluation
CPT Code Short Description
27130 Total hip arthroplasty
27447 Total knee arthroplasty
43239 EGD biopsy single/multiple
45385 Colonoscopy w/lesion removal
70450 CT head w/o contrast
93000 Electrocardiogram complete
93306 TTE w/Doppler complete


    • Communication technology-based services: CMS proposes allowing communication technology-based services to be billable separately for brief communication services when providers check in with beneficiaries via telephone or other telecommunication devices or receive images from patients for remote evaluation to determine whether an office visit or other service is needed. CMS proposes 0.25 work RVUs for these services using HCPCS code GVCI1.

CMS also proposes paying separately for new codes describing interprofessional internet consultation. Communication technology based services would not be subject to the limitations on Medicare telehealth services.

    •  Wholesale acquisition cost-based payment for Part B drugs: CMS proposes reducing the add-on amount for Part B drug payments based on Wholesale Acquisition Cost to 3 percent effective Jan. 1, 2019.

Quality Payment Program 

The PFS proposed rule includes changes to the QPP, including the Merit-based Incentive Payment System (MIPS). The table and information below summarize key proposed changes for the 2019 MIPS performance period and the 2021 payment period. 

2018 Final 2019 Proposed
Performance Threshold 15 points 30 points
Quality 50 percent 45 percent
Cost 10 percent 15 percent
Improvement Activities 15 percent 15 percent
Advancing Care/Promoting Interoperability 25 percent 25 percent
MIPS Payment adjustment +/- 5 percent +/- 7 percent


    • MIPS payment adjustments: To avoid a negative payment adjustment, clinicians must have a final MIPS score equal to or greater than the performance threshold. The maximum payment adjustments for performance in year 2019 is +/- 7 percent and would apply to payments in 2021.
    • Quality category: CMS proposes removing 34 quality measures, including QPP185 (Colonoscopy Interval for Patients with a History of Adenomatous Polyps – Avoidance of Inappropriate Use).
    • Cost category: CMS proposes adding a new cost measure for screening/surveillance colonoscopy to the performance category beginning with the 2019 MIPS performance period.
    • Improvement activities: CMS proposes adding six new improvement activities. 
    • Promoting interoperability: CMS renamed the “Advancing Care Information” performance category “Promoting Interoperability.” Proposed 2019 changes include:
        • Reporting a total of six measures from four objectives.
        • Use of electronic health record (EHR) technology certified to the 2015 Edition. 
        • Simplifying scoring methodology; concept of Base and Performance scores eliminated. 

CMS proposes continuing the “all or nothing approach” for this performance category. If a MIPS-eligible clinician fails to report on a required measure or reports a “no” response on a “yes or no” measure, the clinician would receive a score of zero for the category (unless an exclusion applies).

    • Small practices: CMS proposes additional policies to increase flexibilities for small practices, including allowing small practices, whether reporting as individual clinicians or as a group, to use a claims-based measure submission option. CMS does, however, propose eliminating the 5-point bonus applied to a small practice’s total performance score. Instead, CMS proposes to apply a 3-point bonus to the Quality performance category for small practices.
    • Alternative payment models (APMs): CMS proposes increasing the Advanced APM Certified Electronic Health Record Technology (CEHRT) threshold, so that an Advanced APM must require that at least 75% of eligible clinicians in each APM entity use CEHRT and allows eligible clinicians to become qualified participants through a combination of participation in Advanced APMs and other payer Advanced APMs. 

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