American Medical Association

Summary: 2019 Medicare Physician Fee Schedule and Quality Payment Program Final Rule

On Nov. 1, 2018, the Centers for Medicare and Medicaid Services (CMS) released the 2019 Physician
Fee Schedule (PFS) and Quality Payment Program (QPP) final rule, which will be published in the
Federal Register on Nov. 23, 2018. This is the first year CMS combined the Medicare PFS and QPP
rules. CMS published several fact sheets on the final rule including a fact sheet on the QPP changes and a
fact sheet on the PFS changes for 2019.

One week later, CMS released a snapshot of physician performance during the first year of the QPP,
2017. These data indicate that 93% of clinicians who were MIPS-eligible in 2017 will get a positive
MIPS incentive payment in 2019.

AMA is continuing to review the rule and will work with its colleagues in the Federation to further
analyze these policies in the coming weeks. Below is a summary of the key policies included in the final
regulation and the QPP performance results.

I. Physician Fee Schedule

Physician Payment Update
The 2019 PFS conversion factor is $36.0391. The Anesthesia conversion factor is $22.2730. The 2019
conversion factors reflect a statutory update of .25%, offset by a budget neutrality adjustment of -0.14%,
resulting in a 0.11% update.

Evaluation and Management (E/M) Office Visits and Documentation Guidelines
In the 2019 proposed rule, CMS proposed revisions to the E/M documentation guidelines intended to
reduce administrative burdens on physicians. In addition, CMS proposed coding and payment changes to
new and established patient office visit services. The AMA led the development of a joint comment letter
from 170 physician and other health professional organizations calling for CMS to finalize several
proposed changes to E/M documentation guidelines for CY2019. The AMA is pleased that CMS is
implementing the documentation policies which will significantly reduce administrative burdens and
allow all physicians to spend more time with their patients. The AMA is also grateful that CMS has
acknowledged the work of the AMA’s CPT/RUC Workgroup on E/M and has postponed any coding and
payment-related changes for E/M office visit services until CY2021. This delay in implementation will
allow the CPT Editorial Panel to consider the Workgroup’s proposal in February 2019, followed by
prompt consideration by the AMA/Specialty Society RVS Update Committee (RUC).

On page 584 of the rule, CMS states:
“We recognize that many commenters, including the AMA, the RUC, and specialties that
participate as members in those committees, have stated intentions of the AMA and the CPT
Editorial Panel to revisit coding for E/M office/outpatient services in the immediate future.
We note that the 2-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. 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.”
© 2018 American Medical Association. All rights reserved.

Removing Restrictions on E/M Coding
CMS finalized several changes to E/M documentation guidelines which were strongly supported by the
AMA and other members of the Federation:

• The requirement to document medical necessity of furnishing visits in the home rather than office
will be eliminated.
• Physicians will no longer be required to re-record elements of history and physical exam when
there is evidence that the information has been reviewed and updated.
• Physicians must only document that they reviewed and verified information regarding the chief
complaint and history that is already recorded by ancillary staff or the patient.

These changes will take effect Jan. 1, 2019. CMS estimates that these changes will reduce clinician
regulatory burdens associated with E/M documentation by $84 million in 2019.

The Original Proposal Condensing Office Visit Payment Amounts and Documentation Requirements
In the 2019 proposed rule, CMS proposed to implement single payment rates for new and established
level 2 through level 5 office visits and to reduce documentation requirements for these collapsed
payments to that of a level 2 CPT visit code. The agency proposed to continue to use the existing CPT
structure for office visit codes 99201-99215, though it proposed to change CMS guidelines and only
enforce certain aspects of the CPT structure by allowing physicians to choose the method of
documentation, among the following options:

1. 1995 or 1997 Evaluation and Management Guidelines for history, physical exam and medical
decision making (current framework for documentation)
2. Medical decision-making only
3. Physician time spent face-to-face with patients

CMS had also proposed an add-on code to each office visit performed for primary care purposes and an
add-on code for specialties with inherently complex E/M visits, as well as a new prolonged service code
to be used as an add-on to any office visits lasting more than 30 minutes beyond the underlying visit (i.e.,
hour-long visits in total).

CMS relayed that commenters overwhelmingly opposed the agency’s proposed payment collapse. CMS
will not finalize the proposal for CY 2019.

Other Coding/Payment Proposals Related to E/M
The following policies were also opposed by the AMA and will not be implemented by CMS:
• Payment reductions by 50% for office visits that occur on the same date as procedures (or a
physician in the same group practice). The AMA brought attention to the fact that duplicative
resources have already been removed from the underlying procedure through the current
valuation process.
• In addition, CMS proposed to no longer allow podiatrists to report CPT codes 99201-99215 and
instead would use two proposed G-codes for podiatry office visits.
• Condensed practice expense payment for the E/M office visits, by creating a new indirect practice
expense category solely for office visits, overriding the current methodology for these services by
treating Office E/M as a separate Medicare Designated Specialty. This change would also have
resulted in the exclusion of the indirect practice costs for office visits when deriving every other
specialty’s indirect practice expense amount for all other services that they perform, which would
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have resulted in large payment cuts for many specialties (i.e., a greater than 10% payment
reduction for chemotherapy services).
Proposals for CY 2021 and the CPT/RUC Workgroup on E/M
For CY 2021, the agency conveyed its intention to implement the same payment rates for 99202-99204
and 99212-99214, leaving in place 99201/99211 and 99205/99215 distinct payment rates. In addition,
CMS noted its intention to implement add-on codes for primary care services; inherently complex
specialty E/M visits; and extended visits. These add-on codes would only apply to CPT codes 99202-
99204 and 99212-99214. The AMA has modeled an estimate of the impacts to office visit payments (see
attached). Please note that the AMA analysis focuses on payment redistribution within the office visits
only, while the CMS analysis is based on impact to the specialty’s total allowed charges. Of note, the
implementation of the add-on codes would lead to an offset to the conversion factor or relative values of
CMS noted that it will also consider input from the AMA and the CPT/RUC Workgroup on E/M as well
as input from across the medical community. In response to the Medicare PFS Proposed Rule, the Chairs
of the AMA CPT Editorial Panel and the AMA/RUC formed the CPT/RUC Workgroup on E/M to:
• Capitalize on the CMS proposal and solicit suggestions and feedback on the best coding structure
to foster burden reduction, while ensuring appropriate valuation.
• Consider a code change application to be submitted to the CPT Editorial Panel for consideration
at its Feb. 7-9, 2019 meeting.
The Workgroup is comprised of 12 experts in both coding and valuation (6 members each from each of
the CPT and RUC processes). In addition to the 12 Workgroup members, roughly 300 additional
stakeholders from national medical specialty societies, CMS and other health care-related organizations
have participated.
The Workgroup has expressed its appreciation of the agency’s efforts to address longstanding issues with
E/M services and has worked tirelessly over the past several months to establish a long-term, stable CPT
coding solution. Listening to CMS and other stakeholder concerns, the Workgroup has worked 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
Workgroup proposal will be formally reviewed by the national medical specialty societies via the CPT
Advisory Committee process. The CPT Editorial Panel will review the proposal, and related comments, at
the Feb. 7-9, 2019, meeting.
RUC Recommendations
CMS announced final work relative values for nearly 200 CPT codes reviewed by the RUC. CMS
accepted 80% of the RUC recommendations and 87% of the RUC Health Care Professional Advisory
Committee Review Board recommendations for CPT 2019. The AMA applauds CMS for accepting the
RUC recommendations, such as for new CPT code 99491 for chronic care management personally
delivered by a physician, which was based on survey data from more than 150 physicians, instead of
using the flawed formulaic approach originally proposed. CMS did not consider the RUC
recommendations for 20 X-ray services as formal surveys were not conducted by radiology and other
specialties. CMS will maintain the 2018 values for 20 X-ray services instead of valuing them the same,
regardless of anatomical area imaged or the number of views, as originally proposed. The RUC will work
with specialty societies to conduct and review formal surveys for all 20 X-ray services for CY2020.
© 2018 American Medical Association. All rights reserved.
Modernizing Medicare Physician Payment by Recognizing Communication Technology-Based
CMS is expanding access to medical care using telecommunications technology by finalizing coverage of
several new services, including three new CMS-created HCPCS codes for: brief, non-face-to-face
appointments via communications technology (virtual check-ins); evaluation of patient-submitted photos;
and the foregoing codes bundled together for use by federally qualified health centers and rural health
clinics. In addition, CMS finalized new CPT codes for Inter-professional Internet Consultation (CPT
codes 99451, 99452), as well as unbundling and covering existing CPT codes 99446, 99447, 99448 and
99449. Also consistent with AMA advocacy, CMS finalized new CPT codes for Chronic Care Remote
Physiologic Monitoring (99453, 99454 and 99457).
CMS finalized modifications to existing regulations required by the recent passage of the Bipartisan
Budget Act of 2018 mandating expanded coverage of telehealth (two-way audio, visual real-time
communication between physician and patient). CMS expanded coverage of telehealth services by
modifying or removing limitations relating to geography and patient setting for certain services, including
for end-stage renal disease home dialysis evaluation; diagnosis, evaluation, and treatment of an acute
stroke; and services furnished by certain practitioners in certain accountable care organizations. CMS
expanded telehealth coverage for prolonged preventive services (but coverage would still be subject to
statutory geographic and originating site restrictions). The AMA strongly supports CMS’ expansion of
telehealth coverage.
Medicare Part B Drug Payments
CMS reduces reimbursements for new Part B drugs. Currently paid with an add-on payment of 6%
(before sequester), CMS will reduce the add-on payment to 3% (before sequester) for all drugs with
Wholesale Acquisition Cost (WAC)-based payment rates. Currently, only new drugs lacking Average
Sales Price (ASP) data are paid based on WAC amounts, and usually only for part of the year. When
drugs move to ASP-based payments, the add-on amount will return to 6%. ASP is usually determined
after the first quarter the drug is on the market. The AMA opposed this proposal.
Clinical Laboratory Fee Schedule (CLFS)
CMS finalizes a revision to the “majority of Medicare revenues” threshold component of the new
payment system applicable to tests paid on the CLFS. Under this new payment system, laboratories,
including physician office-based laboratories, are required to participate in reporting to CMS private
payer pricing data if they meet certain thresholds. One of those thresholds is that the laboratory must
receive the majority of its Medicare revenues from payments on the PFS or CLFS. This final rule adjusts
the previous component and moves to exclude payments made under Medicare Part C from the definition
of “total Medicare revenues.” CMS estimates that this will increase the opportunity for labs with large
Part C revenues to participate in the reporting exercise, but states that it expects minimal impact on CLFS
rates. The AMA in unsure of the impact it will have on the number of physician office-based laboratories
that will have to report.
Appropriate Use Criteria
The AUC program requires ordering providers to consult with applicable Appropriate Use Criteria (AUC)
through a qualified clinical decision-support mechanism for applicable imaging services. CMS previously
delayed implementation of this program by including a voluntary reporting period, which started in July
2018 and runs through December 2019. In 2020, the AUC program period will begin with an educational
and operations testing period, during which CMS will continue to pay claims whether or not they
correctly include AUC information. The 2019 final rule:
• Expands the definition of an applicable setting to include independent diagnostic testing facilities;
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• Creates significant hardship exceptions from the AUC requirements that are specific to the AUC
program and independent of other Medicare programs;
• Establishes the coding methods, to include G-codes and modifiers, to report the required AUC
information on Medicare claims;
• Allows non-physicians, under the direction of an ordering professional, to consult with AUC
when the consultation is not performed personally by the ordering professional; and
• Clarifies that the AUC consultation information must be reported on all claims for an applicable
imaging service (e.g., if separate, both the technical and professional claim must include the AUC
In its comments on the proposed rule, the AMA argued that physicians who successfully participate in
either the APM or MIPS side of QPP should be exempt from the AUC program and called on CMS to
extend the AUC testing period to two years.
Teaching Physician Documentation Requirements for E/M Services
CMS is revising federal regulations by allowing the presence of the teaching physician during E/M
services to be demonstrated by notes in medical records made by a physician, resident, or nurse. CMS
also revised federal regulations to provide that the medical record must document the extent of the
teaching physician’s participation in the review and direction of services furnished to each patient, and
that the extent of the teaching physician’s participation may be demonstrated by the notes in the medical
records made by a physician, resident, or nurse.
Practice Expense Relative Values
Market-Based Supply and Equipment Pricing Update
As part of its authority under Section 220(a) of the Protecting Access to Medicare Act of 2014 (PAMA),
CMS initiated a market research contract with a consulting firm, StrategyGen, to update the direct
practice expense inputs for supply and equipment pricing for CY 2019. The AMA and other members of
the Federation questioned the pricing of 62 supply and equipment items and submitted invoices and other
supporting documentation for the pricing of these items. Based on the report from StrategyGen, CMS
finalized updated pricing for 2,070 supply and equipment items currently used as direct practice expense
inputs over a 4-year phase-in, with changes to the pricing for the 62 supply and equipment items flagged
by stakeholders. Although the AMA agrees with CMS that there is a need for comprehensive review of
supply and equipment pricing, we continue to have concerns about StrategyGen’s use of subscriptionbased
benchmark databases that are likely not representative of the typical price paid by small physician
Professional Liability Insurance (PLI) Relative Values
CMS sought comment on ways to improve how specialties in the state-level raw rate filings data are
cross-walked for categorization into CMS specialty codes to develop the specialty-level risk factors and
the PLI RVUs. In a March 30, 2018, letter to CMS, the RUC offered its assistance to CMS to categorize
rate filings and apply the specialty descriptions from the rate filings to the appropriate specialty
codes. The RUC will continue to explore collaboration with CMS on this issue.
As recommended by the RUC and other commenters, CMS added approximately 30 codes to the lowvolume
services to the list of codes for anticipated specialty assignment.
In the Addendum for the CY 2019 Malpractice Risk Factors and Premium Amounts by Specialty, CMS
continues to crosswalk non-MD/DO specialties to the lowest MD/DO risk factor specialty, Allergy
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Immunology. The RUC has consistently maintained that a risk factor linked to a physician specialty is too
high for many of the non-physician health care professions.
Global Surgery Data Collection
The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) required CMS to implement a
process to collect data on postoperative visits and use these data to assess the accuracy of global surgical
package valuation. Beginning July 1, 2017, CMS required groups with 10 or more practitioners in nine
states to use the no-pay CPT code 99024 to report postoperative visits for specified procedures. Of
practitioners that met the criteria for reporting, only 45% participated —this varied substantially by
specialty. Among procedures performed by “robust reporters” of 99024, only 16% of 10-day global
services and 87% of 90-day global services had one or more matched visits reported (volume-weighted).
In the 2019 proposed rule, CMS solicited comments pertaining to increased compliance and whether
visits are typically being performed in the 10-day global period. It also solicited comment on whether use
of modifiers -54 “for surgical care only” and -55 “post-operative management only” should be mandated,
regardless of whether the transfer of care is formalized. In the final rule, CMS noted that most
commenters, including the RUC, said that more time was needed for data collection before drawing any
conclusions. CMS plans to send another letter to eligible practitioners in the nine states to make them
aware of the reporting requirement, as recommended by the RUC and other stakeholders. CMS also plans
to continue to evaluate public comments received.
2019 Potentially Misvalued Codes List
Each year, CMS proposes a list of potentially misvalued codes for review by the RUC and possible
adjustment. Since 2006, the RUC and CMS have identified 2,475 services through 20 different screening
criteria for further review by the RUC. The RUC’s efforts for 2009-2018 have resulted in $5 billion for
redistribution within the PFS. CMS received public nominations identifying nine codes as potentially
misvalued for review in future rulemaking, including seven codes nominated by Anthem. The RUC will
review these services and submit recommendations for future rulemaking.
CPT Code Short Descriptor
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 CT head w/o contrast
93306 TTE w/doppler complete
© 2018 American Medical Association. All rights reserved.
II. Quality Payment Program
General Issues
The AMA is pleased that CMS continues to promote policies which do not disadvantage and provide
relief to physicians who see a small number of Medicare patients.
MIPS Expanded to New Clinician Types
CMS expands the MIPS-eligible clinician definition to new clinician types including physical therapists,
occupational therapists, qualified speech-language pathologists, qualified audiologists, clinical
psychologists, and registered dietitians or nutrition professionals.
Low-Volume Threshold and Opt-In Policy
CMS adds a third criterion for physicians to qualify for the low-volume threshold–providing 200 or fewer
covered professional services to Part B patients. CMS also adopts a new policy that allows physicians to
opt-in to participate in MIPS or create virtual groups and receive corresponding payment bonuses or
penalties if they meet or exceed one or two but not all the low-volume threshold elements (i.e., have less
than or equal to $90,000 in Part B allowed charges for covered professional services, provide care to 200
or fewer beneficiaries, or provide 200 or fewer covered professional services under the PFS).
Performance Threshold
CMS sets the 2019 performance threshold for determining bonuses or penalties in 2021 at 30 points and
the additional exceptional performance threshold at 75 points. CMS was previously required to raise the
performance threshold from 15 points in 2018 to the overall performance mean or median in 2019.
However, the Bipartisan Budget Act of 2018, which was strongly supported by the AMA, gave CMS the
flexibility to gradually increase the performance threshold over the next three years. CMS found the mean
final score in 2017 was 74.01 points and the median final score was 88.97 points.
Medicare Part B Drugs
As Congress required in the Bipartisan Budget Act of 2018, CMS finalizes its proposal to remove Part B
drugs from the low-volume threshold determinations and from physicians’ payment adjustments.
Special Status Determination Periods
CMS consolidates the determination periods to establish whether a physician meets or exceeds the lowvolume
threshold and qualifies for special statuses, including non-patient facing, small practice, hospitalbased
and ASC-based. The new consolidated determination periods run from Oct. 1, 2017 to Sept. 30,
2018 and from Oct. 1, 2018, to Sept. 30, 2019.
Virtual Groups
CMS makes very minor changes to its virtual group policies for the 2019 performance year. Physicians
and groups can inquire about their group size prior to making a virtual group election between Oct. 1 and
Dec. 31 of the calendar year prior to the applicable performance period. Group size inquiries can be made
through the QPP Technical Assistance organizations.
Facility-Based Scoring Option
2019 is the first year physicians may be scored for purposes of the MIPS quality and cost performance
categories based on their attributed hospital’s performance in the Hospital Value-Based Purchasing
Program. Facility-based scores for the 2019 performance period/2021 payment determination are based
on the 12 measures included in the fiscal year 2020 Hospital VBP Program. There is no election or opt-in
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required for facility-based scoring, nor is there an opt-out option. Instead, facility-based scoring
automatically applies to MIPS eligible clinicians and groups who qualify and would benefit by having the
facility-based score for their quality and cost performance. However, facility-based physicians have the
option to participate through traditional MIPS and CMS will pick the best score to make a payment
To qualify for facility-based scoring, physicians must perform 75 percent of their services in inpatient,
on-campus outpatient or emergency room settings, and must have at least one service billed with the place
of service (POS) code used for inpatient (21) or emergency room (23). To be scored as a group, 75
percent or more of the National Provider Identifiers (NPIs) billing under the group’s Tax Identification
Number (TIN) must be eligible for facility-based measurement as individuals, and the group must submit
data in the Improvement Activity (IA) or Promoting Interoperability (PI) categories.
Accounting for Social and Clinical Risk Factors
CMS maintains the complex patient bonus of five points. The eligibility determination period for this
bonus begins Oct. 1 of the calendar year preceding the applicable performance period and ends on Sept.
30 of the calendar year in which the performance period occurs, similar to the changes to the special
status determination period.
Promoting Interoperability (PI) (previously Advancing Care Information): 25 percent of a
physician’s score
The AMA strongly supported a number of finalized changes to the PI category. This is one of the most
significant overhauls of the federal government’s EHR reporting program since its inception and is a solid
step in the right direction.
For example, CMS has eliminated many burdensome and time-consuming measures that evaluate
physicians on actions they cannot control—for example, patients viewing, downloading, or transmitting
their medical records—which allows physician to spend more time on their patients instead of focusing
on how to meet and report on arbitrary requirements.
Further, CMS has eliminated the base, performance and bonus scoring structure used in the first two years
of MIPS and is instead scoring physicians on a 100-point scale at the individual measure level. CMS is
also maintaining the hardship exceptions for this performance category.
2015 Certified Electronic Health Record Technology (CEHRT)
CMS requires all physicians to use 2015 CEHRT in 2019, which the AMA supports for purposes of
increased patient access and advances in interoperability. Physicians who lack access to 2015 Edition
CEHRT, e.g., their EHR vendor does not make 2015 Edition EHR available in time to meet the
requirements of the PI performance category, will be able to request a hardship exception.
New Measures
CMS adds two new measures—scored as bonus points in 2019—to the e-Prescribing objective: Query of
Prescription Drug Monitoring Program and Verify Opioid Treatment Agreement. The Query of
Prescription Drug Monitoring Program measure will remain a bonus through 2020, for which the AMA
advocated. CMS has also consolidated two former measures into one new measure, Receive and
Incorporate Health Information, but there is a new exclusion from this measure when a physician’s EHR
cannot receive or use electronic health information.
© 2018 American Medical Association. All rights reserved.
Reporting Period
Consistent with AMA advocacy, CMS is maintaining a consecutive 90-day reporting period in 2019.
Improvement Activities (IA): 15 percent of a physician’s score
The AMA is very pleased that CMS is maintaining an attestation reporting option and a 90-day reporting
period for the IA performance category; this has been a priority for AMA advocacy in this category.
Advocacy has also successfully focused on maintaining reduced reporting requirements for small and
rural practices. CMS is finalizing six new IAs, modifications to five existing IAs, and removal of one
existing IA.
Bonuses in PI Category
Unfortunately, the previous bonus that physicians could receive in the ACI / PI category for completing
certain IA activities has been removed. The AMA will continue to advocate for CMS to provide credit to
physicians who use health information technology to complete IAs.
New IA Criterion
CMS adopts an additional criterion entitled “Include a public health emergency as determined by the
Secretary” to the criteria for nominating new IAs to promote clinician adoption of best practices to
combat public health emergencies such as the opioid epidemic. New IAs are not required to meet this
criterion; rather, it is an additional option for stakeholders to utilize when submitting nominations for new
Quality: Now 45 percent of a physician’s final score
Meaningful Measures Initiative
CMS is continuing its Meaningful Measures initiative and believes this will streamline reporting for
physicians. Quality measure changes include adding 10 new quality measures, removing 26 measures
immediately, and removing additional measures using a more gradual process provided in the CY 2018
final rule. As part of this effort, CMS finalized its proposal to revise the definition of a high-priority
measure to include quality measures that relate to opioids and to further clarify the types of outcome
measures that are considered high priority. CMS defines a high-priority measure to mean an outcome,
appropriate use, patient safety, efficiency, patient experience, care coordination or opioid-related quality
measure. The AMA is concerned about the large number of measures being removed absent a reduction
in quality reporting requirements and the time needed to develop new measures, and will further analyze
how this will affect physicians in different specialties.
New Reporting Option
CMS allows for a combination of data collection types for the quality performance category. CMS will
score the measure based on the most successful collection type. The multiple-submission type option does
not apply to web-interface reporters.
CMS limits the claims based reporting option to individuals who are in small practices. However, CMS
expands the claims-based reporting option to allow small group practices (15 or fewer eligible clinicians)
to report via claims.
Small Practices
CMS maintains the 3-point floor for quality measures that do not meet the data completeness requirement.
In addition, CMS moves the small practice bonus points to a physician’s quality category score, but
© 2018 American Medical Association. All rights reserved.
increases it to 6 points, as opposed to the proposed 3 points in 2019. The AMA will continue to advocate
for the small practice bonus to apply to a physician’s overall score. Limiting the bonus to the quality
component ignores that small practices also need additional assistance in the other MIPS categories,
particularly cost, to offset sample size reliability concerns, and increases the complexity of scoring.
Reporting Period
CMS maintains a full-year reporting period for the quality performance category in 2019, despite the
AMA’s advocacy to allow physicians and groups the option to submit a minimum of 90-days of data.
Score Re-weighting
CMS re-weights a physicians’ score in the quality performance category if the score cannot be calculated
due to lack of available measures, due to extreme and uncontrollable circumstances, or if an eligible
clinician joined a practice in the last 90-days of a performance period and the practice does not participate
as a group.
Data Completeness Criteria, Threshold and Scoring
CMS maintains that for a physician to be successful in reporting on a measure, they must meet the data
completeness criteria of 60% of all denominator eligible patients, and must report a minimum of 20 cases.
Physicians reporting via claims must report on 60% of Medicare Part B patients only and on a minimum
of 20 cases.
For groups registered to report the CAHPS for MIPS survey, CMS finalizes an additional policy. If the
survey sample size is not sufficient, the total available measure achievement points (the denominator)
would be reduced by 10 points and the measure would receive zero points.
If a measure has a benchmark and a physician meets the data completeness criteria, they are eligible to
receive 3-10 points based on performance compared to the benchmark. If a physician fails to meet the
data completeness criteria, they are only eligible to receive 1 point. Small practices would continue to
receive 3 points if they do not meet the data completeness criteria.
Topped Out Measures
Despite the AMA’s strong objection, CMS finalizes the definition and lifecycle for topped out measures,
the definition and lifecycle for extremely topped out status, and excludes QCDR measures from the
topped-out process.
For the 2020 payment year, 6 measures receive a maximum of 7 measure achievement points, provided
that the applicable measure benchmarks are identified as topped out again in the benchmarks published
for the 2018 performance period. Beginning with the 2021 MIPS payment year, measure benchmarks
(except for Web Interface) that are identified as topped out for two or more consecutive years receive a
maximum of 7 measure achievement points beginning in the second year the measure is identified as
topped out.
Measures Impacted by Clinical Guideline Changes
Measures impacted by clinical guideline changes will be given a score of zero, and the physician who
reports the measure will have his or her quality performance category denominator score reduced by 10.
The AMA was supportive of this proposal as it recognizes changes in scientific evidence and does not
penalize physicians mid-reporting period for guideline changes.
© 2018 American Medical Association. All rights reserved.
Bonus Points
• High-Priority Measures: For the 2019 performance year, as supported by the AMA, CMS
discontinues awarding bonus points to CMS Web Interface reporters for reporting high-priority
measures, but would continue the high priority bonus (as long as a physician reports on a
minimum of one high-priority measure) for all other reporting types.
• End-to-end Reporting: CMS continues to assign bonus points for end-to-end reporting for the
2021 payment year as a way to incentivize reporting through electronic means.
Improvement Scoring
Despite the AMA’s objection, CMS continues to measure improvement in Year 3. In order to receive
improvement points, eligible clinicians must fully participate (i.e. submit all required measures and have
met data completeness criteria for the performance year). However, the quality improvement percent
score is zero if the eligible clinician did not fully participate in the quality category for the current
performance period. Therefore, improvement scoring cannot reduce a clinician’s quality category score,
but only add to the overall quality score. The AMA believes it is premature to begin measuring
improvement due to the lack of access to timely data and experience physicians have with participating in
MIPS and the large number of measures CMS removed from the program.
Future Approaches to Scoring the Quality Performance Category
CMS sought comment on several approaches to scoring quality in the future as an effort to move
physicians toward reporting high-value measures and more accurate performance measurement. The
AMA voiced some initial concerns with the proposals because they appear to add complexity to the
program as opposed to simplifying scoring and reducing physician burden. CMS has taken the AMA’s
comments into consideration and will consider for future rulemaking.
Cost: Now 15 percent of a physician’s final score
Cost Category Weight
Ten percent of physicians’ MIPS score is tied to costs in 2018. This was originally scheduled to rise to
30% in the 2019 performance year; however, the Bipartisan Budget Act of 2018 authorized CMS to
weight costs at any level from 10% to 30% through the next three years. CMS proposed to increase the
cost weight to 15% in 2019 and noted it “anticipates” increasing the weight by an additional 5% in each
of the next two performance years until it reaches the maximum 30% in the 2022 performance year.
Despite protests from the AMA and many other medical organizations, CMS increases the cost category
weight to 15% and maintains all the key provisions in the proposed rule, including several that are
intended to increase the number of physicians who will have cost measures attributed to them. The AMA
had maintained that in its eagerness to expand the impact of this category, CMS was proposing a number
of policies that would compromise the integrity of the cost measures and reward or penalize physicians
Cost Measures
As previously proposed, the final rule retains the two existing cost measures (Medicare Spending Per
Beneficiary and Total Per Capita Cost of Care) with no changes and adds 8 new episode-based measures
in 2019. All the measures include both Part A and Part B costs and are calculated from administrative
claims. CMS intends to continue setting a relatively low 0.4% reliability threshold for all the cost
measures in order to “measure as many clinicians as possible in the cost performance category.”
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Unlike the current measures, which had no real clinical input, the new episode measures were developed
with significant input from clinicians. They have undergone a limited pilot test in which most, but not all,
exceeded the 0.4% reliability threshold. Five of the new measures are tied to costs associated with a
particular procedure (elective percutaneous coronary intervention, knee arthroplasty, revascularization for
lower limb ischemia, routine cataract removal with IOL, and screening colonoscopy). Three (intracranial
hemorrhage or cerebral infarction, simple pneumonia with hospitalization and ST-Elevation Myocardial
Infarction with PCI) involve costs associated with an acute inpatient medical condition. Reliability was
generally higher for the procedural than the medical measures.
Procedural episodes are attributed to any physician who billed one of the trigger procedure codes, and any
physician with at least 10 episodes in a given measure is scored on it. For medical condition measures,
CMS attributes episodes to each physician who bills for inpatient E/M services and is affiliated with a
group (TIN) that provides at least 30% of inpatient E/M codes during a hospitalization for the condition in
question. To have the measure counted in the cost score, the TIN needs a minimum of 20 cases. Earlier
versions of the measure were attributed at the individual level rather than the TIN level unless the
physicians participated as a group. The modification is intended to make more physicians subject to the
cost category.
The AMA believes that well-designed episode-based measures are potentially more fair and accurate than
the MSPB and TPCC and has been very supportive of the process that CMS and its contractor (Acumen)
have used to develop the eight new measures. However, because the eight new measures were subjected
only to a limited pilot, the modified attribution methodology was not tested, at least one measure is not
sufficiently reliable, and the vast majority of physicians are not familiar with the new measures, the AMA
had argued that the cost category weight should stay at 10% in 2019.
Alternative Payment Models (APMs)
The AMA is pleased that CMS agreed not to increase the financial risk requirement for APMs for at least
the next six years. We also appreciate that the agency is engaging with stakeholders that have submitted
proposals for physician-focused APMs to leverage their experiences in the field.
Consistent with AMA recommendations not to require that APMs take increased financial risk in order to
qualify as Advanced APMs, CMS is maintaining the revenue-based financial risk requirement for
Advanced APMs at 8% of revenues through 2024.
Consistent with AMA advocacy, CMS allows Other Payer APMs to describe their compliance with
requirements that APM physicians use CEHRT instead of mandating inclusion of this information in
payment contracts.
As AMA recommended, CMS is permitting Other Payer APMs to be certified as meeting CMS APM
requirements for up to 5 years instead of having to annually re-apply.
Physicians are now able to establish that they meet the All-Payer threshold for Qualified APM
Participants at the practice level in addition to individuals and APM entities.
CMS clarifies that APM participants can meet required Medicare and Other Payer participation thresholds
using a mix of patient counts and payment counts, whatever is most advantageous to the physician.
© 2018 American Medical Association. All rights reserved.
In response to AMA advocacy aimed at helping physicians who practice in areas with an above-average
proportion of Medicare patients in Medicare Advantage (MA) plans, MIPS reporting and payment
adjustments are waived for physicians participating in MA APMs, effective in 2018.
Beginning in 2019 for Medicare APMs and 2020 for Other Payer APMs, the percentage of an APM’s
participating physicians required to use CEHRT increases from 50% to 75%.
Estimated 2019 QPP Impacts
Estimated impacts in the 2019 proposed rule were based on reporting under the legacy programs that
predated MIPS, but the final rule has updated its estimates for the 2019 QPP performance year and 2021
MIPS payment adjustments to reflect actual experience during the first MIPS performance year. CMS
now estimates that 797,990 clinicians will be MIPS eligible in 2019, compared to 650,165 in the proposed
rule. It has also significantly decreased its estimate of number of clinicians that will not be eligible for
MIPS in 2019 due to various exclusions to 677,262, compared to 872,816 in the proposed rule.
Based on the very high percentage of MIPS eligible clinicians in 2017 who participated in MIPS that
year, CMS projects that 97.8% of MIPS eligible clinicians will submit performance data in 2019. Of those
submitting data, 91.2% are projected to receive a positive or neutral payment adjustment in 2021, with the
remaining 8.8% receiving a penalty in 2021. Nearly two-thirds of those projected to receive a positive or
neutral payment adjustment are projected to score high enough for an “exceptional” payment adjustment.
2017 QPP results
CMS separately released data about physician participation results in the first year of MIPS. As a result of
the 2017 transition year for MIPS with its “pick your pace” option, 93% of MIPS eligible clinicians will
receive a positive incentive payment in 2019 and 95% will avoid a penalty. Of the 93% receiving a
positive incentive, 71% earned an additional bonus for exceptional performance by scoring between 70-
100 points in MIPS. In addition, nearly 100,000 physicians earned a 5% lump sum bonus payment in
2019 by participating in Advanced APMs.
It is clear CMS’ transitional implementation of the new MIPS program with a reasonable on-ramp
allowed for broad physician success across practice size, type, specialty and location. The mean score for
MIPS eligible clinicians was 74.01 points, clinicians in rural practices earned a mean score of 63.08
points, and clinicians in small practices received a mean score of 43.46 points. These mean scores are
actually high enough to avoid a penalty or earn a positive incentive payment for the 2017, 2018, and 2019
performance periods.
III. Other Issues
CMS added several policies to this rule that were not addressed in this proposed rule.
• Medicare Shared Savings Program: CMS issued a proposed rule outlining significant policy
changes for Medicare accountable care organizations (ACOs) for which comments were due in
Oct. 2018. To provide a measure of stability and predictability for ACOs, in this final rule CMS is
finalizing a voluntary 6-month extension for existing ACOs whose participation agreements
expire at the end of 2018, and a methodology for determining financial and quality performance
for the 6-month performance period from January–June 2019.
© 2018 American Medical Association. All rights reserved.
• Substance Use Treatment: Based on a provision in the recently enacted Substance Use-Disorder
Prevention that Promotes Opioid Recovery and Treatment (SUPPORT) for Patients and
Communities Act that was strongly supported by the AMA, CMS is removing the originating site
geographic requirements and adding 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 on or after July 1, 2019.
Estimated Impact of CY2021 Office E/M Payment Collapse
Analysis uses CY2017 Medicare Utilization and CY2019 Final Medicare CF and RVUs for both CY2019 and CY2021 Estimates
Medicare Designated Specialty
Total Estimated Medicare
Payment for Office Visits
for CY2019
Total Estimated Medicare
Payment for Office Visits
Collapsing Level 2‐4 Only
Percent Change in Office
Visit Payment (Collapsing
Payment for Levels 2‐4
Add‐on G Codes
Medicare Payment
Estimate (GPC1X and
Approximate Impact of ‐2.4
Percent Conversion Factor/
RVU Adjustment to Offset
TOTAL $ 23,459,535,194 $ 2,278,650,777 $ (2,290,124,554)
ADDICTION MEDICINE $ 4,680,886 $ 4,596,012 ‐2% $ (222,894)
ALLERGY/IMMUNOLOGY $ 96,414,642 $ 95,542,484 ‐1% $ 12,704,060 $ (6,083,603)
ANESTHESIOLOGY $ 170,551,425 $ 169,023,146 ‐1% $ (50,118,238)
CARDIAC ELECTROPHYSIOLOGY $ 124,148,218 $ 115,611,189 ‐7% $ (14,318,223)
CARDIAC SURGERY $ 23,295,582 $ 23,285,500 0% $ (7,131,789)
CARDIOLOGY $ 1,683,175,918 $ 1,539,957,598 ‐9% $ 202,033,721 $ (132,979,742)
CERTIFIED CLINICAL NURSE SPECIALIST $ 34,711,016 $ 34,078,872 ‐2% $ (1,776,628)
CERTIFIED NURSE MIDWIFE $ 2,542,267 $ 2,869,682 13% $ (132,081)
CERTIFIED REGISTERED NURSE ANESTHETIST $ 1,212,846 $ 1,185,069 ‐2% $ (28,696,861)
COLORECTAL SURGERY (PROCTOLOGY) $ 32,744,893 $ 35,471,863 8% $ (4,067,461)
CRITICAL CARE (INTENSIVISTS) $ 36,134,578 $ 33,467,605 ‐7% $ (8,453,489)
DERMATOLOGY $ 892,877,725 $ 1,069,421,380 20% $ (89,324,392)
DIAGNOSTIC RADIOLOGY $ 12,295,073 $ 13,454,446 9% $ (124,260,075)
EMERGENCY MEDICINE $ 165,640,879 $ 165,007,154 0% $ (76,776,615)
ENDOCRINOLOGY $ 376,157,895 $ 337,698,043 ‐10% $ 43,540,306 $ (12,357,319)
FAMILY MEDICINE $ 3,634,810,233 $ 3,518,168,727 ‐3% $ 508,582,405 $ (157,968,190)
GASTROENTEROLOGY $ 496,814,262 $ 488,459,983 ‐2% $ (41,174,302)
GENERAL PRACTICE $ 182,814,456 $ 185,797,356 2% $ 25,788,414 $ (9,798,420)
GENERAL SURGERY $ 332,581,560 $ 361,584,549 9% $ (48,984,000)
GERIATRIC MEDICINE $ 62,903,100 $ 58,134,025 ‐8% $ 7,449,852 $ (4,742,957)
GERIATRIC PSYCHIATRY $ 5,203,311 $ 5,191,737 0% $ (470,288)
GYNECOLOGICAL ONCOLOGY $ 28,912,978 $ 27,869,838 ‐4% $ (1,417,699)
HAND SURGERY $ 62,337,124 $ 70,968,047 14% $ (5,286,793)
HEMATOLOGY $ 35,900,886 $ 33,518,662 ‐7% $ (1,711,939)
HEMATOLOGY/ONCOLOGY $ 700,349,990 $ 661,933,927 ‐5% $ 81,211,928 $ (38,180,367)
HOSPICE AND PALLIATIVE MEDICINE $ 6,495,913 $ 6,194,451 ‐5% $ 583,646 $ (983,571)
INFECTIOUS DISEASE $ 87,352,895 $ 84,159,088 ‐4% $ 10,830,063 $ (15,853,812)
INTERNAL MEDICINE $ 3,900,244,206 $ 3,741,274,335 ‐4% $ 523,592,121 $ (264,031,332)
INTERVENTIONAL CARDIOLOGY $ 232,144,948 $ 211,624,802 ‐9% $ (22,019,994)
INTERVENTIONAL PAIN MANAGEMENT $ 169,422,386 $ 165,425,835 ‐2% $ 23,474,448 $ (10,834,154)
INTERVENTIONAL RADIOLOGY $ 9,530,144 $ 10,109,688 6% $ (9,508,396)
MAXILLOFACIAL SURGERY $ 4,585,779 $ 5,543,234 21% $ (449,459)
MEDICAL ONCOLOGY $ 217,787,525 $ 205,569,022 ‐6% $ (11,720,083)
NEPHROLOGY $ 367,949,958 $ 335,948,629 ‐9% $ 41,786,439 $ (53,118,229)
NEUROLOGY $ 672,663,831 $ 624,593,663 ‐7% $ 65,034,030 $ (37,059,286)
NEUROPSYCHIATRY $ 3,355,882 $ 3,159,917 ‐6% $ (254,023)
NEUROSURGERY $ 116,673,304 $ 120,963,053 4% $ (19,314,889)
NUCLEAR MEDICINE $ 3,277,069 $ 3,021,782 ‐8% $ (2,551,392)
NURSE PRACTITIONER $ 1,450,774,818 $ 1,458,674,768 1% $ 213,587,271 $ (83,981,278)
OBSTETRICS/GYNECOLOGY $ 226,871,578 $ 240,247,403 6% $ 32,275,120 $ (13,775,207)
OPHTHALMOLOGY $ 518,602,849 $ 518,227,282 0% $ (134,452,525)
OPTOMETRY $ 275,518,842 $ 295,215,836 7% $ (30,981,063)
ORAL SURGERY $ 8,560,373 $ 9,449,205 10% $ (1,354,414)
ORTHOPEDIC SURGERY $ 954,634,897 $ 1,052,774,904 10% $ (91,803,186)
OSTEOPATHIC MANIPULATIVE MEDICINE $ 20,655,982 $ 21,319,269 3% $ (1,210,579)
OTOLARYNGOLOGY $ 486,686,537 $ 524,576,786 8% $ 70,462,635 $ (30,892,502)
PAIN MANAGEMENT $ 167,851,133 $ 163,668,972 ‐2% $ (10,476,401)
PATHOLOGY $ 2,904,658 $ 3,217,016 11% $ (30,736,363)
PEDIATRIC MEDICINE $ 26,010,167 $ 25,481,388 ‐2% $ 3,424,718 $ (1,539,183)
PERIPERAL VASCULAR DISEASE $ 3,046,506 $ 3,047,579 0% $ (539,482)
PHYSICAL MEDICINE AND REHABILITATION $ 298,501,886 $ 293,289,946 ‐2% $ (26,955,697)
PHYSICIANS ASSISTANT $ 887,409,454 $ 928,581,426 5% $ 134,172,254 $ (51,427,720)
PLASTIC AND RECONSTRUCTIVE SURGERY $ 55,840,493 $ 65,682,818 18% $ (9,141,277)
PODIATRY $ 652,741,065 $ 839,440,692 29% $ (52,017,080)
PREVENTIVE MEDICINE $ 6,400,090 $ 6,570,719 3% $ (393,158)
PSYCHIATRY $ 432,127,985 $ 447,068,242 3% $ 65,908,862 $ (28,365,585)
PULMONARY DISEASE $ 521,958,705 $ 485,431,584 ‐7% $ 60,186,839 $ (41,518,447)
RADIATION ONCOLOGY $ 85,133,897 $ 87,119,406 2% $ (43,734,805)
RHEUMATOLOGY $ 377,456,606 $ 347,213,918 ‐8% $ 46,314,201 $ (13,510,736)
SLEEP MEDICINE $ 18,852,333 $ 17,595,979 ‐7% $ (1,052,079)
SPORTS MEDICINE $ 42,412,070 $ 45,034,489 6% $ (2,449,196)
SURGICAL ONCOLOGY $ 18,817,246 $ 19,355,856 3% $ (2,059,241)
THORACIC SURGERY $ 34,472,091 $ 34,948,564 1% $ (8,616,497)
UROLOGY $ 757,728,799 $ 767,862,404 1% $ 105,707,445 $ (44,654,260)
VASCULAR SURGERY $ 116,581,199 $ 126,307,034 8% $ (27,644,647