Proposed 2019 Medicare PFS Could Create Unintended Consequences for Health Care Delivery

The Pennsylvania Medical Society (PAMED) has weighed in on the 2019 Medicare Physician Fee Schedule (PFS) proposed rule, warning of potential unintended consequences for the Medicare population and the health care professionals who serve them.

pfs-cms-commentOn Sept. 10, 2018, PAMED – in collaboration with 11 state-based specialty medical societies – submitted its formal comment letter to Centers for Medicare and Medicaid Services (CMS) Administrator Seema Verma.

“We are deeply concerned over the proposed changes regarding the physician fee schedule, and the effects the proposed regulations will have on health care delivery, and the health and welfare of millions of Medicare beneficiaries,” the letter said.

PAMED and the specialty societies addressed numerous provisions in the Medicare PFS proposal, including:

  • Evaluation and Management (E&M) Documentation Guidelines – PAMED supports efforts to reduce documentation burden. However, in our letter, we note that CMS acknowledges in its proposal that although physician documentation standards would be relaxed, documentation in general would continue in its current state for other reasons, and ultimately not be reduced. Further, physicians would need to continue with burdensome documentation for their non-Medicare patients and for value-based contracts in alternative payment models. Due to this inconsistency, PAMED is reluctant to support proposed changes to documentation standards.
  • Collapsed Payments for E&M Services – PAMED opposes the proposed collapsing of payment rates for levels 2 through 5 for new and established patients. The E&M coding collapse undervalues the element of time involved in dealing with the complicated patient in any discipline. “The proposal is detrimental to physicians in specialties that treat the sickest patients, as well as physicians who provide comprehensive primary care, and ultimately would hurt patients’ ability to access care,” the letter notes.
  • Discount for Same Day Visit and Procedure – For E&M services that are billed with Modifier 25, CMS is proposing to reduce reimbursement for the lower-cost service by 50 percent. PAMED does not support this provision, nothing that “Separate services should be reimbursed appropriately and in accordance with established coding conventions and guidelines, whether used on the same date or different dates.” The letter asked CMS to be aware that the Medicare Part B fee schedule is the basis of many other fee schedules for both Medicare Advantage Organizations and other commercial payers.
  • Alternatives to E&M Payment Structure – PAMED’s letter notes that the higher level 4 and 5 visits are the most common levels one would code for a patient with an acute unstable problem, and/or high complexity medical decision making. For many physicians, this is where the most face-to-face patient time is spent. The current proposal to set it below the current level 4 payment is grossly inadequate. The letter recommends that CMS study alternative proposals. (PAMED’s letter here provides an example of an alternative payment structure.)
  • Proposed New Codes for Complexity, Primary Care, and Prolonged Services – “Overall, we do not support the creation of additional codes and its related increased convolution,” the letter says. Having to create these codes only highlights the problematic nature of the proposed code structure. And, the $67 reimbursement for 30 minutes of prolonged services time would make it difficult for a practice to remain self-sustaining.
  • Telehealth – CMS is proposing to pay for virtual check-ins and remote evaluation of recorded video and/or images submitted by the patient. PAMED supports this proposal.

CMS’ proposed Medicare PFS also includes its suggested blueprint for the Quality Payment Program (QPP) in 2019. PAMED commented on QPP provisions, including on the Merit-based Incentive Payment System (MIPS). The letter addressed issues such as:

  • Opt-in and Voluntary Reporting Low-Volume Thresholds – The letter supports the Opt-In and Voluntary Reporting low-volume thresholds. Some clinicians who were excluded from QPP participation in Years 1 and 2 may have an interest in participating in the QPP.
  • Technology Requirements for the Promoting Interoperability Performance Category – Consideration must be made for the financial burden of the end-user, namely the physician medical practice. Lack of oversight of integration fees passed down from EHR vendor to practice has become problematic. Medical practices who have invested in CEHRT are at the mercy of the vendor as to what the vendor will charge to complete the integration of certain measures. EHR vendors have been afforded an opportunistic position and are assessing exorbitant connection fees plus ongoing maintenance fees to complete an integration with no oversight or protections afforded to physicians.

Read the Comment Letter

To view CMS’ Medicare PFS proposed rule for 2019, visit the Federal Register online here.

PAMED thanks the 11 organizations who provided valuable insights and co-signed the letter to CMS: Keystone Chapter, American College of Surgeons; Metropolitan Philadelphia Chapter, American College of Surgeons; Pennsylvania Academy of Dermatology and Dermatologic Surgery; Pennsylvania Academy of Otolaryngology – Head and Neck Surgery; Pennsylvania Allergy and Asthma Association; Pennsylvania Chapter, American College of Cardiology; Pennsylvania Psychiatric Society; Pennsylvania Rheumatology Society; Pennsylvania Section, American College of Obstetricians & Gynecologists; Pennsylvania Society of Gastroenterology; and Pennsylvania Society of Oncology & Hematology.

Nationwide, the health care community’s reaction to the Medicare PFS proposal was strong, as CMS received more than 15,000 comments on the proposal during the public comment period.

PAMED members with questions can contact our KnowledgeCenter at 855-PAMED4U (855-726-3348) or

For PAMED resources on how to participate in the QPP this year, visit


Leave a comment

norcal advertisement
Norcal Mutual

Learn More 
norcal advertisement