On July 27, 2018, the Centers for Medicare and Medicaid Services (“CMS”) proposed changes for 2019 that some in the industry are describing as the most substantial in more than twenty years. Click here for the full text. Though the proposal was published a month ago, we publish this today because the period of public comment ends soon – on September 10, 2018.

In the proposals, CMS seeks to revise payment policies under the Medicare Physician Fee Schedule. Of particular note is the proposal to treat billing code modifier 25 in a similar manner as it is treated by certain private payers. Modifier 25 is used when a physician performs a procedure on a patient on the same day as the physician also performs a “significant, separately identifiable” evaluation and management service. Currently, when using Modifier 25 in billing to Medicare, the physician would be entitled to full reimbursement for both the procedure and the separate evaluation and management services. The proposal, following in the footsteps of certain private payers, would reduce the reimbursement by 50% given that the two reimbursable services are provided on the same day. Many are concerned that in order to get properly reimbursed, physicians will begin scheduling procedures on different days from evaluation and management services, thus potentially inconveniencing patients and incentivizing physicians to be less efficient.

As mentioned above, the comment period for the proposed changes ends September 10, 2018. If you or your clients take a position on these changes, then we certainly encourage you to go here to post your comment before the deadline. The blue “Comment Now!” button is on the right side of the screen. Note the request that you identify the proposals as CMS-1693-P in the comment.

_________________________________________________________

Vasilios (“Bill”) J. Kalogredis, Esquire is Chairman of Lamb McErlane’s Health Law Department. Bill has been practicing health law for over 40 years, representing exclusively physicians, dentists, group practices, other health care professionals and health care-related entities.

Andrew Stein is an associate at Lamb McErlane PC.  He concentrates his practice at the intersection of health law and business law. He represents individuals and businesses with a primary focus on licensed medical and dental professionals, medical and dental practices, and other health care entities.