Reframing Medicare Physician Payment Policy
for 2019: A Look at Proposed Policy
Authors: Manchikanti Laxmaiah 
Published: October 2019

On July 12, 2018, the Centers for Medicare and Medicaid Services (CMS) released the proposed
2019 Medicare physician fee schedule and quality payment program, combining these 2 rules
for the first time. This occurred in a milieu of changing regulations that have been challenging
for interventional pain management specialists. The Affordable Care Act (ACA) continuous to be
amended by multiple administrative changes. This July 12th rule proposes substantial payment
changes for evaluation and management (E&M) services, with documentation requirements, and
blending of Level II to V CPT codes for E&M into a single payment. In addition, various changes in
the quality payment program with liberalization of some metrics have been published. Recognizing
that there are differing impacts based on specialty and practice type, as a whole interventional
pain management specialists would likely see favorable reimbursement trends for E&M services
as a result of this proposal. Moreover, in comparison with recent CMS final ruling, this proposed
rule has relatively limited changes in procedural reimbursement performed in a facility or in-office
setting.
CMS, in the new rule, has proposed an overhaul of the E&M documentation and coding system
ostensibly to reduce the amount of time physicians are required to spend inputting information into
patients’ records. The new proposed rule blends Level II to V codes for E&M services into a single
payment of $93 for office outpatient visits for established patients and $135 for new patient visits.
This will also have an effect with blended payments for services provided in hospital outpatients.
CMS also has provided additional codes to increase the reimbursement when prolonged services are
provided with total reimbursement coming to Level V payments. Interventional pain managementcentered care has been identified as a specialty with complexity inherent to E&M associated with
these services.
Among the procedural payments, there exist significant discrepancies for the services performed
in hospitals, ambulatory surgery centers (ASCs), and offices. A particularly egregious example
is peripheral neurolytic blocks, which is reimbursed at 1,800% higher in hospital outpatient
department (HOPD) settings as compared with procedures done in the office. The majority of
hospital based procedures have faced relatively small cuts as compared with office based practice.
The only significant change noted is for spinal cord stimulator implant leads when performed in
office setting with 19.2% increase. However, epidural codes, which have been initiated with a
lower payment, continue to face small reductions for physician portion.
This review describes the effects of the proposed policy on interventional pain management
reimbursement for E&M services, procedural services by physicians and procedures performed in
office settings.
Key words: Physician payment policy, physician fee schedule, Medicare, Merit-Based Incentive
Payment System, interventional pain management, regulatory tsunami, Medicare Access and CHIP
Reauthorization Act of 2015