2019 Medicare Part B Fee Schedule

Carl J. Pucci in Finance & Reimbursement

Attached is the 2019 Medicare Part B Fee Schedule, effective 1/1/19 through 12/31/19. To identify the amount for your facility, please locate the appropriate CPT/HCPCS code and match it to the respective facility location column.

As a reminder, the Medicare Part B outpatient therapy cap (KX Modifier) amounts are updated and are $2,040 for occupational therapy, and $2,040 for physical therapy and speech therapy services combined for CY 2019. The targeted medical review process, now-termed Medical Review threshold, amount is $3,000 for PT and SLP services combined and $3,000 for OT services. The Final Rule also reminds providers that the application of therapy caps and therapy caps exception process was repealed effective 1/1/18.

Please refer to the AHCA bulletin below, which provides details of the methodology, as well as related CMS links.

Thanks again to the efforts of Tony Marshall, President and CEO of the Georgia Health Care Association; AHCA is able to offer members the 2019 therapy fees for each CPT/HCPCS Code in each geographic area on our website under the “Medicare Part B Fee Schedules” heading. Please note that the fees effective January 1, 2019 are calculated based upon the Revisions to Payment Policies Under the Physician Fee Schedule (MPFS) and Other Revisions to Part B for Calendar Year (CY) 2019 Final Rule (CMS-1693-F) published in the Federal Register on November 23, 2018.  

Details about the Excel format 2019 therapy fees file workbook on our website are listed below under the heading “AHCA 2019 Medicare Part B Therapy Fees File Details”. 

Background 
On November 23, 2018, the Centers for Medicare and Medicaid Services (CMS) published the CY 2018 Medicare Physician Fee Schedule (PFS) Final Rule (CMS-1676-F) in the Federal Register.  This final rule reflects the requirements of the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) which repealed the Sustainable Growth Rate formula and provisions related to Medicare payment contained in the Bipartisan Budget Act of 2018 (BBA of 2018) signed into law on February 9, 2018. 

The CY 2019 conversion factor is $36.0391 which reflects the update adjustment factor of 0.25 percent and the budget neutrality adjustment of -0.14 percent. Further, the BBA of 2018, Section 50201 - Extension of Work Geographic Practice Cost Index (GPCI) Floor, extended a provision raising the Work GPCI to 1.000 for all localities that currently have a Work GPCI of less than 1.000 through December 31, 2019. Additionally, as required by the ACA, the 1.5 work GPCI floor for Alaska and the 1.0 practice expense GPCI floor for frontier states are permanent, and therefore, applicable in CY 2019.

You may note that after all required adjustments, the conversion factor has increased from $35.9996 for CY 2018 to $36.0391 for CY 2019. However, Table 94 in the Final Rule titled CY 2019 PFS Estimated Impact on Total Allowed Charges by Specialty indicates that, due to relative changes in the weights of various PFS procedure codes, the value of Part B physical and occupational therapy code payments in aggregate will decrease ~1% in 2018.

The final rule continues the multiple procedure payment reduction (MPPR) policy for “always therapy” services.  The MPPR policy required, effective April 1, 2013, a 50 percent reduction to be applied to the practice expense component of payment for the second and subsequent “always therapy” service(s) that are furnished to a single patient by a single provider on one date of service (including services furnished in different sessions or in different therapy disciplines). The MPPR worksheet lists those “always therapy” services subject to the MPPR policy and the reduced fee payment amounts.

Further, the final rule updates the Medicare Part B therapy CPT code list for CY 2019 by deleting two codes (64550 and 96111).

While not impacting fee schedule pricing, the final rule also reminded providers that, effective for January 1, 2018, Section 50202 of the BBA of 2018 repealed the application of the therapy caps and the therapy caps exceptions process while also retaining and adding limitations to ensure appropriate therapy. 

A separate provision of Section 50202 of the BBA of 2018 preserves the former therapy cap amounts as thresholds above which claims must include the KX modifier to confirm that services are medically necessary as justified by appropriate documentation in the medical record. Claims for therapy services above these amounts without the KX modifier are denied. These amounts are now known as the KX modifier thresholds. Just as with the incurred expenses for the therapy cap amounts, there is one KX modifier threshold amount for physical therapy (PT) and speech-language pathology (SLP) services combined and a separate amount for occupational therapy (OT) services. For CY 2019, the KX modifier threshold amounts are: (a) $2,040 for PT and SLP services combined, and (b) $2,040 for OT services. The targeted medical review process, now-termed Medical Review threshold, amount is $3,000 for PT and SLP services combined and $3,000 for OT services. Please see Transmittal 4178/Change Request 11055 and Centers for Medicare and Medicaid Services (CMS) MLN Matters article MM11055 for complete information on the KX modifier thresholds.

Finally, supporting documentation and downloads for Regulation #CMS-1693-F may be found here. An overview of the Physician Fee Schedule Payment Policies may be found here and an overview of skilled nursing facility consolidated billing and annual updates may be found here

AHCA 2019 Medicare Part B Therapy Fees File Details

The 2019 therapy fees for each CPT/HCPCS Code in each geographic area are provided in the attached Excel file. The file contains the following information:

  1. The 2019 Medicare Part B Fee Schedule for Outpatient Rehabilitation for each Carrier and Locality (Part B Fees)
  2. The 2019 Medicare Part B MPPR Fee Schedule for "Always Therapy Services (50% MPPR Factor) for each Carrier and Locality (MPPR Fees)
  3. The 2019 Relative Value Units for each Outpatient Rehabilitation Therapy Code (RVUs)
  4. The 2019 Geographic Practice Cost Indices by Medicare Carrier and Locality (GPCI)
  5. The 2019 Counties Included in 2018 Localities (GPCI Counties) (Same as 2017)

The Part B Fee Schedule amounts are calculated as follows:
    
 ((A1 x B1) + (A2 x B2) + (A3 x B3)) x Conversion Factor (Part B Fees), and
    
 ((A1 x B1) + ((A2 x B2) x (1-MPPR Factor) + (A3 x B3)) x Conversion Factor (MPPR Part B Fees), where:
        A1 = Physician Work RVU
        A2 = Non-Facility Practice Expense RVU
        A3 = Malpractice RVU
        B1 = Work GPCI
        B2 = Practice Expense GPCI
        B3 = Malpractice GPCI

        Conversion Factor = $36.0391

        MPPR Factor = 50%

Resources:
Medicare Expired Legislative Provisions Extended and Other Bipartisan Budget Act of 2018 Provisions

Physician Fee Schedule (MPFS) and Other Revisions to Part B for Calendar Year (CY) 2019 Final Rule (CMS-1693-F) – November 23, 2018 Federal Register 

Revisions to Payment Policies under the Medicare Physician Fee Schedule, Quality Payment Program and Other Revisions to Part B for CY 2019 – Regulation # CMS-1693-F 

Summary of Policies in the Calendar Year (CY) 2019 Medicare Physician Fee Schedule (MPFS) Final Rule – Transmittal 4176/Change Request 11063 

Summary of Policies in the Calendar Year (CY) 2019 Medicare Physician Fee Schedule (MPFS) Final Rule MLN Matters Article – MM11063 

Annual Update to the Per-Beneficiary Therapy Amounts (KX Modifier Thresholds) for CY 2019 – Transmittal 4178/Change Request 11055 

Annual Update to the Per-Beneficiary Therapy Amounts (KX Modifier Thresholds) for CY 2019 MLN Matter Article – MM11055

Physician Fee Schedule Payment Policies 

NYSHFA/NYSCAL CONTACT: 

Carl J. Pucci
Chief Financial Officer
518-462-4800 x36