Medicare releases the 2019 Final Changes to Hospital Outpatient Prospective Payment and Ambulatory Surgical Center Payment Systems and Quality Reporting Programs; Medicare Physician Fee Schedule Final Rule



By guest author: Kalisha Barrett

On November 2, 2018, the Centers for Medicare & Medicaid (CMS) released their final rule to the Medicare Hospital Outpatient Payment System (OPPS), Ambulatory Surgical Center (ASC), and Medicare Physician Fee Schedule (PFS) payment system outlining the changes and new rates that will become effective January 1, 2019.

Each summer, CMS reviews the OPPS, ASC, and PFS payment systems and proposes updates on guidelines to the payment policies, payment rates, and other provisions applicable to services furnished under these various payment systems for the upcoming year. Upon release of the proposed rule, CMS offers a public comment period which allows the opportunity for providers to submit feedback regarding the proposed rates and reimbursement guidelines prior to being finalized by early November. CMS recently finalized their changes to the OPPS, ASC, and PFS for calendar year (CY) 2019 and published them in the Federal Register.

The following is a brief summary of the updates taking effect January 1, 2019:

  • Overall, Hospital Outpatient payment rates increased by 1.35 percent and the ASC rates by 2.1 percent.
  • CMS plans to update the ASC payment system for the CY 2019 through 2023 using a new payment methodology to see if this new payment system will lead to a migration of services from the hospital outpatient setting to the ASC setting.

For additional information on the CMS Final Rule CMS1695-FC, please visit the website.

Hospital Five Year Projections:

An analysis of the data for the cochlear implant and auditory osseointegrated implant (AOI) ambulatory payment classifications (APCs) shows rates have slightly fluctuated over the last five years due to a variety of changes made by CMS. Cochlear implant trends reflect a rate increase since 2015, but result in a slight decrease for CY 2019 in the hospital outpatient and ASC setting.  AOI rates have experienced an overall five percent increase in the hospital outpatient setting and a ten percent increase in the ASC setting over the five years. For CY 2019 AOIs realize over a five percent increase in the hospital outpatient and ASC setting.

projections chart

*Auditory osseointegrated implant rates are for the initial implant procedure CPT code 69714 without mastoidectomy

Please work with your local Field Reimbursement Manager to determine your specific hospital, ASC, or physician rates based on your geographical area.

Physician Fee Schedule:

The updates finalized by CMS for the 2019 Physician Fee Schedule (PFS) result in an overall 0.25% increase in physician payment rates. The Conversion Factor (CF) for CY 2019 is $36.0391, which is slightly higher than the 2018 CF of $35.9996. The updated conversion factor combined with this year’s adjustments to RVUs resulted in only slight changes to the allowed amounts.

The following is a summary of the final changes specific to professional services related to cochlear implants and auditory osseointegrated implants. The tables below illustrate the national average rates for participating surgeons and audiologists for CY 2019:


Surgeons physician fee schedule


audiologists physician fee schedule

Medicare Advantage Plans Propose Additional Telehealth Benefits

CMS recently published a proposed rule CMS-4185-P that includes recommendations for Medicare Advantage Plans (MA) offering additional telehealth benefits for CY2019. The proposed rule includes policy changes to Medicare Advantage plans, Medicare prescription drug benefit, program of all-inclusive care for the elderly (PACE), Medicaid fee-for-service, and Medicaid managed care programs for CY 2020 and 2021. CMS proposes loosening restrictions on telehealth services provided under Managed Medicare plans as provided for in the Bipartisan Budget Act of 2018 which created a new section 1852(m) of the Social Security Act.

The proposal would extend greater flexibility to Medicare Advantage plans in covering telehealth services for members regardless of where they live, urban or rural areas, and from their home rather than requiring them to go to a designated health care facility to receive the telehealth services. It also provides for clinically appropriate services which are not currently covered under the Traditional Medicare program to be covered by Advantage plans. MA plans have always been able to offer more telehealth services than are currently payable under original Medicare through supplemental benefits. However, this proposal allows MA plans to offer telehealth benefits beyond what are allowed under the basic benefits rather than as part of the supplemental benefits. By allowing them to be included as a basic benefits, the telehealth services would be accounted for in the payment CMS makes to Medicare Advantage plans, making the inclusion of such benefits more appealing for them.

CMS is soliciting comments on this proposal and comments are due by December 31, 2018. The proposed rule and electronic comments can be found at the link below:

To submit electronic comments, Click Comment Now!

About our guest author:

Kalisha Barrett is the Health Policy Manager in the Health and Economics Division where she assist with executes strategies aimed at expanding patient access to hearing implants and related services through both state and national advocacy efforts. Additional reimbursement support offered by Cochlear’s Regional Reimbursement team, can be found on the Reimbursement Support page of Cochlear’s US Professional Resources Website. Please do not hesitate to reach out to the Reimbursement Manager associated with your geography for reimbursement assistance or for questions related to this article. Cochlear offers coding assistance through the Coding Support Line accessible by calling 1-800-587-6910 between the hours of 8 AM – 3 PM Mountain time zone or via email at For pre-surgical insurance support, OMS is available to assist with pre-authorizations and appeals and can be reached at 1-800-633-4667 option 4.

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