CMS Notice of Proposed Rule Making
August 16, 2018
The Centers for Medicare & Medicaid Services (CMS) has released its annual Notice of Proposed Rule Making (NPRM) for the 2019 Medicare Physician Fee Schedule (MPFS). In the NPRM, CMS did not discuss valuation for the eight new Category I codes and two modified Category III codes that will be used to report ABA services. They did, however, include the existing Category III code set in Addendum B to the NPRM and listed each of those codes with Medicare Status Indicator C. We have asked CMS to clarify, but at this time it appears that the new Category I and modified Category III codes will be carrier-priced in 2019.
We felt it important to provide this update because we have been made aware of some interpretations of the CMS NPRM document that are causing confusion among providers. Reportedly some have concluded that because there was no valuation information for the new Category I and III codes in the NPRM, those codes have been rescinded. That is incorrect. The CPT Editorial Panel® process is separate and distinct from the CMS valuation process. The eight Category I and two Category III codes for adaptive behavior services that were approved by the CPT Editorial Panel® will be released in the AMA CPT 2019 book, which will be available in ebook form on August 30 through the AMA Store. The new codes will be implemented for reporting on January 1, 2019. CMS has indicated that we can expect to see the new Category I and modified Category III codes in the addenda to the final 2019 MPFS, but again, as of now we do not anticipate that valuations for the new codes will appear in the fee schedule. Providers should be prepared to negotiate 2019 reimbursement rates with carriers.
Providers and the general public can access the NPRM (CMS-1693-P) and its attachments here. Comments on it may be submitted through September 10, 2018. CMS will review and respond to comments when it releases the final 2019 MPFS rule, which is likely to be on or around November 1.
In preparation for the transition to the new code set, our Steering Committee is working on a packet of resources to assist you in implementing the new code set both internally and externally with your payers. We will make every effort to keep you apprised of the availability of those resources and other developments.