2019 Medicare Participation

Physicians need to decide by December 31 whether to participate in Medicare next year.  Click to view details about Medicare Participation for 2019, including opting out. Medicare fee schedule amounts are 5% higher if you participate.  Participation agreements cover the period January 1, 2019 through December 31, 2019, and may not be changed after December 31, 2018.

To be a participating physician:

To be a non-participating physician:

  • If you are currently not participating, do nothing.
  • If you are currently a participant, submit a written, dated notice postmarked prior to January 1, 2019 that includes the provider name and NPI, a statement indicating that you are rescinding your participation agreement.

Submit the Participation Agreement or Disenrollment to:

Novitas Solutions
Provider Enrollment Services
P.O. Box 3157
Mechanicsburg, PA 17055-1816

Medicare Changes for 2019

CMS announced the following changes to reduce the documentation burden beginning January 2019:

  • Eliminate the requirement to document the medical necessity of a home visit in lieu of an office visit;
  • For established patient office/outpatient visits, when relevant information is already contained in the medical record, practitioners may choose to focus documentation on what has changed since the last visit, or on pertinent items that have not changed, and need not re-record the defined list of required elements if there is evidence that the practitioner reviewed the previous information and updated it as needed.  Practitioners should still review prior data, update as necessary, and indicate in the medical record that they have done so;
  • Additionally, for E/M office/outpatient visits for new and established patients, practitioners need not re-enter information on the patient’s chief complaint and history that has already been entered by ancillary staff or the beneficiary. The practitioner may simply indicate in the medical record that he or she reviewed and verified this information; and
  • Removal of potentially duplicative requirements for notations in medical records that may have previously been included in the medical records by residents or other members of the medical team for E/M visits furnished by teaching physicians.

Starting in 2019, practitioners are allowed to be separately paid for brief communication technology-based services when the patient checks in with the practitioner via telephone or other telecommunications device to decide whether an office visit or other service is needed.  Payment would also be allowed when the practitioner remotely evaluates recorded video and/or images submitted by an established patient to assess whether a visit is needed.

  • In addition, CMS is adding HCPCS codes G0513 and G0514 (Prolonged preventive service(s)) to the list of telehealth services.
  • Through an interim final rule with comment period, CMS is removing the originating site geographic requirements and adds the home of an individual as a permissible originating site for telehealth services furnished for purposes of treatment of a substance use disorder or a co-occurring mental health disorder for services furnished on or after July 1, 2019.

The final 2019 PFS conversion factor is $36.04, a slight increase above the 2018 PFS conversion factor of $35.99.

2019 MIPS Payment Adjustment Fact Sheet

Highlights how CMS assigns final scores to MIPS-eligible clinicians, and how Medicare payment adjustment factors are applied for 2019 based on 2017 MIPS final scores.

MIPS 2017 Performance Feedback

CMS posted the 2017 Performance Feedback User Guide to help eligible clinicians and groups understand their 2017 Merit-based Incentive Payment System (MIPS) performance feedback.  Your 2019 payment adjustment is based on this final score.  Please see the 2017 Performance Feedback Fact Sheet and page 7 of August MPS News for more info.

New Medicare Cards are Here

CMS has finished mailing cards to people with Medicare who live in Delaware, District of Columbia, Maryland, Pennsylvania, Virginia, and West Virginia.  If someone with Medicare says they did not get a card:

  • Print and give them the “Still Waiting for Your New Card?” handout (in English or Spanish).
  • Or tell them to call 1-800-Medicare (1-800-633-4227). Something may need correcting, such as their mailing address.

A secure portal is available to look up the new Medicare Beneficiary Identifier (MBI).  You need to sign up for access to the tool. You can look up MBIs for cards that have been mailed to Medicare patients when they do not or cannot give them. If the tool indicates the card has not been mailed for your Medicare patient, tell your patient to call 1-800-Medicare (1-800-633-4227).

Exemption from MIPS Reporting

Use the MIPS Participation Lookup Tool to find out whether individual clinicians are eligible for the 2018 performance year without needing to log in.  To check your group’s 2018 eligibility for the Merit-based Incentive Payment System (MIPS), log in to the CMS Quality Payment Program website using your EIDM credentials.  Browse to the Taxpayer Identification Number (TIN) affiliated with your group, and click into the details screen to see the eligibility of each clinician based on their NPI and whether they need to participate during the 2018 MIPS performance year.  To set up an EIDM account, use the Enterprise Identity Management (EIDM) User Guide.

As a reminder, the eligibility threshold for 2018 is different – clinicians and groups are now excluded from MIPS if they:

  • Billed $90,000 or less in Medicare Part B allowed charges for covered professional services under the Physician Fee Schedule (PFS)


  • Furnished covered professional services under the PFS to 200 or fewer Medicare Part B -enrolled beneficiaries

In other words, to be included in MIPS for the 2018 performance period you need to have billed more than $90,000 in Medicare Part B allowed charges for covered professional services under the PFS AND furnished covered professional services under the PFS to more than 200 Medicare Part B enrolled beneficiaries.

 APA Webinar: Help with MIPS Reporting for 2018

This one-hour webinar provides the tools needed to be successful in Medicare’s Merit-based Incentive Payment System (MIPS). Many psychiatrists participating in Medicare were impacted by payment reform requirements last year and need to be aware of changes to the program. Topics addressed include how to:

  • Identify what is new for the MIPS program in 2018
  • Determine the circumstances under which physicians are required to do MIPS reporting for 2018
  • Understand the 2018 MIPS reporting requirements
  • Locate additional resources and help to guide physicians in doing MIPS reporting

This webinar, which provides 1 CME or Certificate of Participation, is available on APA’s website. Free for APA members; $25.00 for non-members. To view this webinar, click here.

2018 Medicare Physician Fee Schedule

Annual participation for calendar year 2018 runs through December 31.  Use the fee lookup tool to find fees for 2018.

Assistance with Medicare Appeals, Denials and Grievances

The State Health Insurance Assistance Program (SHIP) meets the most universal needs of Medicare beneficiaries, such as understanding their health insurance benefits, bills, and rights. Trained staff and volunteer counselors in all 23 counties and Baltimore City provide in-person and telephone assistance.  Topics covered include:

  • Medicare Part A: Hospital Insurance
  • Medicare Part B: Medical Insurance
  • Medicare Part C: Advantage Plans
  • Medicare Part D: Prescription Drug Plans
  • Financial Assistance for Low-Income Beneficiaries
  • Billing Issues, Appeals, Denials, and Grievances
  • Medicare Fraud and Abuse

Click here to contact the closest SHIP office.

Qualified Registries for MIPS Data Submission

Under the Medicare Quality Payment Program option, MIPS, there are several data submission methods, one of which is Qualified Registries. A qualified registry is a CMS-approved entity that collects clinical data from MIPS eligible clinicians (both individual and groups) and submits it to CMS on their behalf for purposes of MIPS.  CMS has designated the qualified registries that can report data (measures and/or activities) for the Quality, Advancing Care Information, and Improvement Activities performance categories, on behalf of individual MIPS eligible clinicians and groups for 2017.  Please click here to view the list of registries [the APA’s PsychPRO registry—see next item—is included on page 88.]:

  • These registries have self-nominated and demonstrated that they meet the applicable requirements outlined by CMS at 42 CFR §414.1400 and in the CY 2017 Quality Payment Program final rule with comment period.
  • Each of the 2017 qualified registries has given detailed information, including their contact information, the measures, activities and performance categories they support, services offered, and costs incurred by their clients.

From May 22 MedChi News

Coding Updates

  • On January 12, 2017 CMS published changes that reflect the annual CPT/CHPCS code updates for psychiatric and mental health services (L35101).  Effective for dates of service on and after January 1, either the short and/or the log description was changed for codes 90832, 90833, 90834, 90836, 90837, 90846 and 90847.  Please click here and scroll down to view the updated coding information.
  • The CMS Provider Minute: Psychiatry and Psychotherapy video discusses how to submit documentation for these services, including use of add-on codes when billing for same day evaluation and management and psychotherapy services, and three factors needed for sufficient documentation.
  • On July 13, 2017 Novitas revised its Local Coverage Determination for Psychiatric Codes to clarify Documentation Requirement #4 regarding diagnoses for CPT codes 90791 and 90792.  Item 4 now states, “The medical records must indicate the diagnosis, including psychological and/or medical conditions, as well as any psychosocial and environmental stressors.”  Please click the link and scroll down for complete information.

Prolonged Medicare Services without Face-to-Face Contact Now Payable

Prior to 2017, CPT codes 99358 and 99359 (prolonged services without face-to-face contact) were not separately payable, and were included under the related face-to-face E/M service code.  With CPT code changes effective January 1, these services are now billable.  CMS has posted a file that notes the times assumed to be typical. While these typical times are not required to bill the displayed codes, CMS would expect that only time spent in excess of these times would be reported under CPT codes 99358 and 99359. Further, CMS notes: 1) that these codes can only be used to report extended qualifying time of the billing physician or other practitioner (not clinical staff); and 2) Prolonged services cannot be reported in association with a companion E/M code that also qualifies as the initiating visit for CCM services. Practitioners should instead report the add-on code for CCM initiation, if applicable.  Click here for details.

Medicare Quality Payment Program

Resources on the Quality Payment Program (QPP) website help eligible clinicians prepare to participate:

Download the APA’s fact sheet about the MIPS Quality Performance Category for help deciphering your MIPS composite score and its impact on Medicare Part B payments.   It also includes a Mental/Behavioral Health specialty measure set as well as a list of measures pertinent to psychiatrists.  Visit the APA website for more Medicare payment reform resources, including a MACRA toolkit.

CMS educational videos are available on YouTube at and its Events page (which also includes resources from past MACRA webinars). The on-demand videos explain aspects of the QPP about 10 minutes or less.  One gives a quick general overview.  There are four that cover APMs and five that address MIPS.

Quality Payment Program: Pick Your Pace Online CME

A new, online, self-paced course on participating in the Quality Payment Program (QPP) and Picking a Pace that meets the needs of your practice is now available through the MLN Learning Management System. Find out about::

  • QPP basics;
  • Steps to actively participate to avoid a payment penalty and possibly earn a positive payment adjustment; and
  • Factors in choosing how to participate through either the Merit-based Incentive Payment System (MIPS) or an Advanced Alternative Payment Model (APM).

This course is part of an evolving QPP curriculum that offers knowledge, insight and CME credit. CMS designates this enduring material for a maximum of 0.5 AMA PRA Category 1 Credit. Physicians should claim only the credit commensurate with the extent of their participation. Credit for this course expires May 30, 2020.

APA Advocacy Ends Denial of Medicare Claims for Several Psychiatric Diagnoses

Claims will no longer be denied for some 40 diagnostic codes submitted by mental health practitioners participating in the Medicare Part B program in 13 states, including Maryland, Delaware, Pennsylvania, DC and Arlington and Fairfax counties and the city of Alexandria in Virginia.  Novitas, the Medicare carrier in those areas, responded to APA advocacy and updated its Local Coverage Determinations (LCD) to include the codes. Moreover, claims submitted since December 31, 2015 that had been denied will be retroactively approved and paid.  A list of the diagnostic codes for which services were previously being denied and will now be covered can be found here.

Medicare Covers Psychiatric Collaborative Care Management

As of 2017, CMS reimburses for “Psychiatric Collaborative Care Management Services.”  Coding for those services supports payments to psychiatrists for consultative services they provide to primary care physicians in the collaborative care model.  Take the APA’s online trainings to learn how you can incorporate this model into your practice, free through September 2019.

MACRA Assistance from the APA

The Medicare Access & CHIP Reauthorization Act (MACRA) completely transforms Medicare payment and quality reporting, though the Merit-Based Incentive Payment System (MIPS) and new incentives for “advanced” alternative payment models (APMs).  To help members understand the new regulations, APA has relaunched its Payment Reform webpage and prepared free educational materials and a webinar series. Download the MACRA 101 Primer For Psychiatrists. The recorded presentation “Quality Reporting 101: A How-to Guide for Psychiatrists” is available through the APA Learning Center.

Please use the following APA contacts for MACRA assistance:

The APA Practice Management Helpline at 1-800-343-4671 is available for coding, reimbursement and practice management questions.

E&M Interactive Score Sheet

Novitas posted the E/M Interactive Score Sheet to assist with coding Evaluation and Management services.

Medicare Revalidation Reminder

The Affordable Care Act requires all currently and actively enrolled providers to revalidate their enrollment information every three or five years.  CMS sets every provider’s revalidation due-date at the end of a month, and posts the upcoming six months online. A due date of “TBD” means that CMS has not set the date yet.  Go to the revalidation dates page to search for your due date by name or browse the entire list to find the information needed. For more information, see the revalidation webpage and the FAQs.

If a provider fails to submit the revalidation application by the due date, the provider enrollment record will be deactivated. Deactivated providers must submit a full and complete application to reestablish their provider enrollment record and Medicare billing privileges. An interruption in billing will occur during the period of deactivation, resulting in a gap in coverage.  Retroactive billing privileges back to the period of deactivation will not be granted.  Services provided to Medicare beneficiaries during the period between deactivation and reactivation are the provider’s liability.

Please review the CMS revalidation document for more information.  Any questions or concerns should be directed to Andrea King, Novitas Provider Outreach and Education, at: or 717-526-6392.

Medicare Quality Reporting Videos

CMS offers the following videos on the Medicare Quality Reporting Programs:

Medicare Provider Data Published

CMS is making publicly available a subset of PECOS data to allow providers, suppliers, state Medicaid programs, private payers, etc. to leverage Medicare provider enrollment data. Click here for more information.  The Public Provider Enrollment files are published at and will be updated on a quarterly basis. Opt-out providers will not be included. Elements include:

  • Enrollment ID and PECOS Unique IDs
  • Provider Enrollment Type and State
  • Provider’s First and Last Name/ Legal Business Name
  • Gender
  • NPI
  • Provider or Supplier Specialty
  • Limited address information (City, State, ZIP code)

CMS Provider Screening

CMS has four tactics to reinforce provider screening activities:

  • Increase site visits to Medicare-enrolled providers
  • Enhance address verification software in PECOS to better detect vacant or invalid addresses
  • Deactivate providers who have not billed Medicare in the last 13 months
  • Identify potentially invalid addresses on a monthly basis using the U.S. Postal Service database

Providers should promptly inform CMS of any changes. For more information, see the fact sheet.

Psychiatry and Psychotherapy Documentation

Proper payment and sufficient documentation go hand in hand. CMS has created a video series to help providers improve in areas identified with a high degree of noncompliance.  The CMS Provider Minute: Psychiatry and Psychotherapy video includes pointers to properly submit documentation for these services.  In about three minutes, the video explains:

  • Use of add-on codes when billing for same day evaluation and management and psychotherapy services
  • Three factors needed for sufficient documentation

Small Practices and Health Professional Shortage Areas & Medically Underserved Populations

CMS launched a new section of the Medicare Quality Payment Program (QPP) dedicated to clinicians working in small or rural practices as well as those treating patients in underserved areas. This page is a single point of reference for the QPP, especially, for those participating under the Merit-based Incentive Payment System (MIPS) track. Quickly locate contact information for organizations that assist practices through the Small, Underserved, and Rural Support initiative using an interactive map. Review the flexibilities to help reduce the participation and reporting burden on small practices for 2017.  More features and information will be added, so submit your feedback to CMS.

MACRA provides direct technical assistance for small practices to participate in the QPP through an organization called IPRO, which serves Maryland, DC and Virginia.

Health Professional Shortage Areas (HPSAs) are designated as having shortages of primary care, dental care, or mental health providers and may be geographic (a county or service area), population (e.g., low income or Medicaid eligible) or facilities (e.g., federally qualified health centers, or state or federal prisons).  Providers who serve these areas are eligible for bonus payments under Medicare.  A search tool is available to check an address for bonus eligibility.  Use another online tool to find HPSAs by state, country and discipline.

Do You Prescribe Part D Drugs?

Medical practitioners must have a status with Medicare for their Medicare patients’ prescriptions or tests or referrals to covered.  Being opted out is a valid status with Medicare, and Medicare will continue to cover all ordering and referring that is done by an opted out physician.  Physicians who do not wish to either opt out or enroll in Medicare now have the option of enrolling just to be able to have their orders and referrals covered by Medicare.  This new option is referred to as the OPR option (ordering, prescribing and referring).

To minimize the impact on beneficiaries, CMS will use a phased approach to enforcement that will begin in the second calendar quarter of 2017 and end with full implementation and enforcement of the Part D prescriber requirement on January 1, 2019.  Please click here for more details.  CMS encourages all providers who prescribe Part D drugs, but are not yet enrolled or validly opted out of Medicare, to enroll in the Medicare Program. Click here for enrollment information.  If you are unsure of your status, check the CMS list of providers who are enrolled in Medicare in an approved or opt out status.

Send questions directly to CMS at or visit Novitas’ JL Enrollment Center for CMS Forms, tutorials, and additional help.

Changes to the Medicare Opt-Out Law

Prior to enactment of the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), physician opt-out affidavits were only effective for 2 years. As a result of changes made by MACRA, valid opt-out affidavits signed on or after June 16, 2015 will automatically renew every 2 years. If physicians who file affidavits effective on or after June 16, 2015 do not want their opt-out to automatically renew, they may cancel the renewal by notifying all Medicare Administrative Contractors (MACs) with which they filed an affidavit in writing at least 30 days prior to the start of the next opt-out period. Valid opt-out affidavits signed before June 16, 2015 will expire 2 years after the effective date of the opt out. If physicians who filed affidavits effective before June 16, 2015 want to extend their opt out, they must submit a renewal affidavit within 30 days after the current opt-out period expires to all MACs with which they would have filed claims absent the opt-out.  Check this CMS publication for more details.

Medicare Private Contracting Change

Physicians who opt-out of Medicare should be aware that CMS has changed its definition of emergency care services to encompass urgent care services, which are furnished within 12 hours to avoid the likely onset of an emergency medical condition.   It has also specified that the enrollment appeals process should be used to appeal Medicare opt-out determinations, such as whether a physician or practitioner has failed to properly opt-out, failed to maintain opt-out, failed to timely renew opt-out, failed to privately contract, or failed to properly terminate opt-out. These changes are effective July 13, 2015. For details, click here.

Sending Documents to Medicare

To expedite claims processing, redeterminations, documentation requests, etc., please be sure to submit documents to Novitas using the correct forms.  Recent analysis revealed several common errors that increase administrative costs for both Novitas and for providers.  For copies of forms and information on form completion, please refer to the Medicare Reference Manual.  In addition, the Medicare Provider Compliance page can help professionals understand common billing problems and avoid improper payments.

Opting Out of Medicare

Since 1998, physicians have been permitted to opt out of Medicare and enter into private contracts with Medicare patients that allow them to set their own fees. A physician who opts out of Medicare agrees not to see any Medicare patients for two years (barring emergencies or urgent services), except for those with whom s/he has entered into private contracts. The opt-out applies for every Medicare patient a physician sees in clinics or elsewhere, not just those seen in private practice. If there is any possibility of having to see Medicare patients as part of a new contract or employment, a physician should not consider opting out of Medicare.  The rules for opting out are very specific. Please continue reading at the APA website.

To search for providers who have opted out of the Medicare program, see the CMS Opt-Out Affidavit listing, which is updated on a quarterly basis.  If you opted out of Medicare and cannot locate your information, please call 1-877-235-8073.

Medicare Resources

A new Behavioral Health Integration Services fact sheet explains psychiatric collaborative care services and how to bill for this model of care.

A new Care Management page is available with fact sheets, FAQs, etc.  Those who provide patients with chronic care management, non-face-to-face services such as reviewing test results or coordinating with other providers, may not be aware of the separate payments under the Medicare Physician Fee Schedule and may not be receiving the full separate payments that are now available. The Chronic Care Management Services Changes for 2017 fact sheet has information about 2017 coding changes, included services and reduced requirements for initiating care. The existing Chronic Care Management Services fact sheet has been revised, and addresses separately payable services for patients with multiple chronic conditions, codes and billing requirements, etc.

Novitas Behavioral Health Page – up-to-date topics, resources, training and coverage information.

Medicare Physician Fee Schedule Fact Sheet — Revised

Health Professional Shortage Area Physician Bonus Program

Medicare Enrollment Guidelines for Ordering/Referring Providers Fact Sheet—Covers three basic requirements for ordering and referring, and who may order and refer for Medicare Part A Home Health Agency, Part B, etc.

Medicare Fraud & Abuse: Prevention, Detection, and Reporting Fact Sheet

Mental Health Services Booklet — Revised—Explains covered and non-covered mental health services, eligible professionals, supplier charts, assignment, outpatient and inpatient psychiatric hospital services, same day billing guidelines, and National Correct Coding Initiative.

Definition of Treatment-Resistant Depression in the Medicare Population

Substance Abuse Services – Describes the levels of services and authorized suppliers that are covered under Medicare, as well as Part D drugs for opioid dependence.

Guidance on dually eligible individuals enrolled in the Qualified Medicare Beneficiary (QMB) Program was updated February 1, 2016. QMB is a Medicaid program for Medicare beneficiaries that exempts them from liability for Medicare cost-sharing. State Medicaid programs may pay providers for Medicare deductibles, coinsurance and copayments. Medicare providers must accept the Medicare payment and Medicaid payment (if any) as payment in full for services rendered to a QMB beneficiary.

Transitional Care Management Services can be billed by one clinician for services during the 30 days after discharge from an inpatient setting that include three TCM components: an interactive contact, certain non-face-to-face services, and a face-to-face visit.

HIPAA Privacy and Security Basics for Providers – Information on covered entities, business associates, and resources.

HIPAA Basics for Providers: Privacy, Security, and Breach Notification Rules – HIPAA basics, such as privacy, security, breach notification rules, covered entities, business associates, and disposal of private health information.

Medical Privacy of Protected Health Information addresses how the privacy rule applies to customary health care practices, tips for securing health information on a mobile device, and HIPAA resources.

Telehealth Services describes services that can be furnished to Medicare beneficiaries via a telecommunications system, including information about originating sites, distant site practitioners, telehealth services, billing and payment for services and facility fees, etc.  Several psychiatric services became eligible for telehealth coverage in 2015.

PECOS Fact Sheet includes Medicare enrollment application submission options, how to complete an enrollment application using PECOS, and PECOS user ID and password helpful hints.

Safeguard Your Identity and Privacy Using PECOS Fact Sheet

The 2013 Physician Quality Reporting System (PQRS)” booklet provides in-depth education on PQRS, including important changes for the 2013 PQRS, 2015 payment adjustment, and more.

Medicare Appeals Process fact sheet explains the five levels of claim appeals in Original Medicare (Parts A and B).

Medicare Secondary Payer fact sheet explains situations when Medicare may pay first or second, coordination of benefits, et.

Medicare Enrollment for Physicians covers determining whether you want to be a participating provider and enrolling in the Medicare Program.