physician fee schedule 2018 proposed rule - aamc€¦ · · 2017-12-11physician fee schedule 2018...

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Physician Fee Schedule 2018 Proposed Rule

August 9, 2017

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Agenda

• Payment Policies and Other Policies

• Conversion Factors, Misvalued RVUs, RVU Targets

• FPSC data analysis of proposed changes

• Payment Rates for Provider-Based Off Campus Hospital Departments

• Payment for Telehealth

• Other Proposals of Interest

• Appropriate Use Criteria for Advanced Diagnostic Imaging

• Patient Relationship Code Reporting

• Expansion of Diabetes Prevention Program


2018 Medicare Physician Fee Schedule Proposed Rule

• Displayed on July 12; published in Federal Register 7/21https://www.gpo.gov/fdsys/pkg/FR-2017-07-21/pdf/2017-14639.pdf

• Supplemental materials (including RVU data)

https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched/PFS-Federal-Regulation-Notices-Items/CMS-1676-P.html

• Comments due September 11; Final rule expected November 1

We are seeking your feedback on the proposals!

https://www.gpo.gov/fdsys/pkg/FR-2017-07-21/pdf/2017-14639.pdf

https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched/PFS-Federal-Regulation-Notices-Items/CMS-1676-P.html


Physician Fee Schedule Proposed Rule

Issued: July 12, 2017

Comment deadline:

September 11, 2017

Final around November 1,

2017; Provisions Effective:

January 1, 2018


Separate Quality Programs are all Sunsetting

A New Consolidated

Pay-for-Performance

Program under

MACRA

Merit-Based Incentive Payment System (MIPS)

Value Modifier Program

Meaningful Use

Program

PQRS


Fee Schedule Remains Bedrock of Payment

Fee Schedule


Payment Policies


Physician Fee Schedule (PFS) Updates

• MACRA repealed Sustainable Growth Rate

• PFS 0.5% update CY 2016-CY 2019

• PFS 0.0% update CY 2020-2025

• PFS updates 2026 and beyond: 0.75% for APM; 0.25% for MIPS

• Merit-Based Incentive Payment System (MIPS) & participation in Alternative Payment Models will drive payment in 2019 and beyond


MACRA Timeline


Targets for “Misvalued” Code Reductions

• 2016: 1.0% reduction

• 2017: .5% reduction

• 2018: .5% reduction

ABLE Legislation established 3 years of target reductions for misvalued codes

• If reductions<target, then all PFS services reduced by difference

• If reductions>target, then no adjustment to PFS, amount over target is applied to next year’s target

Calculation

• Target recapture of -0.19 percent (CMS achieved .31% in reductions)

2018 reduction did not meet the 0.5%

target


Calculation of 2018 PFS Conversion Factor

Conversion Factor 2017 $35.8887

Update Factor 0.50 percent (1.0050)

2018 RVU Budget Neutrality adjustment

-0.03 percent (0.9997)

2018 Target Recapture Amount

-0.19 percent (0.9981)

2018 Conversion Factor $35.9903

Overall update projected to be +0.31% for 2018


CMS Analysis of Specialty Impact

Social Worker (+ 3%)

Clinical Psychologist (+2%)

Psychiatry (+1%)

Physical Medicine (+1%)

Diagnostic Testing Facility

(-6%)

Independent labs (-2%)

Allergy/Immunology (-3%)

Vascular Surgery (-2%)

Cardiac Surgery (-2%)

Cardiology (-2%)


CMS-1676-P, TABLE 40—CY 2018 PFS ESTIMATED IMPACT ON TOTAL ALLOWED CHARGES BY SPECIALTY

CMS Estimated Impact by Specialty

Retrieved 8/4/2017 from https://s3.amazonaws.com/public-inspection.federalregister.gov/2017-14639.pdf, p. 727

-8%

-6%

-4%

-2%

0%

2%

4%

Columns in red represent changes due to Work RVU


FPSC Modeled Changes per 1.0 CFTE Physician

-$2,000

-$1,000

$0

$1,000

$2,000

$3,000

$4,000

Payment Change per 1.0 CFTE Physician in Specialty


Drivers for Ophthalmology Increases

CPT CODE DESCRIPTION

Facility Non Facility

CY 2017 CY 2018%

Change CY 2017 CY 2018%

Change

92012 Eye exam establish patient $53.83 $53.63 0% $86.49 $88.90 3%

92014 Eye exam&tx estab pt 1/>vst $81.47 $81.30 0% $125.25 $127.73 2%

66821 After cataract laser surgery $316.18 $318.33 1% $334.84 $337.05 1%

66984Cataract surg w/intraocular lens 1 stage procedure $651.02 $655.66 1% $0.00 $0.00 0%

67210 Treatment of retinal lesion $509.26 $512.88 1% $526.85 $530.52 1%

Proposed Payment Changes

Note: Exams furnished in the non-facility setting have greater changes.

Ophthalmology SpecialtyPayments

Per 1.0 CFTE

Ophthalmology: Oculoplastic $ 1,254

Ophthalmology: Retinal $ 2,198

Ophthalmology: General / Comp $ 2,266

Ophthalmology: Glaucoma $ 3,465

CPT codes and descriptions are copyright 2017 American Medical Association. All Rights Reserved. Applicable FARS/DFARS apply.


Radiation Oncology Change



CY 2017 CY 2018%


Change

77427Radiation tx management x5 $189.13 $194.11 3% $189.13 $194.11 3%

Proposed Payment Changes

Initial analysis shows payment increases of $2,225 per 1.0 CFTE MD for Radiation Oncologists tied to increases for CPT Code 77427.

Payment is the same in facility and non-facility settings.



Cardiology Specialties Vary in Impact



CY 2017 CY 2018%


Change

93015 Cardiovascular stress test NA NA NA $77.52 $71.62 -8%

93458L hrt artery/ventricle angio $310.44 $277.36 -11% $310.44 $277.36 -11%

Decreases in payments expected for Invasive and Invasive-Interventionalists. Changes are driven by CPT Codes 93015 and 93458

Increases in payments expected for Electrophysiologists and NoninvasiveCardiologists with payment increases for transthoracic echocardiograms.



CY 2017 CY 2018%


Change

93307 Tte w/o doppler complete $45.94 $46.43 1% $45.94 $46.43 1%



Other Changes

• Nephrology: 1% increase in payments per 1.0 CFTE MD for 90935-Hemodialysis one evaluation

• Payments for the high-volume CPT Code 88305-Tissue Exam by Pathologists are increased by 1% but offset for Mohs Surgery and Dermatopathology by CPT Code 17000-Destruct premalg lesion




CY 2017 CY 2018%


Change

17000 Destruct premalg lesion $54.55 $53.94 -1% $67.83 $66.18 -2%

88305 Tissue exam by pathologist $39.84 $40.31 1% $39.84 $40.31 1%


Background: Payment for Off-Campus Provider-Based Hospital Departments

Section 603 of Bipartisan Budget Act of 2015 requires payment for services furnished by off-campus provider based departments under Part B system other than Hospital Outpatient Prospective Payment System (OPPS).

The new payment rate policy does not apply to hospitals that were furnishing covered OPD services before November 2, 2015.


2017 Payment Rates for “Nonexcepted” Off Campus Outpatient Hospital Departments

For 2017, CMS made the Physician Fee Schedule the payment system and set payment rates based on a 50-percent reduction to the OPPS payment rates

(inclusive of packaging).

The adjustment is referred to as the “PFS Relativity Adjuster

Must report a modifier “PN” on each UB 04 claim line to indicated nonexcepted items or service


2018 Proposed Payment Rates for Off-Campus Provider-Based Hospital Departments

CMS proposes to revise the PFS relativity adjuster to 75% reduction of the OPPS rate

Uses different methodology in 2018 to compare office and OPPS rates. Packaging payment rates and MPPR reductions still apply.

CMS seeks comments on whether it should adopt a different relativity adjuster, such as 40 percent of the OPPS rate.


Other Off Campus Hospital Provisions

• CMS specifies that all beneficiary cost-sharing rules that apply under the PFS will continue to apply to all nonexcepted items and services furnished by off-campus OPDs

• The supervision rules continue to apply to off campus departments that furnish nonexcepted services


Evaluation and Management (E/M) Documentation Guidelines

CMS invites comments on:

• Approaches to guideline revision that reduce burden and leverage electronic health technology

• Revisions that deemphasize history and physician exam performance

• Consideration of reducing or evening eliminating the history and physical exam components at all E/M code levels.

• Extension of practitioner autonomy to determine volume of documentation

• Guidelines structured to match documentation to patient complexity (particularly medical decision-making)


Care Management Services

• Affirms commitment to recognize and appropriately pay for effective, efficient, care management services.

• Invites comments about expansion outside of traditional office visit, refining the code set, ensuring appropriate payment, reducing burden


Expansion of Telehealth Services

CMS Proposes to add the following codes:

• HCPCS code G0296: Counseling visit to discuss the need for lung cancer screening using LDCT

• CPT codes 90839 and 90840: Psychotherapy for crisis; first 60 minutes


Expansion of Telehealth Services

CMS Proposes to add the following codes:

• CPT code 90875: Interactive complexity

• CPT codes 96160 and 96161: Administration of patient-focused health risk assessment instrument and Administration of caregiver-focused health risk assessment instrument

• HCPCS code G0506: Comprehensive assessment or/and care planning for patients requiring chronic care management services.


Telehealth: Elimination of GT modifier

• Effective January 1, 2017 Place of Service (POS) code 02 Telehealth is required on professional claims

• CMS proposes to eliminate required use of the GT modifier on professional claims


Telehealth: Remote Patient Monitoring

• CMS requests comment on whether to make separate payment for CPT codes that describe remote patient monitoring.

• CPT code 99092: Collection and interpretation of physiologic data digitally stored and/or transmitted by patient to caregiver

– What is the value of this service?

– Should payment be separate?


Appropriate Use Criteria (AUC) for Advanced Diagnostic Services

Established by Protecting Access to Medicare Act of 2014

Criteria for physicians to better identify the appropriate advanced diagnostic imaging service:

• Appropriate Use Criteria (AUC) must be developed by qualified provider-led entities (list published in June 2016).

• Clinical decision support mechanism (CDSMs) are electronic tools physicians will use to access the AUC to determine appropriateness of advanced diagnostic imaging test.

• Requirement that in future ordering physicians must begin consulting CDSMs and furnishing professionals must append AUC information about ordering physician’s consultation to Medicare claim

• Identification of Outlier physicians in the future


AUC Proposals (on or after Jan. 1, 2019)

Ordering Professional

• Must consult AUC through qualified CDSMs for tests ordered on or after January 1, 2019.

• (delayed from statutory requirement of 2017).

Furnishing Professional: Must report the following

• Must report:

• Which qualified CDSM was consulted by ordering professional

• Whether service ordered would adhere to AUC or not, or whether AUC not applicable; and

• NPI of ordering professional


AUC Proposals for Implementation

In 2018 reporting is voluntary and will allow for education and testing

Beginning 2019, payment may only be made if the claim includes the proposed information required by furnishing professionals.

It applies across the following payment systems (PFS, hospital outpatient, ASC)

CMS proposes a G code and modifiers to implement


AUC: Codes for Reporting

CMS proposes generic G-code

• G-code indicates CDSM was consulted

• G-code indicates CDSM not consulted

• In future, will be specific G codes for each CDSM

CMS proposes modifiers to provide information on adherence to the AUC

• The imaging service adheres to applicable AUC

• The imaging service would not adhere to AUC; or

• AUC not applicable to imaging service ordered


New Coding Systems: MACRA

• Statute required claims submitted after Jan. 1, 2018 must include:– Patient Condition Groups: Based on a patient’s chronic

conditions, current health status, and recent significant history (e.g. hospitalization or surgery) (better risk adjustment)

– Care Episode Groups: Create to define the types of procedures or services furnished for particular clinical conditions or diagnoses (kinds of services physicians can control)

– Patient Relationship categories: Distinguish the relationship and responsibility of a physician with a patient at the time of furnishing the item/service. (accountability)


Patient Relationship Modifiers

• Beginning January 1, 2018 claims for services provider may voluntarily submit claims with modifiers.

• Duration of voluntary modifier reporting period is not specified.


Proposed Patient Relationship HCPCS Modifiers and Categories

Number Proposed HCPCS Modifier Patient Relationship Categories

1x X1 Continuous/Broad Services

2x X2 Continuous/Focused Services

3x X3 Episodic/Broad Services

4x X4 Episodic/Focused Services

5X X5 Only as Ordered by Another Clinician


Patient Relationship ModifiersRelationship Category Description Example

Continuous/Broad Clinicians who provide the principal care for a patient, where there is no planned endpoint of the relationship

Primary care, specialists providing comprehensive care to patients in addition to specialty care, etc

Continuous/Focused Could include a specialist whose expertise is needed for the ongoing management of a chronic disease or a condition that needs to be managed and followed for a long time.

Rheumatologist taking care of a patient’s rheumatoid arthritis longitudinally but not providing general primary care services

Episodic/Broad Clinicians that have broad responsibility for the comprehensive needs of the patients, but only during a defined period and circumstance, such as a hospitalization.

Hospitalist providing comprehensive and general care to a patient while admitted to the hospital.


Patient Relationship Modifiers

Relationship Category Description Example

Episodic/Focused A specialist focused on particular types of time-limited treatment.

An orthopedic surgeon performing a knee replacement and seeing the patient through the postoperative period.

Only As Ordered By Another Clinician

A clinician who furnishes care to the patient only as ordered by another clinician.

A radiologist interpreting an imaging study ordered by another clinician


2018 PQRS Payment Adjustment: Proposed Modifications

• Reduce the number of required measures from 9 measures across 3 domains to 6 measures with no domain requirement (does not apply to Web Interface)

• Eliminate requirement to report cross-cutting measure

• Eliminate requirement that group practices of 100 or more EPS that use GPRO must administer to CAHPS for PQRS patient survey.


2018 Value Modifier Program: Proposed Modifications

Proposes to modify VM policies for 2018 payment adjustment; would result in fewer EPs and groups receiving negative VM adjustment & size of positive adjustments would be reduced.

All groups and practitioners that avoid the PQRS payment reduction would be held harmless from downward adjustments in quality tiering for 2018.

Adjustment for those would fail to report PQRS reduced from -4 percent to -2 percent for groups with 10 or more

For groups with 10 or more Eps, maximum upward adjustment reduced from +4x to +2x and average quality would reduce from 2.0x to 1.0x


Expansion of Medicare’s Diabetes Prevention Program


Medicare Diabetes Prevention Program (MDPP)

What: Structured health behavior change program delivered in community and health care settings by training community health workers or health professionals, administered by Centers for Disease Control (CDC)

Why: Diabetes affects more than 25% of Americans aged 65 or older and accounts for $104 billion annually which are anticipated to grow by 2050

Who: Targets individuals with prediabetes (individuals who have blood sugar higher than normal but not yet in the diabetes range)

Program Structure: Consists of 16 intensive “core sessions” of a CDC-approved curriculum in a group-based setting that provides practical training in long-term dietary change, increased physical activity, and problem solving strategies for overcoming challenges to sustaining weight loss and a healthy lifestyle. Access to ongoing maintenance sessions after core benefit

Goal: Reduce incidence of Type 2 diabetes by achieving at least 5 percent average weight loss among participants


MDPP’s Proposed Requirements

CMS Proposals for Expansion Beneficiaries Eligibility

Effective date beginning April 1, 2018 (instead of January 1, 2018)

12-month program using the CDC-approved DPP curriculum

Beneficiaries can only enroll in MDPP once Beneficiaries who complete the 12 month program who

achieve and maintain required weight loss can be eligible for monthly maintenance sessions as long as weight loss is maintained

Ongoing maintenance sessions adhere to the same curriculum requirements as the course

Each MDPP session be at least an hour in duration Existing Medicare providers and suppliers must submit a

separate enrollment application for MPDD services and with national provider identification (NPI) required

Pre-diabetic patient having a body mass index (BMI) of 25 or greater (BMI of 23 for Asian beneficiaries)

Following blood levels: Hemoglobin A1c test with a value of 5.7-6.4

percent or; a fasting plasma glucose of 110-125 mg/dL

within last 12 months or; 2-hour plasma glucose of 140-199 mg/dL after

the 75 gram oral glucose tolerance test No previous diagnosis of diabetes (applies only at time

of the first core session)


MDPP Reimbursement

• Number of

Sessions Attended

• Achievement and Maintenance of Min. Weight Loss

Two Factors


MDPP ReimbursementPerformance Goal Payment Per Beneficiary

(with min. weight loss)Payment Per Beneficiary (without min. weight loss)

1 session attended $25

4 sessions attended $30

9 sessions attended $50

3 sessions attended in 1st

core maintenance session interval (months 7-9)

$60 $10

Weight loss of 5%achieved

$160 $0

Advanced weight loss of 9% achieved

$50 $0

Max Total Performancepayment

$810 $125


Diabetes Prevention Program: Social Risk Factors

• No proposal to risk adjust MDPP payments for social risk factors.

• CMS requests comments about social risk factors in the context of the set of MDPP services for future consideration.

• Interested in other types of strategies to assist MDPP suppliers providing access to beneficiaries with social risk factors.


Medicare Shared Savings Program Changes

Revises assignment methodology for

assigning Medicare FFS beneficiaries to an ACO based on utilization of services furnished by

rural health clinics and federally qualified health

care centers.

Adds 3 new chronic care management codes and

behavioral health integration codes to

definition of primary care services

Reduces burden for submitting an initial

Shared Savings Program application and

application for use of SNF 3 day waiver

Makes changes for consistency with the

MIPS program reporting under MACRA


Request for Information on Flexibility

CMS requests ideas for:

• payment system redesign

• streamlining of reporting, monitoring, and documentation requirements

• aligning Medicare requirements and processes with other payers

• operational flexibility

• reducing burden


Resource links

Proposed Rule

• https://www.gpo.gov/fdsys/pkg/FR-2017-07-21/pdf/2017-14639.pdf

CMS Fact Sheet

https://www.cms.gov/Newsroom/MediaReleaseDatabase/Fact-sheets/2017-Fact-Sheet-items/2017-07-13-2.html?DLPage=2&DLEntries=10&DLSort=0&DLSortDir=descending

CMS Fact Sheet on Medicare Diabetes Prevention Program Expansion https://www.cms.gov/Newsroom/MediaReleaseDatabase/Fact-sheets/2017-Fact-Sheet-items/2017-07-13-3.html

https://www.gpo.gov/fdsys/pkg/FR-2017-07-21/pdf/2017-14639.pdf

https://www.cms.gov/Newsroom/MediaReleaseDatabase/Fact-sheets/2017-Fact-Sheet-items/2017-07-13-2.html?DLPage=2&DLEntries=10&DLSort=0&DLSortDir=descending

https://www.cms.gov/Newsroom/MediaReleaseDatabase/Fact-sheets/2017-Fact-Sheet-items/2017-07-13-3.html


Questions and Feedback

Questions and Feedback about PFS Proposals

Gayle Lee, [email protected]

FPSC Projects Related to PFS and Q&E

Dave Troland, [email protected]

Jake Langley, [email protected]

mailto:[email protected]




Questions

Please use the Q&A panel located on the right side of your screen to submit your questions. Send to “All Panelists”.

physician fee schedule 2018 proposed rule - aamc€¦ · · 2017-12-11physician fee schedule 2018...

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