Experience. Integrity. Advocacy.
Experience. Integrity. Advocacy.

Ten Things to Know about the 2015 Medicare Physician Fee Schedule


On July 3, 2014, the Centers for Medicare & Medicaid Services (CMS) issued a proposed rule to update payment policies and payment rates for services furnished under the Medicare Physician Fee Schedule (PFS) on or after Jan. 1, 2015. The 224-page document is loaded with information about everything from Ambulance Extender Provisions to ZIP code analysis.

After spending a few days wading through the proposed rule, reviewing the CMS Fact Sheets, and reading what others are saying, we devised a list of 10 things you should know about the proposed 2015 fee schedule.

1. The proposed fee schedule does nothing to curtail or fix the flawed Sustainable Growth Rate. The Protecting Access to Medicare Act (PAMA) of 2014 mandates no changes to Medicare fees for services furnished through March 31, 2015. Previous estimates by CMS indicate that the decrease in fees starting on April 1, 2015, would be -20.9 percent if no further action is taken by Congress.

2. Malpractice (MP) RVUs will be adjusted this year for all services. Under federal mandate, MP RVUs must be reviewed every five years. The proposed MP RVUs reflect updated professional liability insurance premiums and were calculated using the same methodology as the CY 2010 update.

3. Global periods will all be reduced to 0-days. Under the misvalued code initiative, all 10- and 90-day global codes will be changed to 0-day global codes beginning in CY 2017. With this change, Medicare will pay separately for visits and services furnished after the day of the procedure beginning in CY 2017.

4. Medicare coverage of screening colonoscopies will now include 100 percent fee schedule payment of the anesthesia services furnished by a separate practitioner, as well as the colonoscopy procedure itself. As a result, screening colonoscopies including separate anesthesia will not be subject to the Part B deductible and will not count toward meeting that deductible.

5. The Continuing Education Exclusion will be removed in its entirety from the Open Payments Program. Also known as the Sunshine Act, Open Payments requires annual disclosure of the financial relationships of manufacturers, physicians, and teaching hospitals. Eliminating the exemption for payments to speakers at certain accredited or certifying continuing medical education events allows for more consistent reporting requirements and more consistent data for consumers.

6. CMS will seek to better understand current industry practices for using and billing for substitute physicians, also known as “locum tenens” (LTs). Through a call for comments, CMS hopes to asses the impact that policy changes regarding the use of LTs might have on patient access to physician services.

7. Comments also are being solicited regarding the appropriateness of payments for subsequent interpretations of existing images under the Medicare PFS. Specifically, CMS is hoping to understand whether the uncertainty about payment for secondary interpretations inhibits physicians from seeking out, accessing, and utilizing existing images.  Payment for subsequent interpretations currently is allowed only under special circumstances. As well, public input will help CMS determine whether allowing more routine Medicare payments for these second professional components would be likely to reduce the incidence of duplicative studies.

8. CMS will continue to expand their Physician Compare website by increasing the amount of physician quality data available to the public. All 2015 PQRS GRPO web interface, registry, and EHR measures for group practices of two or more eligible professionals and Accountable Care Organizations will be made available on Physician Compare in 2016. Also, 20 PQRS individual measures reported in 2013 and collected through a registry, EHR, or claims will be posted in 2015. All 2015 PQRS individual measures collected via registry, EHR, or claims would be made available for public reporting on Physician Compare in late 2016.

9. Avoiding a 2017 payment adjustment for the Physician Quality Reporting System (PQRS) requires reporting quality data for 2015 at the level that previously earned an incentive. The 2015 reporting year also is the first in which no incentives are provided for PQRS.

A variety of reporting mechanisms are available, including claims, qualified registry, electronic health record (EHR), and qualified clinical data registry (QCDR) for providers reporting as individuals, or qualified registry, EHR, CMS-Certified Survey Vendor, and web-interface for providers participating in the GRPO option. For most reporting methods, reporting quality data for nine measures across three National Quality Strategy Domains (NQSD), in addition to two cross-cutting measures if the provider has at least one face-to-face visit with a Medicare beneficiary, will allow a provider to avoid the 2% payment adjustment. The Measure Applicability Validation will continue to apply for providers not able to meet those minimums.

Twenty-eight new individual measures and two measures groups are proposed to fill existing measure gaps. As well, 73 measures will be removed from reporting for the PQRS. These proposed changes would bring the PQRS individual measure set to 240 total measures, with increasing emphasis toward registries and EHR and away from claims-based reporting.

10. The Value-Based Payment Modifier (VBPM) will apply to all physicians beginning with the 2017 payment adjustment year (2015 reporting year). As well, specified non physician providers also will be subject to the VBPM in 2017. For the 2016 payment adjustment year (2014 reporting year), only physicians in groups of 10 or more were required to participate.

As in previous years, successful participation in PQRS helps providers avoid automatic negative adjustments, and quality data from the PQRS program and other claims and payment analysis determines quality tiering for upward, neutral, or downward adjustments. For 2017/2015, downward adjustments plummet to negative four percent and upward adjustments soar as high as four percent. Solo providers and providers in groups up to nine will not be subjected to downward tiering adjustments in 2017.

For more information, the full text of the proposed rule is available from CMS. Also, look for more analysis about the PFS from CIPROMS in the coming days.

— All rights reserved. For use or reprint in your blog, website, or publication, please contact us at cipromsmarketing@ciproms.com. Photo by David Goehring via Flickr used with permission under the Creative Commons License.


Charity Singleton Craig

Charity Singleton Craig is a freelance writer and editor who provides communications and marketing services for CIPROMS. She is responsible for creating, editing, and managing all content, design, and interaction on the company website and social media channels in order to promote CIPROMS as a thought leader in healthcare billing and management.

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