Over the past week, the Centers for Medicare and Medicaid Services (CMS) released final rules outlining how Medicare will pay major health care providers and suppliers in 2015, including physicians and non-physician practitioners, hospital outpatient departments, ambulatory surgical centers, home health agencies, and dialysis facilities that treat patients with end-stage renal disease.
In the next few weeks, we will look primarily at the Medicare Physician Fee Schedule (MPFS) and the Ambulatory Surgery Center Payment Schedule, exploring the updated guidelines that will affect our client base. Specifically, we will provide detailed analysis of the following:
- the value-based payment modifier, which will affect all physicians starting with 2015 services affecting 2017 payments,
- updated PQRS guidelines, along with new, modified, and retired measures,
- provisions affecting anesthesia and emergency medicine practices, and
- provisions affecting ambulatory surgery centers.
More generally, however, we wanted to highlight the following items from the 2015 MPFS.
Sustainable Growth Rate
The Protecting Access to Medicare Act of 2014 provides for a zero percent PFS update for services furnished between January 1, 2015 and March 31, 2015. Beginning April 1, 2015, however, current law requires the enactment of the sustainable growth rate formula which would reduce the PFS rates by an average of 21.2 percent from the CY 2014 rates. As in most prior years, Congress will likely take action to avert the large reduction, and experts throughout the healthcare industry hope the change will be a permanent SGR fix.
Chronic Care Management
Beginning in 2015, Medicare will reimburse for chronic care management (CCM) services – non-face-to-face services to Medicare beneficiaries who have multiple, significant, chronic conditions (two or more). Covered services include regular development and revision of a plan of care, communication with other treating health professionals, and medication management.
Payment for CCM is set at $40.39 and can be billed up to once per month per qualified patient. As part of this newly covered service, CMS also will allow greater flexibility in the supervision of clinical staff providing CCM services.
Enhanced Transparency in Setting PFS Rates
CMS will change the process for valuing new, revised, and potentially misvalued codes beginning with a transition year in CY 2016 and a full implementation in CY 2017. Under the new process, the American Medical Association’s CPT Editorial Panel will provide CMS with codes and recommendations earlier in the year so that changes can be included in the proposed fee schedule, allowing for public comments.
Global Surgery
After being highlighted for review by the HHS Office of Inspector General, 10- and 90-day global periods for all surgical procedures are being transformed to 0-day global codes: 10-day in 2017 and 90-day in 2018. As such, all medically reasonable and necessary visits would be billed separately during the pre- and post-operative periods outside of the day of the surgical procedure.
Services performed in off-Campus provider-based departments
CMS will collect data on services furnished in off-campus provider-based departments (PBD) by requiring hospitals to report a HCPCS modifier for those services and by requiring physicians and other billing practitioners to report these services using a new place of service code on professional claims. The current POS code 22 (outpatient hospital department) will be deleted, and two new codes will be established—one to identify outpatient services furnished in on-campus, remote or satellite locations of hospital, and another to identify services furnished in an off-campus hospital PBD setting that is not a remote location of a hospital, a satellite location of a hospital or a hospital emergency department. POS code 23 (emergency room-hospital) will be maintained to identify services furnished in an emergency department of the hospital.
Data collection will be voluntary for hospitals in 2015 and required beginning on January 1, 2016. The new place of service code will be required for professional claims as soon as it is available, but not before January 1, 2016.
Physician Compare Website
The 2015 PFS final rule continues to build on CMS’ phased approach for public reporting on Physician Compare. All 2015 PQRS GPRO web interface, registry, and EHR measures for group practices of two or more EPs and all measures reported by ACOs will be made available for public reporting on Physician Compare in 2016. Also, all 2015 PQRS individual measures collected via registry, EHR, or claims for individual eligible providers will be made available for public reporting on Physician Compare in late 2016, if technically feasible.
In general, no first year measures will be publicly reported on Physician Compare. All measures submitted, reviewed, and deemed valid and reliable will be reported in the Physician Compare downloadable file; however, not all measures will be included on the Physician Compare profile pages. In addition, the Physician Compare website will include an indicator for all satisfactory reporters under PQRS in 2015 and participants in EHR.
As well, all EPs will receive a green check mark indicating support for Million Hearts if they satisfactorily reports all four of the following individual measures:
- Ischemic Vascular Disease (IVD): Use of Aspirin or Another Antithrombotic;
- Preventive Care and Screening: Tobacco Use;
- Controlling High Blood Pressure; and
- Preventive Care and Screening: Screening for High Blood Pressure and Follow-Up Documented.
For more information, review the draft version of the MPFS final rule. The official copy will be published on November 13, 2014. Or visit the CMS website for fact sheets related to the fee schedule release.
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