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2016 Medicare Physician Fee Schedule Final Rule: A Few Notes for Emergency Physicians


On October 30, the Centers for Medicare and Medicaid Services (CMS) issued a final rule updating payment policies, payment rates, and quality provisions for services furnished under the Medicare Physician Fee Schedule (PFS) on or after January 1, 2016. For the first time, the proposed rule implements several policies mandated under the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) back in April, the same legislation that fixed the flawed Sustainable Growth Rate formula.

Among the many provisions of the proposed fee schedule, the following items are among those most noteworthy for the coming year, particularly for emergency physicians.


The guidelines to successfully report or participate in the Physician Quality Reporting System (PQRS) for the 2016 reporting year (affecting 2018 payments) remain largely the same. One change is that group practices using the GPRO option will now be able to choose the Qualified Clinical Data Registry reporting option, which was previously available only to providers who reported as individuals.

As well, two new measures were approved for emergency medicine for both claims and registry reporting:

  • 415 Emergency Medicine: Emergency Department Utilization of CT for Minor Blunt Head Trauma for Patients Aged 18 Years and Older – Claims and Registry
  • 416 Emergency Medicine: Emergency Department Utilization of CT for Minor Blunt Head Trauma for Patients Aged 2 through 17 Years – Claims and Registry

A third new measure was proposed for emergency medicine but not approved in the final rule: Coordinating Care – Emergency Department Referrals (for asthma and chest pain).

That means for 2016 reporting period, there are a total of nine recommended measures for emergency physicians, all available in registry reporting and seven available for claims reporting. In addition to the two new measures listed above, here is a list of previous measures still available for reporting in 2016.

Finally, under MACRA, PQRS is set to expire with the 2016 reporting year (affecting 2018 payments). The Merit-Based Incentive Payment System (MIPS), mandated through MACRA, will replace PQRS and other Medicare quality programs beginning with the 2017 reporting year (affecting 2019 payments).

Appropriate Use Criteria for Advanced Imaging Services

In the 2014 Protecting Access to Medicare Act (PAMA), Congress required that providers who order advanced diagnostic imaging services, including emergency physicians, must consult with appropriate use criteria via a clinical decision support mechanism. PAMA also required CMS to take other steps toward collecting information on claim forms and ultimately developing a prior authorization program by January 1, 2020.

In the 2016 final rule, CMS implemented the first component of these guidelines by establishing which organizations are eligible to develop or endorse appropriate use criteria, the evidence-based requirements for AUC development, and the process CMS will follow for qualifying provider-led entities. None of these guidelines impact CY 2016 physician payments under the PFS.

Value-Based Payment Modifier

For the 2016 reporting year (affecting 2018 payments), CMS will now include several non-physician practitioners (NPPs) in the Value-Based Payment Modifier (VBPM) program: PAs, NPs, CNSs, and CRNAs. As in the past, those providers newly introduced to the program will be held harmless from downward adjustments, but that provision applies only to those providers who practice as solo NPPs or those who are in a group of only NPPs. Any solo physician or group of two or more physicians and/or NPPs will be subject to upward or downward payment adjustments based on their ratio of quality to cost as compared to other providers in the Medicare program.

CMS did hold steady the adjustment factors and percentages for the upward or downward payment adjustments to +2.0x and -2.0 percent for solo practitioners and groups up to nine providers and +4.0x and -4.0 percent for groups of 10 or more providers.

Like PQRS, the VBPM program is set to expire with the 2016 reporting year (affecting 2018 payments) to be replaced by MIPS.

Potentially Misvalued Codes

The Affordable Care Act (ACA) instructed CMS to identify “misvalued codes” in the Physician Fee Schedule, and PAMA mandated a target for adjustments to misvalued codes in the fee schedule for calendar years 2017 through 2020, with a target amount of 0.5 percent of the estimated expenditures under the PFS for each of those four years. Subsequently, the Achieving a Better Life Experience Act of 2014 (ABLE) accelerated the application of the target by specifying it would apply for calendar years 2016 through 2018, and increasing the target to 1 percent for 2016.

In the 2016 final rule, CMS adopted methodology to implement this provision, including how net reductions in misvalued codes would be calculated. Based on that methodology, CMS identified changes that achieved .23 percent in net reductions, requiring a .77 percent reduction to all 2016 PFS services, as required by the statute. As well, CMS expressed their intentions to continue to review high expenditure services across all specialties that have Medicare allowed charges of $10,000,000 or more. Among those services are several procedures that may be performed in the emergency department, like intubation, temporary bladder catheter, etc. Look for CMS to make further misvalued code changes in the future as they attempt to meet the annual statutory goals.

As well, PAMA specified that if the total RVUs for a service would otherwise be decreased by an estimated amount equal to or greater than 20 percent as compared to the total RVUs for the previous year, the adjustments must be phased-in over a two-year period. CMS finalized the proposal to phase in these reductions by reducing the value for a service by the maximum allowed amount (19 percent) in the first year, and to phase in of the percent remainder of the reduction in the second year.

For more information, review the CMS Fact Sheet about the Final Rule of the MPFS or view the Final Rule in its entirety.

— Compiled and written by for CIPROMS. All rights reserved. For use or reprint in your blog, website, or publication, please contact us atcipromsmarketing@ciproms.com.


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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