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10 Things to Know about Medicare in 2016


As we prepare to turn our calendars to 2016, the Centers for Medicare and Medicaid Services (CMS) will begin to implement new policies and procedures for a new calendar year of claims submission. Here are ten things you need to know if you plan to submit claims for Medicare services in 2016.

Premiums, Deductibles, and Coinsurance

The premiums, deductibles, and coinsurance for Medicare Part B beneficiaries for 2016 are at follows:

  • Standard Premium: $121.80/month
  • Deductible: $166.00/year
  • Coinsurance: 20 percent

For more information, review MLN Matters 9410.

2015 Provider Enrollment Application Fee

The Provider Enrollment Application Fee Amount for Calendar Year 2016 will be $554. This fee will apply to institutional providers that are initially enrolling in the Medicare or Medicaid program or the Children’s Health Insurance Program (CHIP); revalidating their Medicare, Medicaid, or CHIP enrollment; or adding a new Medicare practice location. This fee is required with any enrollment application submitted on or after January 1, 2016, and on or before December 31, 2016.

For more information, review the December 3, 2015, Federal Register [CMS-6066-N].

Part D Prescribers Enrollment

Beginning June 1, 2016, physician or other eligible professionals who prescribe Part D drugs must be enrolled in the Medicare program or must opt out in order to prescribe drugs to their patients with Part D prescription drug benefit plans. In order to ensure seamless prescribing for patients, CMS recommends that all prescribers should begin the enrollment process by January 1, 2016, to allow for the processing of applications.

For more information, visit the Part D Prescriber Enrollment webpage.

Conversion Factor

The 2016 conversion factor for Medicare services is $35.8279. Download complete fee schedules adjusted for locality and applied to all covered services on CMS’s Medicare Physicians Fee Schedule webpage.

Anesthesia Conversion Factor

The national anesthesia conversion factor for 2016 is $22.4426. The 2016 anesthesia conversion factors by locality are available for download on CMS’s Anesthesiologists Center.


A new year means new program requirements for the Physician Quality Reporting System (PQRS) and the Value-Based Payment Modifier (VBPM) program, although the differences between the 2015 and 2016 reporting years are minor. Check out the CIPROMS articles on the program requirements for PQRS and VBPM and plan your 2016 participation in order to avoid penalties of up to 6 percent of your 2018 Medicare payments.


The meaningful use (MU) requirements for the EHR Incentive program continue to be debated, however, to avoid payment adjustments to your 2017 Medicare payments, there’s still an opportunity to attest to MU for 2015 or file a hardship exemption. Visit CMS’s EHR Incentive Programs webpage for more information.

Incomplete Colonoscopies

Effective Jan. 1, 2016, CMS has established new values for incomplete diagnostic and screening colonoscopies performed on or after January 1, 2016. Incomplete colonoscopies are reported with modifier 53. Medicare will pay for the interrupted colonoscopy at a rate that is calculated using one-half the value of the inputs for the codes.

Use these codes for incomplete colonoscopies under the following circumstances:

  • 44388-53 (colonoscopy through stoma);
  • 45378-53 (colonoscopy);
  • G0105-53 (colorectal cancer screening; colonoscopy on individual at high risk); and
  • G0121-53 (colorectal cancer screening; colonoscopy on individual not meeting criteria for high risk).

For more information, review MLN Matters 9317.

On-campus and Off-campus Outpatient Hospital POS Codes

Effective Jan. 1, 2016, CMS is updating the current POS code set in order to differentiate between on-campus and off-campus provider-based hospital departments. New POS code 19 will be added for “Off Campus-Outpatient Hospital,” and POS code 22 will be revised from “Outpatient Hospital” to “On Campus-Outpatient Hospital.”

For more information, review MLN Matters 9231.

CT Scans that Do Not Meet Standards

Beginning in 2016, claims for CT scans that are furnished on non-NEMA Standard XR-29-2013-compliant CT scans must include modifier “CT” which will result in a payment reduction. Beginning January 1, 2016, the payment reduction will be 5 percent and will be applied to the technical component (and the technical component of the global fee). The payment reduction will increase to 15 percent for 2017 and succeeding years.

For more information, review MLN Matters 9250.

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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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