Changes to the 2018 Medicare Fee Schedule Anesthesiologists Need to Know

The Centers for Medicare and Medicaid Services (CMS) recently finalized the 2018 Medicare Physician Fee Schedule (MPFS) and related policies, giving physicians and other eligible providers generally a .41 percent increase as proposed back in July, and giving anesthesiologists particularly a .65 percent increase in the anesthesia conversion factor.

This general payment update reflects the .50 percent update established under the Medicare Access and CHIP Reauthorization Act (MACRA) of 2015, reduced by 0.09 percent, due to the misvalued code target recapture amount, required under the Achieving a Better Life Experience Act of 2014. By applying these adjustments, plus the budget neutrality adjustment for changes in RVUs, to the 2017 PFS conversion factor of $35.89, the proposed 2018 PFS conversion factor is $35.9996.

Payment rates for individual services are then calculated by locality using the following formula: Payment = [(RVU work x GPCI work) + (RVU PE x GPCI PE) + (RVU MP x GPCI MP)] x CF. Indiana and Michigan providers can find an updated fee schedule on the WPS-GHA 2018 Medicare Physician Fee Schedules (MPFS) page.

Anesthesia Conversion Factor

For anesthesiologists, the calculation for the 2018 anesthesia conversion factor — $22.1887 — also results in a slight increase from the 2017 rate of $22.0454. Indiana anesthesiologists, however, will see that anesthesia conversion factor adjusted for locality to $20.53 in 2018, down from $21.09 in 2017.

Gastroenterology Anesthesia Procedures

In 2016, CMS flagged for review two anesthesia procedures that are common during colonoscopies: 00740 – Upper GI and 00810 – Lower GI. Later analysis by CMS revealed that a separate anesthesia service is reported for more than 50 percent of various colonoscopy procedures. Because of that frequency, CMS labeled the codes as misvalued.

In order to address the valuation problems for 2018, CMS is deleting the current CPT codes and creating new ones for anesthesia services furnished in conjunction with and in support of gastrointestinal endoscopic procedures. They also are adjusting the base units of these procedures. For Upper GI procedures, the base units held steady or increased. However, for lower GI procedures the base units drop by one or two points, which represents a 20 to 40 percent reduction.

The following table shows both the old and new procedure codes and how they compare.

Code	Description	2017 Base Units	2018 Base Units
00740	Anesthesia for upper gastrointestinal endoscopic procedures, endoscope introduced proximal to duodenum	5	–
00731	Anesthesia for upper gastrointestinal endoscopic procedures, endoscope introduced proximal to duodenum; NOS	–	5
00732	Anesthesia for upper gastrointestinal endoscopic procedures, endoscope introduced proximal to duodenum; endoscopic retrograde cholangiopancreatography (ERCP)	–	6
00810	Anesthesia for lower intestinal endoscopic procedures, endoscope introduced distal to duodenum	5	–
00811	Anesthesia for lower intestinal endoscopic procedures, endoscope introduced distal to duodenum; NOS	–	4
00812	Anesthesia for lower intestinal endoscopic procedures, endoscope introduced distal to duodenum; screening colonoscopy	–	3
00813	Anesthesia for combined upper and lower gastrointestinal endoscopic procedures, endoscope introduced both proximal to and distal to the duodenum	–	5

Insertion of Catheters

In 2017, CPT code 36556 (Insertion of non-tunneled centrally inserted central venous catheter; age 5 years or older) was flagged by CMS as a potentially misvalued code because of its high utilization and expenditures. CMS also flagged three other codes as potentially misvalued because they were part of the same code family: 36555, 36620, and 93503.

Upon review, CMS reduced the work RVUs for all four codes based on the recommendations of the RVU Update Committee (RUC). These changes account for RVU reductions from 13 to 31 percent.

Code	Description	2017 Work RVUs	2018 Work RVUs
36555	Insertion of non-tunneled centrally inserted central venous catheter; younger than 5 years of age	2.43	1.93
36556	Insertion of non-tunneled centrally inserted central venous catheter; age 5 years or older	2.50	1.75
36620	Arterial catheterization or cannulation for sampling, monitoring or transfusion (separate procedure); percutaneous.	1.15	1.00
93503	Insertion and placement of flow directed catheter (eg, Swan-Ganz) for monitoring purposes.	2.91	2.00

Quality Reporting

While the PQRS and Value Modifier programs have been replaced with the MACRA Quality Payment Program Merit-based Incentive Payment System (MIPS), physicians may still experience the impact of the PQRS/Value Modifier penalties in 2018, based on the 2016 reporting year. The data for that final reporting year had to be submitted by March 2017, so physicians can no longer adjust their submissions. However, CMS is finalizing their proposals to modify the performance guidelines to better align the past programs with the new MIPS guidelines.

Specifically, CMS is changing the current PQRS program policy that requires reporting 9 measures across 3 National Quality Strategy domains to require only 6 measures.

Likewise, for the Value Modifier, CMS is finalizing the following changes:

Reduce the automatic downward payment adjustment for not meeting minimum quality reporting requirements from -4 percent to -2 percent for groups of ten or more clinicians; and from -2 percent to negative -1 percent for physician and non-physician solo practitioners and groups of two to nine clinicians;
Hold harmless all physician groups and solo practitioners who met minimum quality reporting requirements from downward payment adjustments for performance under quality-tiering for the last year of the program; and
Align maximum upward adjustment amounts to 2 times the adjustment factor for all physician groups and solo practitioners.

For more information about the 2018 Medicare Physician Fee Schedule, review the CMS Fact Sheet or the complete Final Rule.