Physician Fee Schedule 2018 Final Rule - AAMC Medicare Physician Fee Schedule Final Rule • Displayed November 2, published in Federal Register November 15 • Supplemental materials

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Physician Fee Schedule 2018 Final Rule

December 11, 2017

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Agenda

• Payment Policies and Other Policies

• Conversion Factors, Misvalued RVUs, RVU Targets

• Payment Rates for Provider-Based Off Campus Hospital Departments

• Payment for Telehealth

• Other Proposals of Interest

• Appropriate Use Criteria for Advanced Diagnostic Imaging

• Patient Relationship Code Reporting

• Expansion of Diabetes Prevention Program


2018 Medicare Physician Fee Schedule Final Rule

• Displayed November 2, published in Federal Register November 15https://www.gpo.gov/fdsys/pkg/FR-2017-11-15/pdf/2017-23953.pdf

• Supplemental materials (including RVU data)https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched/PFS-Federal-Regulation-Notices-Items/CMS-1676-F.html

https://www.gpo.gov/fdsys/pkg/FR-2017-11-15/pdf/2017-23953.pdf

https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched/PFS-Federal-Regulation-Notices-Items/CMS-1676-F.html


Physician Fee Schedule Final Rule

Proposed Rule issued: July

12, 2017

Proposed Rule

comment deadline:

September 11, 2017

Final rule published: November

15, 2017

Final Rule provisions effective: January 1,

2018


Separate Quality Programs are all Sunsetting

A New Consolidated Pay-for-Performance

Program under

MACRA

Merit-Based Incentive Payment System (MIPS)

Value Modifier Program

Meaningful Use

Program

PQRS


Fee Schedule Remains Bedrock of Payment

Fee Schedule


Payment Policies


Physician Fee Schedule (PFS) Updates

• MACRA repealed Sustainable Growth Rate

• PFS 0.5% update CY 2016-CY 2019

• PFS 0.0% update CY 2020-2025

• PFS updates 2026 and beyond: 0.75% for APM; 0.25% for MIPS

• Merit-Based Incentive Payment System (MIPS) & participation in Alternative Payment Models will drive payment in 2019 and beyond


MACRA Timeline


Targets for “Misvalued” Code Reductions

• 2016: 1.0% reduction

• 2017: .5% reduction

• 2018: .5% reduction

ABLE Legislation established 3 years of target reductions for misvalued codes

• If reductions<target, then all PFS services reduced by difference

• If reductions>target, then no adjustment to PFS, amount over target is applied to next year’s target

Calculation

• Target recapture of -0.09 percent (CMS achieved .41% in reductions)

2018 reduction did not meet the 0.5%

target


Calculation of 2018 PFS Conversion Factor

Conversion Factor 2017 $35.8887

Update Factor 0.50 percent (1.0050)

2018 RVU Budget Neutrality adjustment

-0.10 percent (0.9990)

2018 Target Recapture Amount

-0.09 percent (0.9991)

2018 Conversion Factor $35.9996


Malpractice RVUs: No change in final rule

• In proposed rule, CMS discussed updating malpractice relative units with new premium data and specialty risk factors. (use of new data would have negatively impacted many specialists).

• Concerns raised that the proposed valuation changes were not indicative of what is actually occurring in professional liability market.

• In final rule, CMS decides not to update malpractice data. They will continue to use the same data collected for the 2015 MP RVU update.

• The next update must occur by 2020.


CMS Analysis of Specialty Impact

Social Worker (+ 3%)

Clinical Psychologist (+2%)

Psychiatry (+1%)

Infectious disease (+1%)

Cardiology (+1%)

Diagnostic Testing Facility

(-4%)

PT/OT (-2%)

Independent labs (-1%)

Allergy/Immunology (-3%)

Vascular Surgery (-1%)


Overview

• Coding changes (additions/deletions)

– Diagnostic radiology

– Artificial heart procedures and other Cardiology services

– Esophagectomy additions

– Collaborative care management

• Specialty impact

– Cardiology: Electrophysiology

– Cardiology: Noninvasive

– Pediatric Cardiology: Noninvasive

– Pediatric Cardiology

– Thoracic Surgery

• GPCI gains and losses


.

New Radiology Chest and Abdominal X-Ray Codes

New CPT Codes

CPT

CodeCPT Description 2018 wRVU

71045 X-ray exam chest 1 view 0.18

71046 X-ray exam chest 2 views 0.22

71047 X-ray exam chest 3 views 0.27

71048 X-ray exam chest 4+ views 0.31

74018X-ray exam abdomen 1

view0.18

74019X-ray exam abdomen 2

views0.23

74021X-ray exam abdomen 3+

views0.27

Deleted CPT Codes

CPT

CodeCPT Description 2017 wRVU

71010 Chest x-ray 1 view frontal 0.18

71015 Chest x-ray stereo frontal 0.21

71020 Chest x-ray 2vw frontal&latl 0.22

71021 Chest x-ray frnt lat lordotc 0.27

71022 Chest x-ray frnt lat oblique 0.31

71023 Chest x-ray and fluoroscopy 0.38

71030 Chest x-ray 4/> views 0.31

71034 Chest x-ray&fluoro 4/> views 0.46

71035 Chest x-ray special views 0.18

74000 X-ray exam of abdomen 0.18



Chest x-ray CPT codes 71010-71035 (described as ‘stereo’) deleted

Chest x-ray CPT codes added based on number of views, simplifying code selection.

Abdominal x-ray CPT codes 74000-74020 deleted

Abdominal x-ray CPT codes added based on number of views


• CPTs 33927-33929 replace 0051T-0053T Category III codes (emerging

technologies, services and procedures.

• 33927 will no longer be gap-filled and may receive fewer Work RVUs than in

2017

• 33928 and 33929 will be subject to FPSC gap-filling methodology

Total Heart Replacement System Codes

Move from Category III to Category I

CPT Code CPT Description2018

wRVU

2017

wRVU*

33927 Impltj tot rplcmt hrt sys 49.00 53.26

33928 Rmvl & rplcmt tot hrt sys 0 0

33929 Rmvl rplcmt hrt sys f/trnspl 0 0

* wRVUs calculated using the FPSC gap-filling methodology• Gap-filling is applied to codes with zero work, practice expense, and malpractice RVUs

• Locally weight ratio of charges to RVUs


CPT codes 43286, 43287 and 43288 created to report

esophagectomy via laparoscopic and thoracoscopic approaches.

CPT codes 43107, 43112, and 43117 were also reviewed as part of

the family with the three new codes. CPT code 43112 was revised

to clarify the nature of the service being performed.

– Additional specialty impact information detailed in following slide

Esophagectomy


wRVU

43286 Esphg tot w/laps moblj 55.00

43287 Esphg dstl 2/3 w/laps moblj 63.00

43288 Esphg thrsc moblj 66.42


Three new, time based codes for psychiatric collaborative care

management (CoCM):

Collaborative Care Management


wRVU

99492 1st psyc collab care mgmt; 70 min 1.70

99493 Sbsq psyc collab care mgmt; 60 min 1.53

99494 1st/sbsqpsyc collab care; each additional 30 min 0.82


Specialty Impacts


Work RVU

per 1.0 cFTE

Non Facility Total RVU

per 1.0 cFTE

Facility Total RVU

per 1.0 cFTE

-3.1% -1.7% -1.8%

Cardiology: Electrophysiology Observed Overall Loss

% Variance (2018 vs. 2017)

Negative figures = reduction

CPT

CodeCPT Description

2018

wRVU

2017

wRVU

wRVU

Change

%

Change

Mean Impact

wRVU per 1.0 cFTE

per MD

93295Dev interrog remote

1/2/mlt0.74 1.29 -0.55 -43% -169

93613Electrophys map 3d add-

on5.23 6.99 -1.76 -25% -132


SpecialtyWork RVU

per 1.0 cFTE

Non Facility

Total RVU per 1.0 cFTE

Facility Total RVU

per 1.0 cFTE

Mean Impact

wRVU per 1.0 cFTE per MD

Cardiology: Noninvasive +2.3% +2.0% +2.1% +174

Pediatric Cardiology: Noninvasive +2.0% +1.7% +1.8% +102

Pediatric Cardiology +1.3% +1.2% +1.2% +60

Adult and Pediatric Cardiology Echo w/Doppler Accounts for Overall Increase

% Variance (2018 vs. 2017)


CPT

CodeCPT Description

2018

wRVU

2017

wRVU

wRVU

Change

%

Change

93306 Tte w/doppler complete 1.50 1.30 +0.20 +15%


Work RVU

per 1.0 cFTE

Non Facility Total RVU

per 1.0 cFTE

Facility Total RVU

per 1.0 cFTE

+1.0% +0.6% +0.7%

Surgery Thoracic Displays Increase Due to Esophagectomy wRVU Change

% Variance (2018 vs. 2017)


CPT

CodeCPT Description

2018

wRVU

2017

wRVU

wRVU

Change

%

Change

Mean Impact

wRVU per 1.0 cFTE

per MD

43117Partial removal of

esophagus57.50 43.65 +13.9 +32% +43

43112 Removal of esophagus 62.00 47.48 +14.5 +31% +29

43107 Removal of esophagus 52.05 44.18 +7.9 +18% +16


• Based on an average mix of Work, Practice Expense and Malpractice RVUs, we found

the following year-over-year changes from 2017 to 2018.• a

• The 1.0 Work GPCI floor required by Section 201 of the MACRA of 2015 expires on

December 31, 2017, therefore the Work GPCIs for 2018 do not reflect a 1.0 floor.

Geographic Pricing Cost Index (GPCI) Gains and Losses

Locality Name2018

Work GPCI

2018

PE GPCI

2018

MP GPCI

Work

GPCI % Change

Oklahoma 0.961 0.891 0.954 -4%

Rest of Missouri 0.961 0.863 0.993 -4%

Mississippi 0.961 0.870 0.370 -4%

West Virginia 0.966 0.857 1.296 -3%

Kansas 0.966 0.911 0.615 -3%

Iowa 0.969 0.907 0.423 -3%

Indiana 0.969 0.919 0.379 -3%

Nebraska 0.970 0.910 0.318 -3%

Arkansas 0.971 0.872 0.576 -3%

Kentucky 0.974 0.880 0.819 -3%

Locality Name2018

Work GPCI

2018

PE GPCI

2018

MP GPCI

Work

GPCI % Change

Metro Boston 1.033 1.179 1.061 1%

San Francisco

(Alameda/Contra Costa

Cnty)

1.075 1.325 0.421 1%

Los Angeles (Orange

County)1.046 1.177 0.694 0.5%

Decreases due to potential GPCI floor expiration


Background: Payment for Off-Campus Provider-Based Hospital Departments

Section 603 of Bipartisan Budget Act of 2015 requires payment for services furnished by off-campus provider based departments under Part B system other than Hospital Outpatient Prospective Payment System (OPPS).

The new payment rate policy does not apply to hospitals that were furnishing covered OPD services before November 2, 2015.


2017 Payment Rates for “Nonexcepted” Off Campus Outpatient Hospital Departments

For 2017, CMS made the Physician Fee Schedule the payment system and set payment rates based on a 50-percent reduction to the OPPS payment rates

(inclusive of packaging).

The adjustment is referred to as the “PFS Relativity Adjuster”

Must report a modifier “PN” on each UB 04 claim line to indicated nonexcepted items or service


2018 Payment Rates for Off-Campus Provider-Based Hospital Departments

CMS proposed 75 percent reduction in payment for nonexcepted services at off campus OPDs (current reduction is 50 percent)

In response to comments, CMS finalizes a 60 percent reduction instead of 75 percent proposed.


Other Off Campus Hospital Provisions

• CMS specifies that all beneficiary cost-sharing rules that apply under the PFS will continue to apply to all nonexcepted items and services furnished by off-campus OPDs

• The supervision rules continue to apply to off campus departments that furnish nonexcepted services


Evaluation and Management (E/M) Documentation Guidelines

CMS invited comments on:

• Approaches to guideline revision that reduce burden and leverage electronic health technology

• Revisions that deemphasize history and physician exam performance

• Consideration of reducing or evening eliminating the history and physical exam components at all E/M code levels.

• Extension of practitioner autonomy to determine volume of documentation

• Guidelines structured to match documentation to patient complexity (particularly medical decision-making)


Evaluation & Management Documentation Guidelines

AAMC Comments

• With increased use of EHR, and movement to team-based care, E&M guidelines impose a significant administrative burden and are an impediment to good patient care.

• For surgical/subspecialties, a comprehensive exam is not always relevant.

• Determination of the level of service should be based on medical decision-making, not time alone.

CMS Final Rule

• CMS will consider these issues for future rulemaking, but the immediate focus will be on revision of current E&M guidelines in an effort to reduce unnecessary administrative burden.


Expansion of Telehealth Services

CMS finalized the addition of the following codes:

• HCPCS code G0296: Counseling visit to discuss the need for lung cancer screening using LDCT

• CPT codes 90839 and 90840: Psychotherapy for crisis; first 60 minutes


Expansion of Telehealth Services

CMS finalized the addition of the following codes:

• CPT code 90785: Interactive complexity

• CPT codes 96160 and 96161: Administration of patient-focused health risk assessment instrument and Administration of caregiver-focused health risk assessment instrument

• HCPCS code G0506: Comprehensive assessment or/and care planning for patients requiring chronic care management services


Telehealth: Elimination of GT modifier

• Effective January 1, 2017 Place of Service (POS) code 02 Telehealth is required on professional claims

• CMS finalized the proposal to eliminate required use of the GT modifier on professional claims

• Institutional claims, and federal telemedicine programs in AK and HI will need to continue using the GT modifier


Telehealth: Remote Patient Monitoring

• CMS activated separate payment for CPT code 99091, changing status from bundled

• 99091: Collection and interpretation of physiological data digitally stored and/or transmitted by the patient and/or caregiver

• Medicare allowed payment: $58.68


Appropriate Use Criteria (AUC) for Advanced Diagnostic Services

Established by Protecting Access to Medicare Act of 2014

Criteria for physicians to better identify the appropriate advanced diagnostic imaging service:

• Appropriate Use Criteria (AUC) must be developed by qualified provider-led entities (list published in June 2016).

• Clinical decision support mechanism (CDSMs) are electronic tools physicians will use to access the AUC to determine appropriateness of advanced diagnostic imaging test.

• Requirement that in future ordering physicians must begin consulting CDSMs and furnishing professionals must append AUC information about ordering physician’s consultation to Medicare claim.

• Identification of Outlier physicians in the future.


AUC Implementation

CMS makes the AUC consultation and reporting requirements effective for an educational and operational testing period beginning on January 1, 2020. From mid-2018 through 2019, a voluntary physician participation period will run.

In future, payment may only be made if the claim includes the proposed information required by furnishing professionals.

It applies across the following payment systems (PFS, hospital outpatient, ASC)


AUC Implementation: What is Required?

Ordering Professional

• Must consult AUC through qualified CDSMs for tests ordered on or after January 1, 2020.

• (delayed from statutory requirement of 2017).

Furnishing Professional: Must report the following

• Must report:

• Which qualified CDSM was consulted by ordering professional

• Whether service ordered would adhere to AUC or not, or whether AUC not applicable; and

• NPI of ordering professional

CMS will continue to pay claims whether or not they correctly include appropriate

information.


New Coding Systems: MACRA

• Statute required claims submitted after Jan. 1, 2018 must include:– Patient Condition Groups: Based on a patient’s chronic

conditions, current health status, and recent significant history (e.g. hospitalization or surgery) (better risk adjustment)

– Care Episode Groups: Create to define the types of procedures or services furnished for particular clinical conditions or diagnoses

– Patient Relationship categories: Distinguish the relationship and responsibility of a physician with a patient at the time of furnishing the item/service. (accountability)


Patient Relationship Modifiers

• Beginning January 1, 2018 claims for services provider may voluntarily submit claims with modifiers.

• Duration of voluntary modifier reporting period is not specified.


Patient Relationship HCPCS Modifiers and Categories

Number Proposed HCPCS Modifier Patient Relationship Categories

1x X1 Continuous/Broad Services

2x X2 Continuous/Focused Services

3x X3 Episodic/Broad Services

4x X4 Episodic/Focused Services

5X X5 Only as Ordered by Another Clinician


Patient Relationship ModifiersRelationship Category Description Example

Continuous/Broad Clinicians who provide the principal care for a patient, where there is no planned endpoint of the relationship

Primary care, specialists providing comprehensive care to patients in addition to specialty care, etc

Continuous/Focused Could include a specialist whose expertise is needed for the ongoing management of a chronic disease or a condition that needs to be managed and followed for a long time.

Rheumatologist taking care of a patient’s rheumatoid arthritis longitudinally but not providing general primary care services

Episodic/Broad Clinicians that have broad responsibility for the comprehensive needs of the patients, but only during a defined period and circumstance, such as a hospitalization.

Hospitalist providing comprehensive and general care to a patient while admitted to the hospital.


Patient Relationship Modifiers

Relationship Category Description Example

Episodic/Focused A specialist focused on particular types of time-limited treatment.

An orthopedic surgeon performing a knee replacement and seeing the patient through the postoperative period.

Only As Ordered By Another Clinician

A clinician who furnishes care to the patient only as ordered by another clinician.

A radiologist interpreting an imaging study ordered by another clinician


2018 PQRS Payment Adjustment: Finalized Modifications

• Reduced the number of required measures from 9 measures across 3 domains to 6 measures with no domain requirement (does not apply to Web Interface)

• Eliminated requirement to report cross-cutting measure

• Eliminated requirement that group practices of 100 or more EPS that use GPRO must administer to CAHPS for PQRS patient survey.


2018 Value Modifier Program: Finalized Modifications

Finalized modifications to VM policies for 2018 payment adjustment; would result in fewer EPs and groups receiving negative VM adjustment & size of positive adjustments would be reduced.

All groups and practitioners that avoid the PQRS payment reduction will be held harmless from downward adjustments in quality tiering for 2018.

Adjustment for those who fail to report PQRS are reduced from -4% to -2% for groups with 10 or more EPs and at least one physician. Reduced from -2% to -1% for groups with between 2 and 9 Eps, physician solo practitioners, non-physician EP groups.

For groups with 10 or more EPs, maximum upward adjustment reduced from +4x to +2x and average quality would reduce from 2.0x to 1.0x.


Expansion of Medicare’s Diabetes Prevention Program


Medicare Diabetes Prevention Program (MDPP)

What: Structured health behavior change program delivered in community and health care settings by training community health workers or health professionals, administered by Centers for Disease Control (CDC)

Why: Diabetes affects more than 25% of Americans aged 65 or older and accounts for $104 billion annually which are anticipated to grow by 2050

Who: Targets individuals with prediabetes (individuals who have blood sugar higher than normal but not yet in the diabetes range)

Program Structure: Consists of 16 intensive “core sessions” of a CDC-approved curriculum in a group-based setting that provides practical training in long-term dietary change, increased physical activity, and problem solving strategies for overcoming challenges to sustaining weight loss and a healthy lifestyle. Access to ongoing maintenance sessions after core benefit

Goal: Reduce incidence of Type 2 diabetes by achieving at least 5 percent average weight loss among participants


MDPP’s Finalized Requirements

CMS Finalized Requirements Beneficiaries Eligibility

Effective date beginning April 1, 2018 (instead of January 1, 2018)

Services begin April 1, 2018 Providers can begin enrolling January 1, 2018

12-month program using the CDC-approved DPP curriculum

Beneficiaries can only enroll in MDPP once Beneficiaries who complete the 12 month program who

achieve and maintain required weight loss can be eligible for up to one year of monthly maintenance sessions as long as weight loss is maintained

Ongoing maintenance sessions adhere to the same curriculum requirements as the course

Each MDPP session be at least an hour in duration Existing Medicare providers and suppliers must submit a

separate enrollment application for MPDD services and with national provider identification (NPI) required

Pre-diabetic patient having a body mass index (BMI) of 25 or greater (BMI of 23 for Asian beneficiaries)

Following blood levels: Hemoglobin A1c test with a value of 5.7-6.4

percent or; a fasting plasma glucose of 110-125 mg/dL

within last 12 months or; 2-hour plasma glucose of 140-199 mg/dL after

the 75 gram oral glucose tolerance test No previous diagnosis of diabetes (applies only at time

of the first core session)


MDPP Reimbursement

• Number of

Sessions Attended

• Achievement and Maintenance of Min. Weight Loss

Two Factors


MDPP ReimbursementPerformance Goal Payment Per Beneficiary

(with min. weight loss)Payment Per Beneficiary (without min. weight loss)

1 session attended $25

4 sessions attended $50

9 sessions attended $90

2 sessions attended in 1st

core maintenance session interval (months 7-9)

$60 $15

Weight loss of 5%achieved

$160 $0

Advanced weight loss of 9% achieved

$25 $0

Max Total Performancepayment

$670 $195


Diabetes Prevention Program: Social Risk Factors

• CMS requested comments about social risk factors in the context of the set of MDPP services for future consideration.

• CMS will be reviewing comments made as they consider additional policies surrounding social risk factors in the future.


Medicare Shared Savings Program Changes

Revises assignment methodology for

assigning Medicare FFS beneficiaries to an ACO based on utilization of services furnished by

rural health clinics and federally qualified health

care centers.

Adds 3 new chronic care management codes and

behavioral health integration codes to

definition of primary care services

Reduces burden for submitting an initial

Shared Savings Program application and

application for use of SNF 3 day waiver

Makes changes for consistency with the

MIPS program reporting under MACRA


Resource links

Medicare Physician Fee Schedule Final Rule https://www.gpo.gov/fdsys/pkg/FR-2017-11-15/pdf/2017-23953.pdf

CMS Fact Sheet on Medicare Physician Fee Schedulehttps://www.cms.gov/Newsroom/MediaReleaseDatabase/Fact-sheets/2017-Fact-Sheet-items/2017-11-02.html

AAMC Webpage: Physician Payment and Qualityhttps://www.aamc.org/initiatives/patientcare/patientcarequality/311244/physicianpaymentandquality.html

https://www.gpo.gov/fdsys/pkg/FR-2017-11-15/pdf/2017-23953.pdf

https://www.cms.gov/Newsroom/MediaReleaseDatabase/Fact-sheets/2017-Fact-Sheet-items/2017-11-02.html

https://www.aamc.org/initiatives/patientcare/patientcarequality/311244/physicianpaymentandquality.html


Questions and Feedback

Questions and Feedback about PFS Final Rule

Gayle Lee, [email protected]

Kate Ogden, [email protected]

FPSC Projects Related to PFS and Q&E

Dave Troland, [email protected]

Jake Langley, [email protected]

mailto:[email protected]




Documents

Physician Fee Schedule 2018 Final Rule - AAMC Medicare Physician Fee Schedule Final Rule • Displayed November 2, published in Federal Register November 15 • Supplemental materials