Health Reform WK-EDGE CMS finalizes physician fee schedule payment rates for 2018, off-campus PBD cuts concerning to AHA
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Thursday, November 9, 2017

CMS finalizes physician fee schedule payment rates for 2018, off-campus PBD cuts concerning to AHA

By Kelly J. Rooney, J.D., M.P.H.

Payment for physicians will increase slightly in 2018. CMS released a Final rule revising payment policies for the Physician Fee Schedule (PFS) and Medicare Part B with updates affecting such matters as 2018 payment rates generally, payments for telehealth services and those provided in off-campus provider-based departments, as well as the Medicare Shared Savings Program and the Physician Quality Reporting System, among others. This is one of several rules that the new Administration states is part of a strategy to provider better access, quality, affordability, empowerment, and innovation in the health care system. The Final rule will publish in the Federal Register on November 15, 2017.

Overall updates. Payment rates will increase 0.41 percent for CY 2018, reflecting the 0.50 percent increase established under the Medicare Access and CHIP Reauthorization Act (MACRA) (P.L. 114-10), reduced by 0.09 percent required under the Achieving a Better Life Experience Act of 2014 (ABLE Act) (P.L. 113-295). The ABLE Act mandates the identification of potentially misvalued services and then adjustment to be made to their RVUs accordingly. The final PFS conversion factor is estimated at 35.9996, up from 35.8887 in 2017, and the anesthesia conversion fact is estimated to be 22.1887.

Telehealth services. The following additions will be made to the CY 2018 telehealth list, as they were found to be similar to services currently on the list: HCPCS code G0296 (counseling visit to discuss need for lung cancer screening using low dose CT scan); CPT codes 90839 and 90840 related to psychotherapy for crisis; CPT code 90785 for interactive complexity; CPT codes 96160 and 96161 for administration of patient-focused and caregiver-focused health risk assessment instruments; and HCPCS code G0506 for comprehensive assessment of and care planning for patients requiring chronic care management services. Further, in response to public comments, the status of CPT code 99091 (related to remote patient monitoring) will change from bundled to a separate payment in 2018. In response to the Proposed rule, stakeholders requested further expansion of access to telehealth services (see CMS plans changes to physician fee schedule, July 14, 2017). Although CMS noted it was limited by statute, it reiterated its commitment to expanding the services in future rulemaking.

Off-campus provider-based departments (PBDs). Pursuant to the Bipartisan Budget Act of 2015 (BBA) (P.L. 114-74), the PFS is the applicable payment system for certain items and services furnished by off-campus hospital outpatient PBDs. For 2017, the PFS payment rate for these services was 50 percent of the Outpatient Prospective Payment System (OPPS) payment rate, and the 2018 PFS Proposed rule proposed changing it to 25 percent. However, a "middle ground" was agreed to and a payment rate of 40 percent of the OPPS payment rate is final for 2018, which amounts to a 20 percent reduction to the current PFS payment rate for these services.

The American Hospital Association, responding to the 2018 PFS Final rule, claims this would "adversely impact patient access to care by reducing Medicare rates for services hospitals provide in ‘new’ off-campus hospital clinics." AHA Executive Vice President Tom Nickels expressed concern for the impact on "rural and vulnerable communities" that lack sufficient access.

Care coordination in FQHCs and RHCs. Starting for services provided January 1, 2018, rural health clinics (RHCs) and federally qualified health centers (FQHCs) must use new code G0511 (general care management) to bill for chronic care management (CCM) or general behavioral health integration (BHI) services and new psychiatric collaborative care model (CoCM) code G0512 for psychiatric CoCM services, either alone or with other payable services on the claim. Claims using the old code, CPT 99490, for dates of service on or after January 1, 2018 will be denied.

Medicare Diabetes Prevention Program (MDPP) expanded model. The Medicare Diabetes Prevention Program (MDPP) expanded model, which will allow beneficiaries access to evidence-based diabetes prevention services, will be implemented for 2018. The goal is to reduce the progression to type 2 diabetes in individuals diagnosed with pre-diabetes. The program offers beneficiaries practical training in long-term dietary change, increased physical activity, and behavior change strategies for weight control. The MDPP will be paid under a value-based payment structure and additional policies and enrollment requirements for suppliers are provided in the PFS Final rule.

Appropriate Use Criteria for imaging services. The Medicare Appropriate Use Criteria (AUC) Program for Advanced Diagnostic Imaging is delayed until January 1, 2020 (it had been proposed to begin January 1, 2019). In 2020, physicians and ordering professionals must to start using the AUCs when ordering applicable imaging services and reporting consultation information on the Medicare claim. Early adopters may start reporting consultation information on claims starting as early as July 2018.

PQRS. The Physician Quality Reporting System (PQRS), which required the reporting on certain quality measures or be subject to downward payment adjustment of 2.0 percent, is now replaced by the Merit-Based Incentive Payment System (MIPS) under the Quality Payment Program (QPP). Last data submission for PQRS is for the first quarter of 2018, and last reporting period is 2016. The first performance period for MIPS is 2017. Under PQRS, there are nine measures but the Final rule will reduce the reporting burden down to six measures for the 2016 reporting period.

Medicare Shared Savings Program. In order to reduce burden and streamline the Medicare Shared Savings Program (MSSP) operations, accountable care organizations (ACOs) no longer need to list each physician working in FQHC or RHC on ACO participant list. Other changes include reducing burden on ACOs when submitting initial MSSP applications or applications for use of SNF 3-day rule waiver and revisions to the definition of primary care services for ACO assignment purposes.

Biosimilar payments. CMS is changing the policy to separately code and pay for biological biosimilar products under Medicare Part B. Effective January 1, 2018, newly approved biosimilar biological products with a common reference product will no longer be grouped into the same billing code.

Other provisions. A number of potentially misvalued codes were identified by stakeholders in response to the 2018 PFS Propose rule, and for the most part, CMS noted that it would consider whether review is warranted and review the recommendations of the Relative Value Scale Update Committee (RUC) as to the appropriate valuation.

The PFS Proposed rule asked for public comments on how to reduce the administrative burden for "evaluation & management (E/M) guidelines" and care management services because comments from stakeholders are that the guidelines are outdated and burdensome. CMS determined, based on comments, that more opportunities for collaboration and more from stakeholders will be considered regarding this idea and will be taken into account in future rulemaking.

The 21st Century Cures Act (P.L. 114-255) sec. 5004(a) changed the payment for infusion drugs furnished through a covered item of durable medical equipment from an average wholesale price to an average sales price methodology starting in 2017. The 2018 Final rule revises 42 CFR sec. 414.904(e)(2) accordingly.

The Proposed rule solicited comments regarding the initial data collection and reporting periods for the Clinical Laboratory Fee Schedule and will consider the comments in future rulemaking.

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