CMS Releases CY2016 Physician Fee Schedule Proposed Rule :: Reliant Rehab

CMS Releases CY2016 Physician Fee Schedule Proposed Rule

First Physician Fee Schedule Since SGR Repeal Courtesy of

CMS released the CY2016 Physician Fee Schedule Proposed Rule that updates payment policies, payment rates, and quality provisions for services furnished under the Medicare Physician Fee Schedule (PFS) on or after January 1, 2016.

This is the first PFS proposed rule since the repeal of the Sustainable Growth Rate (SGR) formula by the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA). CMS is proposing a number of new policies, including changes to several of the quality reporting initiatives that are associated with PFS payments, including the Physician Quality Reporting System (PQRS), the Physician Value-Based Payment Modifier (Value Modifier), and the Medicare Electronic Health Record (EHR) Incentive Program, as well as changes to the Physician Compare website on MACRA merged the PQRS, the Value Modifier and the EHR Incentive program into the Merit-Based Incentive Payment System (MIPS). 

Below are a few sections we noted in our rapid review. There are many sections including a productivity adjustment for clinical lab and DMEPOS Fee Schedules that we need to more carefully review. We will provide a more thorough summary in the coming weeks.

Misvalued Codes
The Affordable Care Act instructed CMS to identify “misvalued codes” in the Physician Fee Schedule, which CMS does through the annual rulemaking process. The proposed rule includes proposals to implement statutory adjustments to physician payments based on misvalued codes. CMS has previously included therapy codes on the misvalued code list. 

In the Protecting Access to Medicare Act of 2014 (PAMA), Congress set 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. If the net reductions in misvalued codes in 2016 are not equal to or greater than 1 percent of the estimated expenditures under the fee schedule, a reduction equal to the percentage difference between 1 percent and the estimated net reduction in expenditures resulting from misvalued code reductions must be made to all PFS services.

In this proposed rule, CMS is proposing a methodology for the implementation of this provision, which includes how net reductions in misvalued codes would be calculated. Based on that methodology, CMS has identified changes that achieve 0.25 percent in net reductions. However, CMS could make further misvalued code changes in the final rule to move closer to the statutory goal of 1 percent based on public comment and new recommendations.

In last year’s rule, CMS finalized a new process establishing values for new, revised and potentially misvalued codes. Under the new process, CMS included proposed values for these services in the proposed rule, rather than establishing them as interim final in the final rule with comment period. CY 2016 represents a transition year for this new process. For CY 2016, CMS is proposing new values in the proposed rule for the codes for which CMS received complete RUC recommendations by February 10, 2015. For recommendations regarding any new or revised codes received after the February 10, 2015 deadline, including updated recommendations for codes included in this proposed rule, CMS will establish interim final values in the final rule with comment period, consistent with previous practice.

Advance Care Planning
The proposed rule includes a proposal that supports patient- and family-centered care for seniors and other Medicare beneficiaries by enabling them to discuss advance care planning with their providers. The proposal follows the American Medical Association’s recommendation to make advance care planning services a separately payable service under Medicare. The Medicare statute currently provides coverage for advance care planning under the “Welcome to Medicare” visit available to all Medicare beneficiaries, but they may not need these services when they first enroll. Establishing separate payment for advance care planning codes provides beneficiaries and practitioners greater opportunity and flexibility to utilize these planning sessions at the most appropriate time for patients and their families.

Portable X-ray
CMS proposes to clarify that current sub regulatory guidance means that, when more than one patient is X-rayed at the same location, the single transportation payment under the PFS is to be prorated among all patients (Medicare Parts A and B, and non-Medicare) receiving portable X-ray services during that trip, regardless of their insurance status.

CMS is proposing to the revise the Medicare Telehealth Services Program, beginning in Calendar Year 2016, to allow two new End Stage Renal Disease(ESRD)-related services and prolonged service inpatient CPT codes. The prolonged service codes can only be billed in conjunction with subsequent hospital and subsequent nursing facility codes. Limits of one subsequent hospital visit every three days, and one subsequent nursing facility visit every thirty days, would continue to apply when the services are furnished as telehealth services.

CMS is also proposing to revise the regulations to include a certified registered nurse anesthetist (CRNA) to the list of distant site practitioners who can furnish Medicare telehealth services.

Comments are due to CMS by September 8, 2015. 

Read the pre-publication version of the proposed rule:

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