CMS Releases Final 2016 Physician Fee Schedule and Hospital Outpatient Rules

Today, the Centers for Medicare and Medicaid Services (CMS) released two final regulations of note to cardiovascular professionals. These rules determine the payment levels and associated policies for services provided under the Physician Fee Schedule and the Hospital Outpatient Prospective Payment System (HOPPS). Consistent with the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), physicians will see a 0.5 percent formula increase on Jan. 1. Unrelated payment formula changes result in an estimate that payment for cardiology services will neither increase nor decrease from 2015 to 2016. However, this estimate is based on the entire universe of cardiology services and can vary widely depending on the mix of services provided in a practice.

According to ACC President Kim Allan Williams Sr., MD, FACC, "the defeat of the flawed sustainable growth rate formula earlier this year began a transition to the new value-based payment program under MACRA. Through today's rule CMS maintains stability by not making drastic changes to existing Medicare quality reporting programs. This stability will help clinicians become more familiar with the current program elements that will continue in 2016 and are likely to transition to the new payment system."

He adds that "we appreciate that CMS continues to seek public input – particularly from the people attempting to implement new policies at the practice level. Clinicians must be able to focus on delivering high-quality patient care rather than navigating burdensome administrative requirements in a new payment landscape. We know that CMS is sensitive to access, delivery, quality and fairness in payment."

Other proposals for cardiology contained in the rules include:

Physician Fee Schedule

  • CMS will delay the requirement that clinicians ordering advanced imaging services (e.g., CT, MR, SPECT) consult with appropriate use criteria (AUC) through a qualified clinical decision support mechanism starting on Jan. 1, 2017. CMS will issue additional regulations on this program in the CY 2017 and CY 2018 rulemaking cycles.
  • CMS finalized with modifications the process for selecting AUC developed by national professional medical specialty societies and other provider-led entities for the AUC consultation requirement that will apply to professionals ordering advanced imaging services.
  • CMS maintains most existing policies applicable to the Physician Quality Reporting System (PQRS) for the 2016 performance year. Under most individual reporting options, eligible professionals will continue to report at least nine measures across at least three domains. Failure to successfully report PQRS quality measures in 2016 will continue to result in a -2 percent payment adjustment in 2018.
  • Application of the Value-Based Payment Modifier on 2018 payments will be expanded to non-physician eligible professional solo practitioners and group practices (e.g., physician assistants, nurse practitioners and clinical nurse specialists) based on the 2016 performance period.
  • The Agency seeks review of 103 services with Medicare allowed charges of $10 million or more as a prioritized subset of codes under the statutory category of "codes that account for the majority of spending under the physician fee schedule." This list includes transthoracic echocardiography, electrophysiology device monitoring services and 3-D electrophysiology mapping. SPECT-MPI services were removed from the list after the ACC and other stakeholders indicated they did not fit the specified criteria.
  • CMS finalized revisions to physician self-referral (Stark) regulations it believes will accommodate delivery and payment system reform, reduce burden and facilitate compliance.
  • The Agency collected initial comments related to the implementation of the Merit-Based Incentive Payment System and Alternative Payment Model payment pathways and will continue consider these comments along with those received through the MACRA Request for Information.

Hospital Outpatient Prospective Payment System

  • CMS finalized changes to its existing "rare and unusual" exceptions policy to allow Part A payment on a case-by-case basis for inpatient admissions that do not satisfy the two-midnight benchmark. The Agency will use quality improvement organizations to educate doctors and hospitals about Part A payment policy for inpatient admissions. Certain restrictions on recovery audit contractors' review of admitting decisions will also be implemented. These include changes to the "look-back period," limits on additional documentation requests and requirements for timely reviews.
  • CMS continues its policy to package payment for items and services that are integral, ancillary, supportive or adjunctive to a primary service. Starting in 2016, payment for bivalirudin and abciximab will be packaged into the Ambulatory Payment Classification (APC) payment for the primary procedure, such as a percutaneous coronary intervention or percutaneous transluminal coronary angioplasty.
  • For 2016, CMS will implement nine new Comprehensive APCs (C-APCs), including one new C-APC for comprehensive observation services. This will provide a single payment for all services received during a non-surgical encounter with a high-level outpatient hospital visit or emergency department visit and eight or more hours of observation. All surgical procedures, regardless of the date of service, will be paid separately.
  • CMS finalized updates to the APC structure for imaging services, including the creation of the Level 4 Nuclear Medicine and Related Services group to appropriately recognize the resource costs and clinical distinctions of PET imaging services.
  • For 2017 and subsequent years, hospitals that fail to meet the requirements of the Hospital Outpatient Quality Reporting Program will receive a 2 percent reduction to their annual fee schedule update factor. CMS will also continue to explore electronic clinical quality measures for use in future years of the program.

More information will be forthcoming as ACC Advocacy staff review and analyze the regulations.

Additionally, the 2015 Cardiovascular Summit: Solutions for Thriving in a Time of Change, taking place Feb. 18 - 20, 2016, in Las Vegas, will feature several sessions related to changes in the final rule. Registration is now open.

Clinical Topics: Anticoagulation Management, Arrhythmias and Clinical EP, Invasive Cardiovascular Angiography and Intervention, Noninvasive Imaging, Implantable Devices, SCD/Ventricular Arrhythmias, Atrial Fibrillation/Supraventricular Arrhythmias, Novel Agents, Interventions and Imaging, Computed Tomography, Echocardiography/Ultrasound, Nuclear Imaging

Keywords: Angioplasty, Balloon, Coronary, Antibodies, Monoclonal, Centers for Medicare and Medicaid Services (U.S.), Documentation, Echocardiography, Stress, Electrophysiology, Emergency Service, Hospital, Fee Schedules, Hirudins, Immunoglobulin Fab Fragments, Inpatients, Medicare, Nuclear Medicine, Nurse Clinicians, Nurse Practitioners, Outpatients, Patient Care, Peptide Fragments, Physician Assistants, Physician Self-Referral, Quality Improvement, Tomography, X-Ray Computed, Tomography, Emission-Computed, Single-Photon

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