The Physician Fee Schedule was released in tandem with the proposed 2018 Hospital Outpatient Prospective Payment System (OPPS) rule. The outpatient rule indicates a 1.75 percent payment update for hospitals. Highlights from both proposed rules include:

Physician Fee Schedule

• Proposals to implement the new appropriate use criteria (AUC) requirement for advanced imaging services (i.e., SPECT MPI, CT and MR). Specifically:
• The proposal to require ordering professionals to consult with AUC through a qualified clinical decision support mechanism (CDSM) beginning Jan. 1, 2019, delaying this requirement one year. CMS also proposes the list of data elements that ordering professionals must report on the claims form under this program, including the use of new Healthcare Common Procedure Coding System (HCPCS) codes. The list of qualified CDSMs is posted on the CMS AUC Program website.
• The proposal to consider the 2019 reporting year as a testing and education year.
• CMS will seek comments on how the AUC program can support a Merit-Based Incentive Payment System (MIPS) quality measure.
• Proposed hardship exceptions to the requirement to consult AUC and report data to CMS, including lack of face-to-face patient interaction, clinicians who have been in practice for less than two years and the lack of availability and control over Certified Electronic Health Record Technology and internet connectivity.
• Reduction of payment rates for certain items and services furnished by off-campus hospital provider-based departments from 50 percent of OPPS to 25 percent of OPPS.
• A request for information regarding changes that could be made to regulations to relieve administrative burdens and better achieve program transparency, flexibility and innovation.
• Updates to values for stress echocardiography, transthoracic echocardiography, electrophysiology (EP) device monitoring services, EP 3D mapping add-on services and extremity angiography radiological supervision and interpretation, resulting from previously directed reviews of work and practice expense inputs. More detail will be available after CMS posts supporting data tables.
• Proposed values for new codes describing INR anticoagulation management billed per test regardless of where the test result is obtained and endovenous ablation of incompetent extremity veins.
• A net reduction in expenditures resulting from adjustments to misvalued codes of 0.31 percent, missing the 2018 statutory target of 0.50 percent. The remaining 0.19 percent will be removed through an across-the-board reduction to all fee schedule services.
• To align with MIPS requirements, clinicians and groups who successfully reported six quality measures for Physician Quality Reporting Program for 2016 will avoid the –2.0 percent penalty that was to be applied in 2018. This is a reduction from the required nine measures across three National Quality Strategy domains. Additionally, the maximum penalties for the Value-based Payment Modifier would be reduced from –4.0 percent to –2.0 percent for groups of 10 or more and –2.0 percent to –1.0 percent for groups of 10 or fewer.
• CMS proposes the list of Level II HCPCS modifiers used to capture patient relationship categories required by Medicare Access and CHIP Reauthorization Act of 2015 for improved cost measurement. Voluntary use of these modifiers will begin on Jan. 1, 2018.
• Changes to the Medicare Shared Savings Program Accountable Care Organizations, including the addition of chronic care management codes to the definition of primary care services for attribution purposes.

Hospital Outpatient Prospective Payment System

• Updates for policies related to ambulatory payment classifications (APCs), including the proposed addition of a new APC for certain imaging procedures, without contrast, to better classify services based on resource homogeneity.
• CMS will seek comments on packaging policies that provide no separate payment for services and items such as drugs functioning as supplies in diagnostic tests and procedures or surgical procedures that are ancillary to a primary procedure.
• The removal of six measures from the Hospital Outpatient Quality Reporting Program in either the CY 2020 or CY 2021 payment determinations, including OP-4: Aspirin at Arrival.
• Similar with the fee schedule proposed rule, CMS seeks information on ways to achieve transparency, flexibility, program simplification and innovation.

ACC staff are reviewing the proposed rules to identify additional topics of interest to members. More information will be forthcoming in the Advocate newsletter and on ACC.org. The College will submit written comments at the end of the summer.

Not long before the final rules are released in the fall, experts will discuss federal legislative and regulatory topics at ACC’s 2017 Legislative Conference Sept. 10 – 12 in Washington, DC. Don’t miss this opportunity to learn about hot button issues facing cardiologists and to ensure the voice of cardiology is heard on Capitol Hill.

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Under the proposal, CMS will continue to treat the 2018 performance year as another transition year of QPP and maintain program flexibility. Based on 2018 performance, clinicians and groups will be eligible to receive up to +/- 5 percent in bonuses or penalties on Medicare Part B services provided in 2020 under MIPS. Qualifying participants in an Advanced APM will be eligible to receive a five percent lump sum bonus. Highlights of the proposed rule include:

• MIPS Weighting For 2018 Performance Year/2020 Payment Year
• Maintain 60 percent weight for Quality.
• Maintain 15 percent weight for Improvement Activities.
• Maintain 25 percent weight for Advancing Care Information; clinicians can use 2014 or 2015 certified electronic health record technology (CEHRT), with a bonus for using 2015 CEHRT.
• Maintain zero weight for Cost; however, CMS seeks comments on introducing this category at 10 percent. CMS continues to develop and test episode-based measures which will be introduced over time.

"While the ACC will be reviewing the rule in detail, we were encouraged to see that CMS has listened to feedback from the public and recognizes a need to continue supporting clinicians in their transition to a value-based payment environment." — Mary Norine Walsh, MD, FACC

• Increasing the low-volume threshold to less than or equal to $90,000 in Medicare Part B allowed charges or less than or equal to 200 Part B patients to allow more small practices to qualify for MIPS exemption.
• Implementation of virtual groups, allowing small groups and solo practitioners under two or more taxpayer identification numbers to participate in MIPS as a single group for both 2018 and 2019. Technical assistance will be made available to these practices.
• Implementation of facility-based measures in MIPS to allow clinicians to be assessed based on their facility’s performance.
• Continued recognition of qualified clinical data registries such as NCDR’s PINNACLE Registry and Diabetes Collaborative Registry as MIPS data reporting options.
• Advanced APM
• Maintenance of the nominal risk and qualifying participant thresholds for the Advanced APM pathway.
• Implementation of the ‘All-Payer Combination Option’ for the Advanced APM pathway starting in the 2019 performance year.
• CMS seeks comments on broadening the definition of Physician-Focused Payment Models to include Medicaid or Children’s Health Insurance Program beneficiaries.
• Other key items are included in the CMS fact sheet.

The ACC is reviewing this rule in further detail and will provide more details via the ACC Advocate newsletter or online at ACC.org/Advocacy. Additionally, the College is soliciting feedback from member groups in preparation for submitting written comments.

“Next year (2018) will be another transition year for clinicians adjusting to the Quality Payment Program,” notes ACC President Mary Norine Walsh, MD, FACC. “While the ACC will be reviewing the rule in detail, we were encouraged to see that CMS has listened to feedback from the public and recognizes a need to continue supporting clinicians in their transition to a value-based payment environment.”

The policies in this proposed rule impact the 2018 performance year and future years under QPP. To learn about the current requirements for the 2017 performance year, visit ACC’s MACRA Information Hub at ACC.org/MACRA.

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“As the burden of cardiovascular disease continues to rise, cardiac rehabilitation remains critical to heart failure management and successful recovery from heart attacks and cardiac surgery. Current health care policy requires physicians to supervise cardiac rehabilitation services, which can create limitations to access for millions of patients, adversely impacting population health outcomes. The passage of S.1361 would remove barriers by allowing all providers to practice to the highest level of their education, training and certification,” said Linda L. Hart, DNP, RN, ACNP-BC, AACC. “We’re grateful to Senate leadership for introducing S. 1361 and encourage commitment to this legislation that will allow patients across the nation to more easily access high-quality cardiovascular care.”

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