The Centers for Medicare and Medicaid Services (CMS) on July 3 released two proposed rules with important ramifications for cardiovascular professionals. These rules address Medicare payment and quality provisions for physicians and hospital outpatient services in 2015. The rules indicate that physicians will see no change in payment for the first 3 months of 2015 due to the latest sustainable growth rate (SGR) patch. However, the SGR will take effect April 1, 2015 unless Congress again intervenes. At that time physicians would face a 20.9 percent cut as a result of the legally mandated SGR. Hospitals will receive a 2.1 percent increase in payment for outpatient services. As in previous years, the ACC continues to fight to avoid cuts to Medicare payment for cardiovascular services. Aside from the across-the-board cuts associated with the SGR, CMS estimates that the physician rule will increase payments by 1 percent to cardiologists from 2014 to 2015. This estimate is based on typical practice and can vary widely depending on the mix of services provided in a practice.

Additional Resources Summary of 2015 proposed Physician Fee Schedule Summary of 2015 proposed Hospital Outpatient Rule ACC Comments to CMS

Some of the other most important proposals for cardiology contained in the rules include:

Physician Fee Schedule

• In response to an Office of the Inspector General report and other concerns about misvaluation of surgical services, CMS proposes to transition all 10- and 90-day global period codes to 0-day global periods starting in CY 2017.
• CMS proposes policies to apply the value-based payment modifier to all physician and nonphysician eligible professionals. The agency also proposes to expand public reporting of clinical quality measures.
• CMS would create a new code to report non-face-to-face chronic care management. This proposal caps a 2-year effort to create a mechanism to pay physicians for managing complex patients and follows the CY 2013 implementation of transitional care management services that include non-face-to-face work.
• In this proposed rule, the agency seeks review of 65 services with Medicare allowed charges of $10 million or more as a prioritized subset of codes under the newly established statutory category of "codes that account for the majority of spending under the physician fee schedule." This list includes SPECT MPI, transthoracic echocardiography, and stress echocardiography.
• CMS proposes to delete the exception in the Physician Payment Sunshine Act (Open Payments Program) for reporting of indirect payments by industry to physicians serving as faculty for accredited and/or certified continuing medical education.

View a detailed summary of the 2015 proposed Physician Fee Schedule.

Hospital Outpatient Rule

• The requirements for physician certification of inpatient admissions would be revised under this proposal to apply only for long-stay cases and costly outlier cases. CMS believes that in most cases, the admission order, medical record and notes contain sufficient information to support the medical necessity of an inpatient admission.
• To better understand the effect of hospital-owned practices on payment trends, CMS proposes to create a HCPCS modifier to be reported with every code furnished in this setting beginning Jan. 1, 2015.
• For 2015, CMS proposes to implement 28 Comprehensive Ambulatory Payment Classifications (APCs) after delaying them for 2014. Services assigned to the comprehensive APCs will be defined as primary services, with payment for all other services reported under a single hospital stay packaged under the primary service.
• For 2017 and subsequent years, CMS proposes to remove three measures from the Hospital Outpatient Quality Reporting Program (OQR): OP-4: Aspirin at Arrival (NQF #0286), as well as two prophylactic antibiotic surgery measures. CMS considers these measures to be "topped out," meaning that performance among hospitals is so high and unvarying that meaningful distinctions and improvements in performance can no longer be made. Hospitals that fail to meet the OQR reporting requirements will continue to face a 2 percent point reduction in payment.

View a detailed summary of the 2015 proposed Hospital Outpatient Rule.

The ACC submitted formal comments to CMS detailing the strengths and weaknesses of the cardiovascular-related provisions included in the proposals. Read the physician and hospital proposed rule comments in their entirety or review a shorter summary of recommendations.

Keywords: Healthcare Common Procedure Coding System, Faculty, Tomography, Emission-Computed, Single-Photon, Echocardiography, Stress, Medicaid, Centers for Medicare and Medicaid Services, U.S., Medical Records, Length of Stay, Education, Medical, Continuing, Fee Schedules, Medicare, Certification

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