2015 Physician Fee Schedule Final Rule Summary

The Centers for Medicare and Medicaid Services (CMS) on Oct. 31 released the 2015 Physician Fee Schedule final rule, covering payments and related policies for services provided by physicians or in the physician office setting. Provisions of the rule will be implemented on Jan. 1, 2015. The rule indicates that physicians will see no change in payment for the first three months of 2015 due to the latest Sustainable Growth Rate (SGR) patch. However, the SGR will take effect April 1, 2015, unless Congress once again intervenes. At that time physicians would face a 21.2 percent cut as a result of the legally mandated SGR.

Changes unrelated to the SGR result in no overall change to payment for services provided by cardiologists in 2015. This estimate is based on the entire universe of cardiology services and can vary widely depending on the mix of services provided in a particular practice. You can view the impact on several key cardiology services here.

The Physician Fee Schedule rule continues CMS’s work of recent years to emphasize quality and implement programs like the Physician Quality Reporting System (PQRS) and Value-Based Modifier (VM). Physicians who do not successfully participate in PQRS in 2015 will receive a 2 percent penalty in 2017. CMS has expanded the VM program to all physicians and physician practices in 2015 for payment adjustments in 2017. Other key provisions of the physician fee schedule rule include:

Quality and Value Programs

Physician Quality Reporting System 

Eligible professionals (EPs) who do not satisfactorily report to PQRS for the 2015 performance period (Jan. 1 – Dec. 31, 2015) will receive a -2 percent payment adjustment on Medicare Part B fee-for-service payments in the 2017 payment year. To satisfactorily report, EPs will need to meet the applicable criteria for reporting individual measures or measures groups via claims, a qualified registry, electronic health record (EHR), qualified clinical data registry (QCDR) (i.e. PINNACLE Registry), or the Group Practice Reporting Option (GPRO) interface.

In 2015, 255 individual measures will be available for reporting. Most EPs will need to report nine measures across three National Quality Strategy domains for successful reporting in 2015. The ACC will be posting additional information on the measure and reporting changes over the coming weeks.

Value-Based Modifier

CMS will apply the VM to all physicians and physician groups starting in the 2017 payment year, using 2015 performance data on quality and cost measures.

Quality tiering under the VM will also apply to all physicians and physician groups starting in payment year 2017. CMS originally proposed a maximum payment adjustment of +/- 4 percent for all physicians based on their quality/cost performance. In the final rule, CMS revised this policy to apply the maximum 4 percent adjustment only to groups of ten or more EPs. Solo practitioners and groups of two to nine EPs will be eligible for a maximum upward adjustment of 2 percent and will not be subject to any downward adjustments for 2017. The VM will apply to nonphysician EPs beginning in 2018.

ACC will provide additional information on the VM over the coming weeks.

Physician Compare

CMS will expand public reporting of group-level measures by making all 2015 PQRS GPRO measure sets across group reporting mechanisms available for public reporting on Physician Compare in 2016 for groups of two or more eligible professionals. In order to facilitate public reporting, CMS will also publicly report 2015 Consumer Assessment of Healthcare Providers and Systems survey data in 2016 for groups of two or more EPs and accountable care organizations.

CMS will expand public reporting of individual EP measures collected via registry, EHR or claims, except for new and first year measures, beginning in late 2016, if technically feasible. In addition, all 2015 QCDR measures and data will be publicly reported in 2016 on Physician Compare, with the exception of first year measures.

In addition, EPs satisfactorily reporting all four of the following individual measures in 2015 will receive green check mark on Physician Compare indicating support of the Million Hearts:

  • Ischemic Vascular Disease: Use of Aspirin or Another Antithrombotic
  • Preventive Care and Screening: Tobacco Use
  • Controlling High Blood Pressure
  • Preventive Care and Screening: Screening for High Blood Pressure and Follow-Up Documented

Electronic Health Record Incentive Program

EPs and eligible hospitals not demonstrating meaningful use of Certified Electronic Health Record Technology may be subject to a downward payment adjustment in 2015. The final rule recognizes the extension of the hardship exception deadline to Nov. 30, 2014, for EPs and eligible hospitals unable to meet program requirements due to “extreme and uncontrollable circumstances” such as lack of sufficient internet access, newly practicing EPs and other situations outside of the EP’s or eligible hospital’s control. See if you qualify for the exception.

Payment Issues

Global Periods

CMS finalized a proposal to transition all 10- and 90-day global period codes to 0-day global periods. Services with 10-day global periods would be revised for calendar year (CY) 2017. Services with 90-day global periods would follow in CY 2018. Cardiologists have a modest number of 90-day services in the electrophysiology and interventional areas that will be impacted by this proposal. This change will greatly impact surgical specialties, perhaps none more than cardiac surgeons.

Potentially Misvalued Services

With the large project to dramatically change services’ global periods, CMS did not finalize its proposal to review 65 high expenditure services as potentially misvalued. This list included SPECT-MPI, transesophageal echocardiography (TEE), stress echo, and electrophysiology device programming. However, CMS maintains its belief that a high expenditure screen may be useful to identify misvalued codes in the future. These and other services will likely be revisited in one or several years.

Physician Fee Schedule Ratesetting Transparency

In a significant process change, beginning with CY 2017 rulemaking, CMS will change the process for valuing new, revised and potentially misvalued codes. Rather than including these services in the final rule on an interim-final basis, the vast majority of codes will be addressed through notice and comment rulemaking prior to adoption and implementation. This means stakeholders will have the opportunity to review and comment on these items in July and August with the possibility of revisions for the following year, rather than seeing them in November with no possibility for revision.

Transesophogeal Echocardiography

Physicians who provide TEE guidance during structural heart interventions can now report CPT code 93355 with a work value that more appropriately captures the required physician work. The entire family of TEE codes was also reviewed and is slated for modest increases in physician work on an interim-final basis.

Complex Chronic Care Management

Medicare continues to emphasize care coordination services by finalizing a proposal to make separate payment for non-face-to-face chronic care management (CCM) services beginning in 2015. Physicians can report CPT code 99490 up to once per calendar month per qualified patient in 2015 to Medicare beneficiaries who have multiple, significant chronic conditions (two or more). CCM services include regular development and revision of a plan of care, communication with other treating health professionals, and medication management.

Off-Campus Provider-Based Departments

CMS revised its proposal to create a Healthcare Common Procedure Coding System modifier to be reported with every code furnished in this setting beginning Jan. 1, 2015. Instead, hospitals will be required to report a modifier for those services furnished in an off-campus provider-based department of the hospital and physicians and other billing practitioners will be required to report these services using a new place of service code on professional claims. Data collection will be voluntary for hospitals in 2015 and required beginning on Jan. 1, 2016. The new professional claims place of service code will be required for professional claims as soon as it is available, but not before Jan. 1, 2016.

Open Payments (Sunshine Act)

CMS removed the exception in the Open Payments Program (Physician Payments Sunshine Act) for reporting of indirect payments by industry to physicians serving as faculty for accredited and/or certified continuing medical education. CMS believes eliminating the exemption for payments to speakers at certain accredited or certifying continuing medical education events will create a more consistent reporting requirement, as a different exclusion would still apply to these indirect payments. That provision excludes indirect payments or other transfers of value where the applicable manufacturer is unaware of the identity of the covered recipient.

Keywords: Physicians, Motivation, Follow-Up Studies, Specialties, Surgical, Healthcare Common Procedure Coding System, Fee-for-Service Plans, Tomography, Emission-Computed, Single-Photon, Centers for Medicare and Medicaid Services, U.S., Aspirin, Medicare Part B, Electronic Health Records, Electrophysiology, Education, Medical, Continuing, Health Expenditures, Accountable Care Organizations, Fee Schedules, Tobacco Use, Hypertension, Current Procedural Terminology, Echocardiography, Transesophageal

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