CMS Releases Final 2015 Medicare Physician Fee Schedule and Hospital Outpatient Rules

The Centers for Medicare and Medicaid Services (CMS) on Oct. 31 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). The rules indicate 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 again intervenes. At that time physicians would face a 21.2 percent cut as a result of the legally mandated SGR. Hospitals will receive a 2.3 percent increase in payment. The ACC continues to urge Congress to permanently address this issue. 

Changes unrelated to the SGR result in a flat 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 practice. 

“This year’s rule highlights the continued implementation of quality reporting and value programs in Medicare. As the ACC already encourages physician quality reporting through our registries, we are pleased to see our input on these programs taken seriously,” said ACC President Patrick O’Gara, MD, FACC. “However, while cardiologists will see modest payment increases for selected services, the annual threat of significant reductions in reimbursement due to the SGR formula creates an unsustainable path for physicians to provide quality care to patients and accentuates the need for a definitive solution. CMS and Congress must work with medical providers to ensure that high value care is accessible for all services.”

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

Physician Fee Schedule

  • For satisfactory Physician Quality Reporting System (PQRS) participation, eligible professionals (EPs) or groups must report at least nine measures across three domains for at least 50 percent of the professional’s Medicare Part B fee-for-service patients. At least one of these measures must be from the cross-cutting measure set CMS is introducing for 2015. Failure to meet the 2015 reporting requirements will result in a -2.0 payment adjustment in 2017.
  • The value-based modifier (VBM) will apply to all physician and nonphysician EPs in 2017 based on reporting in 2015. The maximum -4 percent VBM payment adjustment will only apply to groups of ten or more EPs subject to the VBM that do not meet PQRS reporting requirements. Solo practitioners and groups of two to nine EPs will be subject to a maximum payment adjustment of -2 percent for failure to meet the reporting requirements.
  • Under the VBM quality-tiering methodology, CMS will set a maximum bonus or penalty of up to 4 percent of payment for groups of 10 or more EPs based on quality and cost of care classification. Solo practitioners will be eligible for a bonus of up to 2 percent and will not be subject to any penalties based on quality and cost classification.
  • Physicians who provide transesophageal echocardiography (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.
  • CMS is not finalizing its proposal to review high expenditure codes, including SPECT-MPI, TTE, stress echo, and EP device programming. However, CMS maintains its belief that a high expenditure screen may useful to identify misvalued codes in the future.
  • CMS will transition all 10- and 90-day global period codes to 0-day global periods starting in calendar year 2017.
  • Non-face-to-face chronic care management services provided to patients who have multiple, significant, chronic conditions can be reported using code 99490 up to once per calendar month per qualified patient in 2015.
  • CMS removed 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.

Read the 2015 Medicare Physician Fee Schedule final rule summary for additional details. 

Hospital Outpatient Prospective Payment System

  • 25 of the 28 proposed Comprehensive Ambulatory Payment Classifications (APCs) have been finalized for 2015. 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. Comprehensive APCs include automatic implantable cardiac defibrillator, pacemaker and related device procedures; electrophysiologic procedures; and endovascular procedures.
  • CMS will conditionally package all ancillary services assigned to APCs with a geometric mean cost of $100 or less into payment for a primary procedure, unless these services are performed by themselves. This includes electrocardiograms/cardiography and chest x-ray procedures.
  • CMS will begin collecting data on services provided in off-campus provider-based outpatient departments. Services furnished in this setting will be reported with a Healthcare Common Procedural Coding System (HCPCS) modifier on a voluntary basis for one year, beginning Jan. 1, 2015. Reporting the new HCPCS modifier will be mandatory Jan. 1, 2016.
  • The requirements for physician certification of inpatient admissions will only apply only to 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.

Read the 2015 HOPPS final rule summary for additional information. 

Resources for Navigating the Change

Keywords: Physicians, Defibrillators, Endovascular Procedures, Healthcare Common Procedure Coding System, Fee-for-Service Plans, Faculty, X-Rays, Tomography, Emission-Computed, Single-Photon, Centers for Medicare and Medicaid Services, U.S., Electrocardiography, Medical Records, Length of Stay, Medicare Part B, Education, Medical, Continuing, Health Expenditures, Fee Schedules, Certification, Current Procedural Terminology, Echocardiography, Transesophageal, Prospective Payment System

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