A Closer Look at the Final 2016 PFS and HOPPS Rules

The Centers for Medicare and Medicaid Services (CMS) released two final regulations of note to cardiovascular professionals in late October 2015. These rules determine the payment levels and associated policies for services provided under the Physician Fee Schedule (PFS) 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. National pricing for a number of specific codes commonly reported by cardiology practices is available.

Some of the 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., computed tomography, magnetic resonance, SPECT) consult with appropriate use criteria (AUC) through a qualified clinical decision support mechanism starting on January 1, 2017. CMS will issue additional regulations on this program in the contact year (CY) 2017 and CY 2018 rulemaking cycles.

Under the program, ordering clinicians will have to consult with AUC developed by a qualified provider-led entity, which includes national medical specialty societies such as the ACC. CMS finalized with modifications for the requirements for such entities, including requirements of the AUC development team size and structure, the evidence review process, and the process for ensuring transparency and managing conflicts of interest among those developing the AUC. The College will be submitting an application letter to have ACC’s AUC qualified for use under the Medicare program. CMS intends to provide the list of qualified AUC developers in 2016.

CMS indicated that the CY 2017 Physician Fee Schedule will provide the clarifications, definitions, and process for identifying qualified CDS mechanisms. CMS intends to provide the initial list of approved clinical decision support mechanisms in summer 2017.

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.

In response to comments from the ACC and others, CMS finalized an updated version of its proposal to clarify that under circumstances where the supervising practitioner is not the same as the referring, ordering or treating practitioner, only the supervising practitioner may bill Medicare for the incident to service. This is not a policy change. Rather, the new regulatory language formalizes a policy that had been stated indirectly through previous rulemaking at 42CFR§410.26.

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 , taking into account recommendations submitted by the ACC and several cardiovascular specialty groups. Final changes include 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, and a more appropriate APC placement for cardiac MR with stress imaging (CPT 75563) that avoids a proposed payment decrease of over 50 percent.

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.

Additionally, the 2015 Cardiovascular Summit: Solutions for Thriving in a Time of Change, taking place Feb. 18 - 20, 2016, in Las Vegas, NV, 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.), Decision Support Systems, Clinical, Echocardiography, Electrophysiology, Fee Schedules, Hirudins, Immunoglobulin Fab Fragments, Magnetic Resonance Spectroscopy, Medicare, Nuclear Medicine, Positron-Emission Tomography, Quality Improvement, Tomography, Emission-Computed, Single-Photon, Medicare Access and CHIP Reauthorization Act of 2015

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