CMS Releases Proposed 2017 Medicare Physician Fee Schedule and Hospital Outpatient Rules

The Centers for Medicare and Medicaid Services (CMS) today released the proposed 2017 Medicare Physician Fee Schedule, which addresses Medicare payment and quality provisions for physicians in 2017. Under the proposal, physicians will see a 0.1 percent conversion factor payment decrease on Jan. 1, 2017. CMS estimates that the physician rule will increase payments to cardiologists 1 percent from 2016 to 2017. This estimate is based on typical practice and can vary widely depending on the mix of services provided in a practice.

The Physician Fee Schedule was released following the proposed 2017 Hospital Outpatient Rule, which was released on July 6 and indicates a 1.6 percent payment update for hospitals. Highlights from both 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 begin requiring ordering professionals to consult with AUC through a qualified clinical decision support mechanism (CDSM) no earlier than Jan 1, 2018.
    • The definition of a CDSM that can be used under the program, and the qualifications and requirements that the mechanisms must meet in order to be qualified for use under the program. The first qualified CDSMs are expected to be announced on June 30, 2017.
    • The initial list of eight priority clinical areas that will be used to identify outliers who will be subject to prior authorization under the program starting in 2020. Advanced imaging services for chest pain (including angina, suspected acute myocardial infarction and suspected pulmonary embolism) has been proposed as a priority clinical area.
    • Proposed exceptions to the requirement to consult AUC and report data to CMS, including services related to an emergency medical condition, services paid under Medicare Part A, and professionals seeking a hardship exception under the Electronic Health Record (EHR) Incentive Program.
  • Updates to the Medicare Shared Savings Program, including alignment of measures to those proposed in the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) proposed rule, and the proposal to allow eligible professionals to report Physician Quality Reporting System (PQRS) data separately when the Accountable Care Organization fails to report on behalf of the clinician.
  • Proposed policies for calculating 2017 and 2018 Value-Based Modifier cost and quality tiering when data issues or other unanticipated program issues arise, which may affect the data used for scoring.
  • Given the implementation of the MACRA Quality Payment Program in 2019, CMS does not propose major policy updates related to the PQRS, EHR Incentive Program and Value-Based Modifier, as these programs will be replaced by the Merit-Based Incentive Payment System and Advanced Alternative Payment Model programs.
  • Proposed expansion of the Medicare Diabetes Prevention Program through a national rollout in 2017 or a phased-in approach. This model would be the second Center for Medicare and Medicaid Innovation model and first preventive model to be eligible for national expansion under statutory requirements.
  • CMS proposes to review claims, survey practitioners and observe care to accurately value 10- and 90-day global services. Any practitioner who furnishes a 10- or 90-day global procedure would report new pre- and post-operative services codes for this data collection.
  • CMS proposes to separately pay for the work of moderate sedation, and to reduce services for which moderate sedation was previously considered inherent by the amount of the separate payment. This will affect billing for many interventional and electrophysiology services.
  • To recognize the additional resource costs of practitioners who spend an extraordinary amount of time outside the in-person office visit caring for patients, CMS proposes to pay for non-face-to-face prolonged services using existing Current Procedural Terminology codes 99358 and 99359.
  • CMS estimates a net reduction in expenditures resulting from adjustments to misvalued codes of 0.51 percent, meeting the 2017 statutory target of 0.50 percent.

Hospital Outpatient Rule

  • Implementation of Section 603 of the Bipartisan Budget Act of 2015, which requires that certain items and services provided by certain off-campus provider-based departments not be paid under the Hospital Outpatient Prospective Payment System (OPPS) starting Jan 1, 2017.
  • CMS proposes to implement the 90-day EHR Incentive Program reporting period for 2016 for all eligible professionals, eligible hospitals, and critical access hospitals. The reporting period would be any continuous 90-day period between Jan 1, 2016 and Dec 31, 2016. The ACC was instrumental in getting a bipartisan, bicameral bill introduced to raise the profile of this issue and signal the need for CMS to take action.
  • For 2017 and subsequent years, hospitals that fail to meet the requirements of the Hospital Outpatient Quality Reporting Program (OQR) will receive a 2 percent reduction to their annual fee schedule update factor. CMS also proposes to align the OQR with the Ambulatory Surgical Center Quality Reporting Program.
  • The proposed rule includes policies related to ambulatory payment classification payments, packaged OPPS payment, and updates to the Hospital Value-Based Purchasing Program and OQR Program.

ACC staff will continue to review the rules and will provide more details about member and hospital implications in the coming weeks. The College will also solicit feedback from member groups in preparation for submitting comment letters at the end of the summer.

Shortly before the final rules are released, experts will discuss the proposed rules, ACC’s comments, and other relevant regulatory items during a panel at the ACC’s 2016 Legislative Conference, which will take place September 11-13 in Washington, DC. Don’t miss this opportunity to learn about the hot button issues facing health care and ensure the voice of cardiology is heard on Capitol Hill.

Keywords: Accountable Care Organizations, Angina Pectoris, Centers for Medicare and Medicaid Services, U.S., Clinical Coding, Conscious Sedation, Current Procedural Terminology, Decision Support Systems, Clinical, Diabetes Mellitus, District of Columbia, Electronic Health Records, Electrophysiology, Fee Schedules, Health Expenditures, Medicaid, Medicare, Medicare Part A, Myocardial Infarction, Office Visits, Outpatients, Physicians, Prospective Studies, Pulmonary Embolism, Tomography, Emission-Computed, Single-Photon, Tomography Scanners, X-Ray Computed, Value-Based Purchasing, Medicare Access and CHIP Reauthorization Act of 2015

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