Summary of How the 2017 Payment Rules Will Impact Cardiology

On Nov. 2, the Centers for Medicare & Medicaid Services (CMS) released final regulations for the 2017 Physician Fee Schedule (PFS). The PFS rule followed release of the 2017 Hospital Outpatient Prospective Payment System (OPPS) rule release on Nov. 1. These rules set Medicare payment and quality provisions for physicians and hospitals in 2017. Under the PFS rule, physicians will see a slightly positive, 0.24 percent, conversion factor increase starting Jan. 1, 2017. CMS estimates the net impact of payment policy changes to cardiologists in the fee-for-service system to produce roughly level payments from 2016 to 2017. This estimate is based on the entirety of payments to cardiologists and can vary widely depending on the mix of services provided in any given practice. Under the OPPS rule, hospitals will see a 1.7 percent payment increase next year.

Physician Fee Schedule

In this rule, CMS finalized significant proposals to pay for services it believes will enhance care coordination and improve patient care. New codes and/or payment amounts will be incorporated for service such as prolonged evaluation and management (E/M), chronic care management, assessment and care planning for patients with cognitive impairment, management and treatment of patients with behavioral health conditions, and upscaling of the Medicare Diabetes Prevention Program model. While these new tools will be adopted to some degree by all clinicians, they are generally aimed at primary care and cognitive care professionals. Because policies that change payments significantly within the PFS have to remain budget neutral, the resources to support these newly recognized services come from every other service. That is the reason the conversion factor update is lower than the baseline 0.50 percent increase.

  • Several aspects of the new appropriate use criteria (AUC) requirement for advanced imaging services (i.e., SPECT MPI, CT, and MR) were included in this rule:
    • Ordering professionals will be required to consult with AUC through a qualified clinical decision support mechanism (CDSM) no sooner than Jan. 1, 2018.
    • The qualifications and requirements that CDSMs must meet in order to qualify for use in the program were outlined. The first qualified CDSMs will be announced on June 30, 2017.
    • The initial eight priority clinical areas used to identify outliers who will be subject to prior authorization under the program starting in 2020 were finalized. In response to comments from the ACC, chest pain was removed from the list. CMS replaced it with coronary artery disease.
    • 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 will be excepted from the requirement.
  • In response to comments from the ACC and other groups, CMS significantly scaled back its proposal to collect data in 10-minute increments from every clinician who cares for patients during 10- and 90-day global procedures. Data collection will use a single, existing CPT code (99024), be limited to a sample of clinicians, and be targeted for high-volume/high-cost procedures. Any clinician can report voluntarily beginning Jan. 1, 2017. Reporting for selected practices will be effective July 1, 2017.
  • Moderate sedation will be separately billed and paid starting in 2017 using new CPT codes. Services for which moderate sedation was previously considered inherent will be accordingly reduced. This includes many interventional, electrophysiology and some echocardiography services. While this creates greater accuracy and prevents double-payment in instances where a moderate sedation service is provided by a second provider, it creates new billing and workflow requirements.
  • Nineteen zero-day global services typically billed with an E/M service have been finalized for review as potentially misvalued. This list was initially much longer, but the ACC and others pointed out flaws that removed services such as percutaneous coronary intervention from the initially proposed list.
  • New CPT codes describing the work of left atrial appendage closure (33340) and paravalvular leak closure (93590, 93591 and 93592) are available for billing in 2017. The work RVUs for these services was increased by CMS from the July proposal in response to comments from the ACC and others.
  • The Medicare Diabetes Prevention Program will be expanded in 2017. This model will be the second Center for Medicare and Medicaid Innovation model expanded under statutory requirements.
  • The Medicare Shared Savings Plan was revised to allow eligible professionals in accountable care organizations (ACOs) to report quality separately from the ACO.

To see the impact of changes on a list of common cardiovascular services, review this table. Check out CMS’ 2017 PFS Fact Sheet.

Hospital Outpatient Prospective Payment System

  • As required by statute, CMS finalized site-neutral regulations indicating certain items and services provided by certain off-campus provider-based departments cannot be paid under the OPPS. Instead, these services will be paid the same rates as the PFS beginning January 2017. Exceptions allow for services provided by a dedicated emergency department, by a grandfathered off-campus provider-based department billing for covered services prior to Nov. 2, 2015, or by a provider-based department that is located on the hospital campus (within 250 yards).
  • Returning eligible professionals and hospitals may satisfy the EHR Incentive Program meaningful use requirement by reporting any continuous 90-day period within calendar year (CY) 2016. A 90-day EHR reporting period will also be used for CY 2017.
  • Hospitals that fail to meet the administrative, data collection, submission, validation and reporting requirements of the Outpatient Quality Reporting Program (OQR) will be subject to a 2 percent reduction to their annual update factor. The OQR Program will also be aligned with the Ambulatory Surgical Center Quality Reporting Program.
  • Advocacy by the ACC and ASE on the Ambulatory Payment Classification assignments of several cardiovascular imaging services led to placement of these services in more appropriate payment groupings with clinically similar services that have similar costs. CMS has proposed several different assignments to a number of cardiovascular imaging services in recent years. The College will continue to monitor these assignments and look for opportunities to develop more comprehensive solutions in the future.

Review CMS’ 2017 OPPS Fact Sheet.

Clinical Topics: Arrhythmias and Clinical EP, Invasive Cardiovascular Angiography and Intervention, Noninvasive Imaging, Atherosclerotic Disease (CAD/PAD), Implantable Devices, SCD/Ventricular Arrhythmias, Atrial Fibrillation/Supraventricular Arrhythmias, Interventions and Coronary Artery Disease, Interventions and Imaging, Computed Tomography, Echocardiography/Ultrasound, Nuclear Imaging

Keywords: Accountable Care Organizations, Atrial Appendage, Centers for Medicare and Medicaid Services (U.S.), Chest Pain, Coronary Artery Disease, Current Procedural Terminology, Decision Support Systems, Clinical, Diabetes Mellitus, Echocardiography, Electronic Health Records, Electrophysiology, Emergency Service, Hospital, Fee Schedules, Fee-for-Service Plans, Meaningful Use, Medicaid, Medicare, Medicare Part A, Outpatients, Patient Care, Percutaneous Coronary Intervention, Primary Health Care, Prospective Payment System, Tomography, Emission-Computed, Single-Photon, Tomography, X-Ray Computed

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