CMS unveils 2017 physician fee schedule proposed rule
By Grant Huang, CPC, CPMA | July 17, 2016
Primary care physicians will be the biggest beneficiaries of the 2017 Medicare Physician Fee Schedule (PFS), according to an analysis of the PFS proposed rule by The Business of Medicine. Specialty practices can still look forward to better reimbursement for prolonged services, chronic care management, and also imaging services thanks to a proposal to boost RVUs to account for digital image processing.
Overall payments will remain stable – the proposed rule sets the 2017 conversion factor at $35.7751, which is down from the current 2016 conversion factor of $35.8043. This change, which essentially keeps Part B payments flat, is mandated by the budget neutrality requirements in the Medicare Access and CHIP Reauthorization Act (MACRA), the law that repealed the longstanding Medicare payment formula known as the Sustainable Growth Rate (SGR).
MACRA requires CMS to establish positive or flat payment updates from 2016 through 2019, at which point the Merit-Based Incentive Program (MIPS) will begin to adjust payments based on provider performance.
Now let’s take a look at the highlights of the 856-page proposed rule, which CMS released on July 7.
Flat payment update. As mentioned above, the 2017 conversion factor is projected to be $35.7751, which is essentially flat and continues the series of minor payment updates CMS is required to establish as part of MACRA.
Global surgical data-gathering. CMS was committed to turning all codes that currently have 10-day and 90-day global periods into 0-day global codes, a change finalized in the 2015 PFS. However, the MACRA law required CMS to first gather data on post-surgical visits so the agency could accurately value these codes. Thus for the 2017 PFS, CMS is proposing to collect data via claims along with a representative survey of 5,000 randomly sampled providers. All providers that currently perform services with 10-day and 90-day global periods will be required to report additional information on those claims about all services rendered during the global periods. This will be mandatory and while CMS won’t withhold payments from providers who fail to participate, the agency warns it is authorized to withhold up to 5% of Medicare payments and could implement this in a future rule if participation rates aren’t high enough.
Primary care payment increase. CMS aims to increase payment for primary care services in several different ways with the proposed rule. Overall, CMS wants to increase how much primary care physicians are paid for their bread-and-butter E/M services, and the agency is asking for feedback on RVU increases in the proposed rule.
Chronic care management boost. One leg of CMS’ push to increase primary care pay is a proposal to pay more for the existing chronic care management (CCM) codes, as well as add two new CCM codes for complex cases where patients require extra management. Specialists are eligible to report CCM codes and would benefit from this proposal if they specifically treat chronic conditions relevant to their clinical focus, though the codes are only reportable once per month per beneficiary.
Prolonged services. Related to the above bullet, CMS proposes increasing payment for existing prolonged service E/M codes (CPT 99354-99357) and also adding new prolonged service codes for non-face-to-face evaluation and management.
Mobility-related disability code. CMS wants to create a new HCPCS code, GDDD1, that can be billed for E/M encounters where the patient has a mobility-related disability that increases the amount of time the physician must spend with the patient (e.g. moving the patient over stairs or other obstacles). This code would have roughly the same RVUs and payment as a level established patient visit (99212). Though again aimed at primary care providers, specialists such as orthopedists and wound care physicians could benefit from this code since they are also likely to see patients with mobility issues.
Expansion of diabetes prevention services. In a potentially significant change for many patients and providers, CMS wants to expand its Diabetes Prevention Program (DPP) to all states. The program, which is only currently operational in eight states, provides counseling, education, and support services to pre-diabetic patients and those at increased risk of becoming diabetic. Providers who participate receive additional payments for these services.
Increased RVUs for imaging. CMS wants to rework practice expense relative value units (RVUs) for imaging services (CPT codes in the 70000 range) to account for the cost of a picture archiving computer workstation, as well as the time associated with reviewing and scanning images. A total of 426 codes would have their practice expense RVUs modified under the proposed rule, though the actual RVU and payment changes are not specified and CMS is asking for feedback on the “standard time” it takes to scan and review images on workstations.
New Medicare Advantage enrollment rules. CMS wants to require all providers who participate with Medicare Advantage plans to be subject to its enrollment and revalidation process. This would affect only those providers who are currently non-par with Medicare but do participate with private-payer Medicare Advantage (Part C) plans.
Final rule expected this fall
You have until Sept. 6 to submit any comments to Regulations.gov during the public comment period for the proposed 2017 PFS. Typically CMS releases the PFS final rule at the end of October or during the first week of November.