CMS has released a proposed rule that would update the Medicare Physician Fee Schedule for calendar year 2015. Here are eleven things to know about the PFS and the proposed rule.
1. Medicare uses the PFS to reimburse providers for covered physicians’ services provided to Medicare Part B beneficiaries. The PFS assigns relative values to more than 7,000 services meant to account for the amount of work, malpractice expenses, and direct and indirect practice expenses associated with providing the service. The relative value components are also multiplied by a geographic adjustment factor to account for cost variations across localities.
2. The proposed rule doesn’t contain proposals or announcements concerning the PFS update or the sustainable growth rate, a statutory formula meant to control growth in Medicare spending on physicians’ services. Since the PFS rate and SGR-related cuts are determined under a statutory formula, CMS cannot change them. The final figures will be announced in the final rule issued in November. Every year since 2003, Congress has enacted a short-term legislative patch to delay double-digit cuts determined by the SGR. In April, the latest patch was passed, protecting physicians until the end of March 2015. Before that patch took effect, CMS estimated the PFS update for calendar year 2015 would be -20.9 percent.
3. In order to emphasize primary care, CMS has proposed making separate payments for chronic care management services, starting in 2015. The proposed rule includes a payment rate of $41.92 for the CCM services code, which could be billed no more than once per month for each qualified patient. Additionally, CMS has not proposed establishing separate standards providers furnishing these services would have to meet.
4. As part of an ongoing effort to identify and review misvalued codes, CMS has proposed adding 80 codes to the list of those that could potentially be misvalued. The agency identified most of these codes by reviewing high-expenditure services by specialty, although others were selected through methods such as public nomination. Additionally, the proposed rule would refine how CMS accounts for infrastructure costs related to radiation therapy equipment. This would result in a reduction in radiation therapy service payments, which the agency would redistribute to other services.
5. Also under the misvalued code initiative, CMS has proposed converting all 10- and 90-day global codes to 0-day global codes beginning in calendar year 2017. “The Office of the Inspector General has identified a number of surgical procedures that include more visits in the global period than are being furnished,” CMS states in a news release. “In order to address the potential for misvaluation of surgical services, we are proposing to value include in the for these procedures all services provided on the day of surgery, and to pay separately for visits and services actually furnished after the day of the procedure beginning in CY 2017.”
6. CMS has proposed adding annual wellness visits, psychoanalysis, psychotherapy, and prolonged evaluation and management services to the list of services that can be provided to Medicare beneficiaries under the program’s telehealth benefit.
7. CMS is required to review and, if needed, adjust malpractice RVUs every five years. For 2015, the agency conducted its third comprehensive review and update of the RVUs and has proposed new malpractice RVUs for all services, based on updated professional liability insurance premiums.
8. As required by law, the proposed rule would also adult geographic price indices for the PFS. For instance, in 2015, CMS has suggested using territory-level wage data to determine the work GPCI and employee wage component of the Practice Expense GPCI for the Virgin Islands.
9. Under the proposed rule, CMS would begin collecting data on services furnished in off-campus provider-based departments by requiring physicians to report a modifier for services administered in these settings.
10. Furthermore, the proposed PFS rule would waive the deductible and coinsurance associated with anesthesia related to screening colonoscopies, since anesthesia provided separately by an anesthesia professional is “becoming the prevalent practice in connection with screening colonoscopies, replacing the previous standard of moderate sedation provided intravenously by the endoscopist, which was bundled into the payment for the screening colonoscopy codes,” according to CMS.
11. The proposed rule also includes several measures meant to increase transparency. For instance, it includes a provision that would ensure all revisions to payment inputs underpinning final PFS payment rates would be subject to public comment before being used for payment. Additionally, CMS has proposed eliminating the continuing medical education exclusion under the Sunshine Act, which would require pharmaceutical and medical device companies to report payments to physicians for CME.