Author: Emil Engels, MD, MBA, CPC
The Centers for Medicare & Medicaid Services (CMS; see acronyms sidebar) released two final rules in early November that will affect payment for physician services. On Nov. 2, CMS released the Medicare Physician Fee Schedule Final Rule, which governs payment for physician services beginning Jan. 1, 2018. In addition, CMS published the final QPP rule that guides participation in MACRA, via the MIPS or advanced APMs. Usually, CMS publishes these final rules around Halloween, so it seems fitting to ask: Are they a “trick” or a “treat” for anesthesia providers?
Medicare Physician Fee Schedule Final Rule
Every year, CMS publishes a rule that “includes updates to payment policies, payment rates, and quality provisions for services furnished under the Medicare PFS.” In the proposed rule, CMS lists potentially “misvalued” CPT codes, as required by law. Misvalued CPT codes can be identified in a variety of ways, including looking at increases in utilization, changes in practice expenses or advances in technology.
The anesthesia endoscopy codes were identified as misvalued, which initiated a process of review and solicitation of feedback. Key stakeholders conduct surveys and submit comments, including the American Medical Association/Specialty Society RUC, the MedPAC and the ASA. After considering all comments, CMS decided to create a new set of CPT codes to report anesthesia for endoscopies.
Table 1. Changes for GI Endoscopy
Existing ASA Code Current Code Descriptor Current Base Unit Valuea 2018 ASA New Code 2018 New Code Descriptor 2018 CMS-Confirmed Base Unit Value 2018 ASA RVG Publication
00740 Anesthesia for upper GI endoscopy 5 00731 Anesthesia for upper GI endoscopy, other 5 Same as CMS MPFS
00732 Anesthesia for upper GI endoscopy-ERCP 6 Same as CMS MPFS
00810 Anesthesia for lower GI endoscopy 5 00811 Anesthesia for lower GI endoscopy, other 4 Same as CMS MPFS
00812 Anesthesia for screening lower GI endoscopy 3 4
00813 Anesthesia for combined upper/lower GI endoscopy 5 Same as CMS MPFS
a The term “unit” refers to the anesthesia conversion factor. To determine the valuation, multiply the number of units by the anesthesia conversion factor.
The changes and national utilization data are presented in Table 1. Notably, a new code was created for ERCP, which has a higher base unit value than before. This procedure now has 6 base units versus 5. In contrast, reimbursement for lower endoscopies (colonoscopies) has been reduced. Screening colonoscopies will receive only 3 base units (compared to 5 previously), and other colonoscopies will have 4 base units.
The ASA publishes the RVG, which assigns values to CPT codes and may govern commercial contracts. The ASA strongly disagreed with CMS’s valuation, and will have a different base value assignment for screening colonoscopies. From the ASA: “The not-so-good news and of interest to many of us is that CMS decreased the base units for screening colonoscopy to 3 base units (00812). ASA strongly disagrees with this decision. Our member survey data supports 4 units, and our RVG will reflect that. Differing values in the RVG and CMS are not common, but when we strongly disagree and we have survey data to support it, we will be transparent and make the appropriate notations in our RVG.”
In addition, the CPT codes for line placement were identified as potentially misvalued, and new work values were assigned. The changes are summarized in Table 2.
Table 2. Changes for Line Placement
CPT Code Descriptor Current Work RVU RUC Work RVU Final 2018 CMS Work RVU
36555 Insertion of non-tunneled centrally inserted central venous catheter; younger than 5 years of age 2.43 1.93 1.93
36556 Insertion of non-tunneled centrally inserted central venous catheter; age 5 years or older 2.5 1.75 1.75
36620 Arterial catheterization or cannulation for sampling, monitoring or transfusion (separate procedure); percutaneous 1.15 1 1
93503 Insertion and placement of flow directed catheter (eg, Swan-Ganz) for monitoring purposes 2.91 2 2
RVU, relative value unit To calculate valuation, multiply RVUs by the RBRVS conversion factor.
Once again, this change in valuation from CMS is accompanied by a change to the ASA’s RVG. The values for lines in the RVG will now be listed as “I.C.,” for internal consideration. This means that groups will need to negotiate a rate of reimbursement with commercial carriers.
Medicare Conversion Factors
In 2018, overall reimbursement to physicians will increase modestly. The changes are summarized in Table 3.
Table 3. Overall Reimbursement Changes For 2018
RBRVS conversion factor $35.8887 $35.9996
Anesthesia conversion factor $22.0454 $22.1887
Percutaneous Implantation Of Neurostimulator Arrays
More good news for chronic pain physicians is that CMS significantly increased the work valuation for percutaneous implantation of neurostimulator arrays. CPT codes 64453 (percutaneous implantation of neurostimulator electrode array; cranial nerve) and 64555 (percutaneous implantation of neurostimulator electrode array; peripheral nerve) were revalued upward approximately 250%.
Changes to Value-Based Payment Modifier in 2018
The 2018 payment year, based on 2016 performance, will be the final year of the VM. Providers will receive an upward or downward adjustment to their payments based on how well they performed in 2016. In the final rule, CMS made several allowances to align the program more with MACRA and ease the reporting burden for providers. First, providers need to report only six quality measures for 2016, in contrast to the original requirement of nine. In addition, CMS will be agnostic to the NQS domain of those measures and is waiving the requirement for a cross-cutting measure. Finally, CMS has eased the downward adjustments under the VM, much like the “Pick Your Pace” program for MACRA. Physicians who successfully submit data will avoid a downward adjustment from quality tiering. CMS is also reducing the penalties for groups that did not participate in the PQRS, from 4% to 2% (for groups of nine or less, the penalty goes from 2% to 1%).
MACRA and MIPS in 2018
In my article titled “MACRA 2018: A Look Ahead,” which was posted on Nov. 2, 2017 on AnesthesiologyNews.com, I discuss changes to the QPP in 2018. That guidance was based on the proposed rule, and since that time, the final rule, including additional significant changes, has been published. These changes to the MIPS program are summarized below.
The data completeness threshold has been increased from the proposed rule. The threshold had been set at 50%, but it is now 60% in the final rule. This means you must submit quality data on 60% of eligible patients for a particular measure (including commercial insurance holders) in 2018. The margin for error is getting smaller, so it will be important to have effective quality data capturing and reporting early in the year.
In addition, the final scoring threshold has been set at 15 points. A full discussion of scoring is beyond the scope of this article, but a provider must score at or above the threshold to avoid a penalty. In 2017, the threshold was 3 points, and a provider could avoid a penalty by submitting one measure, one time, for one patient. In 2018, clinicians need to submit multiple measures and should participate in the improvement activities category to avoid a penalty.
Originally, the cost category was proposed to have zero weight. However, in the final rule, cost has been assigned a weight of 10%. No action is required on your part—cost data are collected on an administrative basis from claims. However, you should be aware of how the cost score is calculated. To be held accountable for cost, your practice has to be attributed patients. Most anesthesia providers will not be attributed patients. If you are attributed patients, CMS will be looking at two cost measures continued from the value-based modifier: total costs per capita and Medicare spending per beneficiary. In the future, CMS will include costs related to episodes of care, like surgeries, and anesthesiologists will have greater exposure in the cost category.
2018 Score Weighting
As I described in the November 2017 article, most anesthesia providers will be excluded from the advancing care information category. If you have attributed patients, the cost category will count 10% toward your final score. In this situation, your final score will be weighted as follows: 75% quality, 10% cost and 15% improvement activities. If you don’t have attributed patients, cost will not count, and your final score will be weighted 85% quality and 15% improvement activities.
List of Acronyms
APMs Alternative payment models
ASA American Society of Anesthesiologists
CMS Centers for Medicare & Medicaid Services
ERCP Endoscopic retrograde cholangiopancreatography
MACRA Medicare Access and CHIP Reauthorization Act of 2015
MedPAC Medicare Payment Advisory Commission
MIPS Merit-Based Incentive Payment System
MPFS Medicare Physician Fee Schedule
NQS National Quality Strategy
PFS Physician Fee Schedule
QPP Quality Payment Program
RBRVS Resource-based relative value scale
RUC Relative Value Scale Update Committee
RVG Relative Value Guide
RVU Relative value unit
VM Value-Based Payment Modifier
Exemption for Extreme and Uncontrollable Circumstances
CMS acknowledges that many clinicians have been adversely affected by recent natural disasters, including hurricanes Harvey, Irma and Maria. Natural disasters and other uncontrollable circumstances impede a physician’s participation in the QPP. CMS provides examples of uncontrollable circumstances, including a hurricane, natural disaster or public health emergency. Clinicians can apply for an exemption, and those in affected areas will receive an automatic exemption. To quote CMS: “Clinicians in affected areas that do not submit data will not have a negative adjustment. We know that the circumstances have created a significant hardship that has affected the availability and applicability of measures.”1 However, if you live in an affected area and submit data, you will be scored: “Clinicians that do submit data will be scored on their submitted data. This allows them to be rewarded for their performance in MIPS. Because MIPS is a composite, clinicians have to submit data on two or more performance categories to get a positive payment adjustment.”1 For more information, visit the QPP website qpp.cms.gov.
Health care is changing rapidly, as evidenced by the two final rules released in November. To be successful, clinicians must keep pace and adjust to the ever changing reimbursement landscape. Anesthesia providers had payments for colonoscopies and line placement reduced, whereas reimbursement for implantation of neurostimulators and the conversion factor increased. The QPP moves ahead, with several key changes that continue the shift from paying for volume to value.
www.cms.gov/ Medicare/ Quality-Payment-Program/ Resource-Library/ QPP-Year-2-Final-Rule-Fact-Sheet.pdf. Accessed December 2, 2017.