On November 2, 2016, the Centers for Medicare & Medicaid Services (CMS) released the Final Rule for the 2017 Medicare Physician Fee Schedule (MPFS). This important announcement outlined the paltry – and disappointing – 0.24% increase to Medicare payments in 2017. This small boost is based on the 2017 MPFS conversion factor (CF) of $35.89, an increase to the 2016 CF of $35.80. For physician specialties, Ophthalmology and Urology are slated for the biggest hits with an estimated 2% reduction, with no single specialty receiving a boost exceeding 1%.
Behavioral health, however, was clearly the winner as the beneficiary of CMS’ new payment policies. Multiple new codes – and corresponding payment – were introduced for behavioral health, a service commonly provided by primary care practices. These included CPT® codes G0502, G0503, and G0504 for psychiatric collaborative care and G0507 for general behavioral health integration. The latter is a new code to pay for the comprehensive assessment and care planning for patients with cognitive impairment. Largely mirroring the current chronic care management (CCM) code, 99490, the description for G0507 is: “Care management services for behavioral health conditions, at least 20 minutes of clinical staff time… per calendar month.” Another G-code in this series – comprehensive assessment and care planning for patients with cognitive impairment (code G0505) – was also approved for payment.
Citing a lower-than-expected utilization for CCM services to date, CMS revealed a medley of changes to lower the administrative burden associated with the CCM code, to include eliminating the requirement for a written consent. Furthermore, two new codes for complex CCM services – 99487 and 99489– will be covered in 2017, as well as a new add-on code – G0506 – to serve as payment for the CCM initiating visit.
CMS also provided a positive reimbursement determination for prolonged evaluation and management services – codes 99354, 99358, and 99359. Regrettably, the agency chose to pass on GDDD1, an add-on code proposed to pay physicians for the use of devices to assist patients with mobility issues.
Two specific services – mammography and endoscopy – received notable changes. Propelled by changes to the CPT® codes for mammography that would have equated to drastic payment reductions, CMS issued new descriptors, policies and rates for the existing G-codes used for mammography. As part of a significant revision to services that include moderate sedation, CMS incorporated a new endoscopy-specific moderate sedation code – G0500 – required for 2017. It is described as “moderate sedation services provided by the same physician … performing a gastrointestinal endoscopic service that sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of the patient’s level of consciousness and physiological status; initial 15 minutes of intra-service time…” Given the extraction of moderate sedation from a coding perspective, CMS consequently reduced the work relative value units of hundreds of endoscopy procedures.
Another hit will be felt by practices with film-based imaging. Effective January 1, 2017, the modifier -FX must be used on claims for x-rays that are taken using film. The modifier will trigger a 20% reduction in payment for the x-ray service, a mandate per federal law.
CMS expanded the coverage of telehealth services, with a positive payment determination for end-stage renal disease, advanced care planning and telehealth-specific critical care consultations. Perhaps most importantly, CMS revealed a new place of service code – 02 – specifically designed to report services furnished via telehealth.
Targeting the prevention of Type 2 diabetes, CMS announced the initiation of the Medicare Diabetes Prevention Program (MDPP), which has been a pilot program. Reimbursement won’t commence until 2018, however, with CMS explaining that payment policies will be released in the coming year. CMS had previously proposed to improve payment opportunities for Diabetes Self-Management Training (DSMT), but refused to make alterations in 2017.
On the heels of being halted in the midst of a major overhaul to the global surgery coding system by Congress, CMS announced its intention to re-examine this issue. As of July 1, 2017, surgeons performing select, high-volume, high-cost surgeries – approximately 275 CPT® codes – will be required to report the work associated with patients’ post-operative care via the current code, 99024. CMS is limiting its requirement to surgeons in groups of 10 or more, located in selected states, although other surgeons can voluntarily report.
CMS confirmed that physicians and other eligible professionals (EPs) who are members of accountable care organizations (ACOs) can separately report their PQRS measures for the 2016 performance year. Further, for EPs who were negatively impact by their ACO failing to report on behalf of them, CMS established a secondary PQRS reporting period for calendar year 2015.
Just 24 hours prior to the release of this Final Rule, CMS confirmed the 90-day reporting period (any consecutive 90 days) for the EHR Incentive Program in 2016. Announced in CMS’ ruling on the outpatient prospective payment system, this news was expected, but certainly welcomed by physicians.