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March 27, 2018

Spring OPPS Update Released

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PFS Final Rule Highlights

November 30, 2017:

The final rule on the 2018 physician fee schedule was published in the Federal Register November 15, 2017. Besides updating the conversion factor, the rule addresses telehealth services, nonfacility PE payment, biosimilar drugs, chronic care management, and appropriate use and diabetes prevention programs. The Centers for Medicare and Medicaid Services (CMS) also includes revisions to policies related to the value modifier.

The total effect of the PFS update is an overall +0.41 percent increase in payments. The 2018 conversion factor will be increased by 10 cents to $35.99.

The agency okayed separate payment for CPT code 99091 for remote patient monitoring and finalized several codes for telehealth services : HCPCS Level II codes G0506 (Comprehensive assessment of and care planning for patient requiring chronic care management services) and G0296 (Counseling visit to discuss need for lung cancer screening using low dose CT scan [LDCT] [service is for eligibility determination and shared decision making]), and CPT codes 90785 (an add-on code indicating interactive complexity), 96160 and 96161 (patient- and caregiver-focused health risk assessments), and 90839 and 90840 (crisis psychotherapy). CMS also will no longer require practitioners to report modifier GT (Via interactive audio and video telecommunications systems) on professional claims for telehealth services).

CMS is raising payment for certain face-to-face patient services provided in offices by better recognizing overhead expenses. This affects the minimum nonfacility indirect practice expense (PE) relative value units (RVU) of fewer than 50 codes, most of which describe behavioral health services. The agency explains in the rule that Medicare currently pays less than a dollar more for PE in the nonfacility setting than in the facility setting. So, for example, a 45-minute psychotherapy service is reimbursed less than one dollar more in the office setting than in the facility setting, which does not cover the additional staffing, rent, utilities, etc., involved in the office service.

In an effort to lower drug prices, CMS revisited its grouping of biosimilar products that rely on the same reference product’s biologics license application into the same payment calculation to determine the average sale price payment limit . After analyzing comments, it concluded that the best way to drive drug prices down through increased competition is by having each biosimilar biological product coded and paid for separately under Part B. The agency believes this approach will stabilize the marketplace and will spur the development of more biosimilar products. Beginning January 1, each newly approved biosimilar biological product with a common reference product will have its own code. The agency will issue guidance on how to code biosimilar products currently grouped under a common payment code but does not expect to be able to fully implement this change until midway through 2018.

The final rule also established that rural health clinics (RHC) and federally qualified health centers (FQHC) will be paid for chronic care management, behavioral health integration, and psychiatric collaborative care model (CoCM) services when reported using two new billing codes: G0511 (General care management) and G0512 (Psychiatric CoCM). Payment is on top of the payment for the visit. The agency also is replacing the three psychiatric CoCM codes G0502-G0504 with CPT codes 99492-99494 effective January 1, 2018.

CMS is also finalizing a start date of 2020 for the Medicare Appropriate Use Criteria (AUC) Program for advanced diagnostic imaging so as to ensure a smooth transition for practitioners. It is allowing those affected more time to adjust to the Quality Payment Program before they must participate in the AUC Program. CMS is treating 2020 as an educational and operations testing year for the AUC Program. Physicians will have to use AUCs on their claims, but the claims for advanced diagnostic services will be paid whether or not they contain the proper information about the AUC consultation.

The November rule implements the expanded model of the Medicare Diabetes Prevention Program (MDPP) but pushes the start date of the model to April 1, 2018, instead of January 1, 2018. The agency argues that the extra 90 days will enable more entities to enroll to be Medicare suppliers of MDPP services. CMS outlines the payment structure, enrollment requirements, and compliance standards in the rule.

Finally, the rule revises some policies pertaining to the 2018 value modifier, which enables Medicare to pay physicians based on the measured quality of care provided to patients as compared with the cost of care. CMS is reducing the automatic payment reduction of -4 percent for those not meeting quality criteria to -2 percent for groups of at least 10 clinicians, and -1 percent for solo practitioners and those in groups of fewer than 10 clinicians. The agency is holding harmless clinicians who qualified to avoid quality performance downward payment adjustments under quality tiering for the last year of the physician quality reporting system (PQRS), while aligning the maximum upward adjustment to two times the adjustment factor. CMS will not report 2018 value modifier data since 2018 would be the only year data would be reported, given that PQRS has been replaced by the Quality Payment Program.

The final physician fee schedule rule can be accessed online at https://s3.amazonaws.com/public-inspection.federalregister.gov/2017-23953.pdf.


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