2017 Proposed Rule Physician Fee Schedule in the Federal Register

Transcription

1 2017 Proposed Rule Physician Fee Schedule in the Federal Register Thursday, December 15, 2016 Noon 1:00 Pacific / 1:00 2:00 Mountain / 2:00 3:00 Central / 3:00-4:00 PM Eastern Lucy Zielinski, Vice President Alex Pinto, Manager GE Healthcare Camden Group

2 Webinar Objectives o Cite the major changes to the 2017 Physician Fee Schedule final rule o Understand the impact of the 2017 Physician Fee Schedule changes to physicians o Determine the roadmap for physicians 2

3 Physician Fee Schedule: Background and 2017 Final Rule 3

4 Medicare/Physician Fee Schedule History Affordable Care Act Physician Quality Reporting System became permanent Health Care Financing Administration adopted CPT for Medicare Part B Charge-based fee changed to Resource- Based Relative Value Expenses started exceeding yearly targets MIPS and alternative APM under Physician Fee Schedule proposal Promotion of meaningful use of certified EHR technology Medicare Program is established Introduced the Medicare Economic Index ( MEI ) Value Performance Standard replaced by Sustainable Growth Rate formula Physician Quality Reporting System is established as an adjustment for payments 4

5 Key Forces Driving Change Volume-to-Value Payment Models Innovation and Technology ACA and Health Reform Consumerism Collaboration Competition Interoperability and Analytics Total cost of care 5

6 2017 Final Rule - CMS Resources Additional Resources Read the rule Agency/Docket Number: CMS-1654-F 6

7 Relative Value Unit Payments under the PFS are based on the national uniform RVUs that account for the relative resources used in furnishing a service. Practice Expense ( PE ) Malpractice Expense ( MP ) Adjusted for Geographic cost variations Physician Work RELATIVE VALUE UNIT ( RVU ) 7

8 Calculating Payments Formula for Calculating Payments Payment = [(RVU work x GPCI work) + (RVU PE x GPCI PE) + (RVU MP x GPCI MP)] x CF* RVU GPCI PE MP CF Relative Value Unit Geographic Practice Cost Indices Practice Expense Malpractice Expense Conversion Factor (updated annually for PFS) *Different formula used for anesthesia 8

9 Payment Modifiers Impact on payments 2017 CMS Final Rule, Physician Fee Schedule: No Change Between Proposed and Final Rule 9

10 2017 Major Provisions 1. Conversion factor and RVU changes 2. Primary Care and Telehealth services 3. Potentially mis-valued codes and other reductions 4. Diabetes Prevention Program ( DPP ) expansion 5. Other provisions 6. MACRA provisions 10

11 Key Changes for 2017: Conversion Factor and RVU Changes 11

12 Conversion Factor Difference PFS Anesthesia $ $ $ $ $ $ The proposed rule called for minor cent decreases in the conversion factor 12

13 For Example 99213: Office or other outpatient visit for the evaluation and management of an established patient (Proposed) Work RVU (Final) PE RVU MP RVU Total RVUs Conversion Factor Payment* $73.40 $73.34 $73.57 Proposed: *Excludes GPCI adjustment Final: $.06 decrease $.17 increase 13

14 PFS 2017 Impact by Specialty -5% Independent Laboratory -2% Ophthalmology, Urology -1% Diagnostic Testing, Gastroenterology, Interventional Radiology, Neurosurgery, Optometry, Oral/Maxillo Surgery, Otolaryngology, Pathology, Radiology, Vascular Surgery +1% Allergy/Immunology, Family Practice, General Practice, Geriatrics, Internal Medicine, Multispecialty Clinics/Other, Physical/Occupational Therapy, Changes reflect the combined RVU impact of work, PE, and MP changes; Specialties not listed should have a combined impact of 0 14

15 PE RVUs Rule Changes PE Inputs for Digital Imaging Revised Calculations for Professional PACS Workstation Time Standardization of Clinical Labor Time Imaging: Standard clinical labor time has been finalized for 4 of the 5 tasks Additionally, removed the film-based supply and equipment items, but maintained clinical labor minutes assigned related to film technology Pathology: Standard clinical labor time have been finalized for 6 of the 17 tasks Equipment recommendations for scope equipment Structure separates the scope and the associated video system 15

16 Digital Imaging Practice Expense Revised calculations for Professional PACS time Diagnostic Procedures: ½ Pre-Service Time + 1/1 Intra-Service Time Therapeutic Procedures: ½ Pre-Service Time + ½ Post-Service Time 16

17 Digital Technology Final Digital Imaging Clinical Labor Task Minutes CL Task Digital Technology Typical Minutes Availability of prior images confirmed 2 Patient clinical information and questionnaire reviewed by technologist, order from physician confirmed, and exam protocoled by radiologist. Review examination with interpreting MD 2 2 Exam documents scanned into PACS. Exam completed in RIS system to generate billing process and to populate images into Radiologist work queue. 1 17

18 Pathology Services Final Pathology CL Task Minutes CL Task Standard CL Time (minutes) Accession specimen/prepare for examination 4 Assemble and deliver slides with paperwork to pathologists 0.5 Assemble other light microscopy slides, open nerve biopsy slides, and clinical history, and present to pathologist to prepare clinical pathologic interpretation Clean room/equipment following procedure (including any equipment maintenance that must be done after the procedure) Dispose of remaining specimens, spent chemicals/other consumables, and hazardous waste Prepare, pack, and transport specimens and records for inhouse storage and external storage (where applicable)

19 Scope Video System Video System Endoscopy Equipment Item (ES031) Finalized as standalone prices for each scope type, and separate prices for the video systems that are used with scopes Scope accessories can be priced separately and are individually evaluated for inclusion in PE methods Changes only for certain codes that make use of specified scopes Scope Video System Monitor Processor Digital Capture Cart Printer Types of Scopes Non- Video Flexible Semi- Rigid Rigid Scopes are further defined by their diagnostic/ therapeutic use 19

20 Reviewed Codes Listed are the Reviewed Codes that Use Scopes Flexible Laryngoscopy family CPT codes 31572, 31573, 31574, 31575, 31576, 31577, 31578, and Laryngoplasty family CPT codes 31580,31584, 31587, , 31591, and

21 Key Changes for 2017: Primary Care and Telehealth Services 21

22 Primary Care Services Separate payment for: non- faceto-face prolonged E/M services; patients with behavioral conditions, mobility-related impairments, and complex CCM Revisions to the scope of service elements for CCM to reduce administrative burden New codes for comprehensive assessment and care planning for patients with cognitive impairment 22

23 Primary Care Services Integrating Behavioral Health CPT Description* wrvu G0502 Initial psychiatric care management 1.70 G0503 Subsequent psychiatric care management 1.53 G0504 Initial/Subsequent psychiatric care management, additional 30 minutes 0.82 G0507 Behavioral healthcare, at least 20 minutes/month 0.61 G0505 Assessment for cognitive impairment 3.44 G0506 Assessment for Chronic Care Management care plan 0.87 G0501 Resource-intensive service for patients with specialized mobility-assistive technology (add-on to E/M) TBD** * Descriptions may be abbreviated; ** Pending further CMS analysis 23

24 Primary Care Services Prolonged and Complex CCM Services CPT Description wrvu Prolonged services Prolonged E/M service before and/or after direct patient care Prolonged E/M service before and/or after direct patient care, each additional 30 minutes Complex CCM services Complex CCM services without patient visit Complex CCM services, additional 30 minutes CCM, 20 minutes/month 0.61 Transition care management Transition care management 14-day discharge Transition care management 7-day discharge 3.05 Italicized codes are 2016 payable services ; no changes to wrvus in

25 Chronic Care Management CCM Scope of service element/ billing requirement Initiating visit Structured recording of patient information using CEHRT Proposed revision Change to patient not seen within 1 year Remove creation of a structured clinical summary via qualified EHR, due to redundancy 24/7 Access to care Change to means to make contact Continuity of care Comprehensive care management Electronic comprehensive care plan Electronic sharing of care plan Beneficiary receipt of care plan Documentation of care plan Management of care transitions Home- and community-based care coordination Change to schedule routine appointments Same Same Required to be timely, but defers methodology Remove written or electronic Remove Change to create and exchange continuity of care documents Same Enhanced communication opportunities Beneficiary consent Same Adjust written consent to be optional Source: Proposed PFS Rule, Table 11 25

26 Telehealth Services Criteria for Payments for Telehealth The service must be on the list of Medicare telehealth services and meet the following requirements: Service must be furnished via an interactive telecommunications system Service must be furnished by a physician or other authorized practitioner Service must be furnished to an eligible telehealth individual Individual receiving the service must be located in a telehealth originating site 26

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28 Proposed Telehealth Additions ESRD, dialysis less than 1 full month per day Younger than 2 years old to 11 years old to 19 years of age For 20 years and older Advance care planning First 30 minutes Each additional 30 minutes Consults for Critical Care Services G0508 Initial telehealth consultation G0509 Subsequent telehealth consultation 28

29 Key Changes for 2017: Mis-Valued Codes and Reductions 29

30 Mis-Valued Services 0-day global procedures with 25 modifier (Table 7 and 8) ESRD ( ) Endoscopes Drug delivery implants (11981 and 11983) Moderate sedation Global surgery package (Table 9 and 10) Therapy Codes (Table 24) 30

31 Multiple Procedure Payment System The professional component ( PC ) of advanced imaging services for Multiple Procedure Payment System ( MPPR ) will be reduced from 25 percent to 5 percent. Diagnostic cardiovascular services Diagnostic imaging services Diagnostic ophthalmology services Therapy services 31

32 Reduction for X-Rays Proposed payment reduction for x-rays taken using plain film Append Modifier FX when x-rays taken using film 20% technical component reduction 32

33 Key Changes for 2017: Diabetes Prevention Program 33

34 Diabetes Self-Management and the DPP Low utilization of diabetes self-management training ( DSMT ) G0108-G0109 Proposes expansion of the Diabetes Prevention Program ( DPP ) into Medicare beginning January 1, 2018 Helps at-risk seniors and people with disabilities from advancing to type 2 diabetes Medicare Diabetes Prevention Program ( MDPP ) 12 months of sessions using a CDC approved DPP curriculum 26 sessions over 6 months followed by 6 sessions over months 7 through 12 34

35 Key Changes for 2017: Other Provisions 35

36 Other Provisions * CCM/TCM in RHCs and FQHCs Appropriate use criteria ( AUC ) for advanced diagnostic imaging services Release of Part C Medicare Advantage Bid Pricing Data and Medical Loss Ratio Data Recoupment of payments to providers sharing the same TIN ACO participants who report PQRS/MIPS measures separately MSSP quality measure sets Physician self-referral updates * List is not comprehensive 36

37 MACRA 37

38 MACRA: QPP MACRA QPP MIPS Alternative Payment Model ( APM ) APMs Fee-For-Service ( FFS ) system Innovative payment model Since most physician practices will likely focus on MIPS initially, lets take a closer look at components of the MIPS track. 38

39 MIPS categories IMPROVEMENT ACTIVITIES QUALITY ADVANCING CARE INFORMATION ( ACI ) COST MIPS GE Healthcare Camden Group October 20,

40 MIPS scoring in % Cost 15% 25% 60% Improvement activities Advancing care information Quality Composite Score = 0 to 100 GE Healthcare Camden Group October 20,

41 Proposed Timeframe 41

42 MIPS: Sample financial impact Reporting years 2017 to 2020 Reporting Year Payment Year MIPS Adjustment /+ 4% Financial Impact 1 ($) (+-) 1 Clinician ,000 80, ,000 $500 million Score > 70 10% adjustment /+ 5% /+ 7% /+ 9% 10, , ,000 14, , ,000 18, , ,000 1 $200K per provider in Medicare allowables 42

43 What does it take to be a high performer? Monitor performance of measures compared to historical values and past CMS benchmarks in an effort to: Exceed performance threshold on quality measures Exceed performance on ACI measures Align improvement activities to support performance 43

44 PFS Roadmap 1. Review rule and comment August 2016 Review rule Comment by Sept 6, Develop work plan October 2016 Create Steering Committee Develop 2017 work plan Perform gap and impact analysis September 2016 Determine financial impact Review new covered services Perform gap analysis Review QRUR report 5. Implement work plan January 2017 Begin using new codes Activate new codes and edits Report 2016 quality data, MU attestations, etc Review final rule and update work plan November December 2016 Revise work plan based on final rule Update code sets and pricing in systems Establish edits to support changes 6. Track and Monitor January December 2017 Monitor and track compliance 44

45 Questions 45

46 Thank You! 46

47 To Complete the Program Evaluation The URL below will take you to HFMA on-line evaluation form. You will need to enter your member I.D. # (can be found in your confirmation when you registered) Enter this Meeting Code: 16AT70 URL: Your comments are very important and enables us to bring you the highest quality programs! 47