In October, the Centers for Medicare and Medicaid Services (CMS) released two final regulations that will impact cardiovascular professionals next year. These rules determine the payment levels and associated policies for services provided under the Physician Fee Schedule and the Hospital Outpatient Prospective Payment System. Consistent with the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), physicians will see a 0.5 percent formula increase on Jan. 1, 2016. Unrelated payment formula changes result in an estimate that payment for cardiology services will neither increase nor decrease from 2015 to 2016. However, this estimate is based on the entire universe of cardiology services and can vary widely depending on the mix of services provided in a practice. Some of the most important provisions for cardiology include: Physician Fee Schedule CMS maintains most existing policies applicable to the Physician Quality Reporting System (PQRS) for the 2016 performance year. Under most individual reporting options, eligible professionals will continue to report at least nine measures across at least three domains. Failure to successfully report PQRS quality measures in 2016 will continue to result in a -2 percent payment adjustment in 2018. CMS finalized the process for selecting AUC developed by national professional medical specialty societies and other provider-led entities for the AUC consultation requirement that will apply to professionals ordering advanced imaging services. CMS collected initial comments related to the implementation of the Merit-Based Incentive Payment System and Alternative Payment Model payment pathways and will continue consider these comments along with those received through a MACRA Request for Information. CMS will delay the requirement that clinicians ordering advanced imaging services (i.e., CT, MR, SPECT) consult with appropriate use criteria (AUC) through a qualified clinical decision support mechanism starting on Jan. 1, 2017. CMS will issue additional regulations on this program in the calendar year (CY) 2017 and CY 2018 rulemaking cycles. CMS seeks review of 103 services with Medicare allowed charges of $10 million or more as a prioritized subset of codes under the statutory category of "codes that account for the majority of spending under the physician fee schedule." This list includes transthoracic echocardiography, electrophysiology device monitoring services and 3-D electrophysiology mapping. SPECT-MPI services were removed from the list after the ACC and other stakeholders indicated they did not fit the specified criteria. CMS finalized revisions to physician self-referral (Stark) regulations that it believes will accommodate delivery and payment system reform, reduce burden and facilitate compliance. Application of the Value- Based Payment Modifier on 2018 payments will be expanded to non-physician eligible professional solo practitioners and group practices (i.e., physician assistants, nurse practitioners and clinical nurse specialists) based on the 2016 performance period. Hospital Outpatient Prospective Payment System For 2016, CMS will implement nine new Comprehensive APCs (C-APCs), including one new C-APC for comprehensive observation services. This will provide a single payment for all services received during a non-surgical encounter with a high-level outpatient hospital visit or emergency department visit and eight or more hours of observation. All surgical procedures, regardless of the date of service, will be paid separately. CMS continues its policy to package payment for items and services that are integral, ancillary, supportive or adjunctive to a primary service. Starting in 2016, payment for bivalirudin and abciximab will be packaged into the Ambulatory Payment Classification (APC) payment for the primary procedure, such as a percutaneous coronary intervention or percutaneous transluminal coronary angioplasty. CMS finalized changes to its existing "rare and unusual" exceptions policy to allow Part A payment on a case-by-case basis for inpatient admissions that do not satisfy the two-midnight benchmark. The Agency will use quality improvement organizations to educate doctors and hospitals about Part A payment policy for inpatient admissions. Certain restrictions on recovery audit contractors' review of admitting decisions will also be implemented. These include changes to the "look-back period," limits on additional documentation requests and requirements for timely reviews. CMS finalized updates to the APC structure for imaging services, including the creation of the Level 4 Nuclear Medicine and Related Services group to appropriately recognize the resource costs and clinical distinctions of PET imaging services. For 2017 and subsequent years, hospitals that fail to meet the requirements of the Hospital Outpatient Quality Reporting Program will receive a 2 percent reduction to their annual fee schedule update factor. CMS will also continue to explore electronic clinical quality measures for use in future years.
Published by American College of Cardiology. View All Articles.