On November 15, CMS published its 393-page 2017 Medicare Physician Fee Schedule Final Rule. Here are 4 need-to-know provisions likely to have a direct impact on practicing physicians in the upcoming year.
1. Conversion Factor
Under the Medicare Access and CHIP Reauthorization Act of 2015, MPFS rates are scheduled to increase by one-half percent each year until 2019. Thus, one may assume the 2017 conversion factor would be $35.98, given the current conversion factor of $35.80.
However, there are other statutory requirements CMS had to take into account in calculating the annual conversion factor, all of which ate into the 2017 MACRA-mandated physician pay raise. As a result, the 2017 conversion factor will be $35.89, representing only a one-quarter percent increase over 2016.
2. Fee-For-Service Care Management
A. CCM Simplification
Approximately two-thirds of traditional Medicare beneficiaries – approximately 35-million individuals – suffer from multiple chronic conditions. Since 2015, CMS has paid for non-face-to-face care management services furnished to these beneficiaries. Physicians, however, have been slow to adopt chronic care management (CCM) services; thus far, only 513,000 beneficiaries have received CCM.
In the 2017 MPFS Final Rule, CMS has finalized substantial revisions to the CCM billing rules effective January 1, 2017. The following changes are intended to reduce the regulatory complexity that has prevented many providers from furnishing these services. (Note that any reference to “physician” below includes non-physician practitioners.)
- Consent form
Pre-2017 rule: A physician cannot bill for CCM unless and until the physician secures the beneficiary’s signature on a consent form, the contents of which are specified in the regulation.
New rule: A physician may simply document in the medical record that certain information regarding CCM was furnished to the beneficiary.
- Initiating visit
Pre-2017 rule: CCM must be initiated by the billing physician during a face-to-face E/M visit (Levels 2-5 E/M visit, an annual wellness visit, or initial “Welcome to Medicare” visit); no CCM services may be billed prior to the date of such visit.
New Rule: Such initiating visit is required only for new patients and patients not seen within the last twelve months.
- 24/7 access to care
Pre-2017 rule: The physician must provide the beneficiary with a means to make timely contact with the practice’s healthcare practitioners who have access to the beneficiary’s electronic care plan.
New rule: The requirement regarding practitioners’ access to the beneficiary’s care plan is eliminated.
- Management of care transitions
Pre-2017 rule: The billing physician must create and exchange with other providers involved in the beneficiary’s care a clinical summary with standardized content formatted according to certified electronic health record (EHR) technology.
New rule: The billing physician must create and exchange with other providers involved in the beneficiary’s care a continuity of care document for which no standardized content, no specific format, and no specific means of transmission is required.
- Sharing of care plan and clinical summaries
Pre-2017 rule: The billing physician must make the electronic care plan available on a 24/7 basis to all the practice’s clinical staff whose time counts toward the time requirement. Also, the physician must share care plan information electronically (by fax only in extenuating circumstances) as appropriate with providers outside the practice. There is no requirement to use a certified EHR to develop or maintain the care plan.
New rule: The electronic care plan must be made available timely within and outside the billing practice as appropriate, and care plan information must be shared electronically (can include fax) within and outside the practice with those involved in the beneficiary’s care.
- Beneficiary receipt of care plan
Pre-2017 rule: The beneficiary must be provided with a written or electronic copy of the care plan.
New rule: The specification of the format in which the care plan is to be provided to the beneficiary is eliminated.
Pre-2017 rule: The billing physician must document the following information using certified EHR technology: (1) the creation of a clinical summary record including the beneficiary’s demographics, problems, medications and medication allergies to inform the care plan, care coordination, and ongoing clinical care; (2) communication to and from home- and community-based providers regarding the beneficiary’s psychosocial needs and functional deficits; and (3) the beneficiary’s consent to receive CCM.
New rule: For items 2 and 3, such communications must be documented in the beneficiary’s medical record, but not necessarily a qualifying certified EHR; see discussion above regarding the form of consent. Use of a certified EHR to generate a clinical summary record still is required.
B. Payment for Complex CCM
To bill for CCM under CPT 99490, clinical staff under the general supervision of a physician must provide a minimum of 20 minutes of non-face-to-face care management services per month. In valuing CCM for purposes of establishing the payment rate, CMS accounted for 20 minutes of staff time. However, when it conducted practitioner interviews as part of its CCM evaluation efforts, CMS learned staff were actually spending 45 minutes to an hour each month with each beneficiary.
For this reason, CMS will begin payment for complex CCM under CPT 99487. The billing rules for CCM (CPT 99490) and complex CCM are the same, except (1) complex CCM requires 60 minutes of non-face-to-face care management services per month, as compared to 20 minutes for CCM; and (2) the beneficiary’s condition must be such to require medical decision-making of moderate to high complexity on the part of the billing physician. CMS also will pay for an add-on code for complex CCM, CPT 99489, for each 30-minute increment that goes beyond the initial 60 minutes.
Here are the national average payment rates for the three CCM codes:
C. Payment for Care Plan Development
Acknowledging complaints that the time spent developing the CCM-required care plan currently is not reimbursed, CMS now will pay physicians for care plan development under a new code, G0506. The agency has adopted the following description for this code:
Comprehensive assessment of, and care planning by, the physician or other qualified health care professional for patients requiring chronic care management services, including assessment during the provision of a face-to-face service.
This add-on code is to be listed separately in addition to the CCM initiating visit and billed separately from monthly care management services. The national average payment rate for G0506 is $63.88 (non-facility) and $46.30 (facility).
While there is no minimum time requirement for G0506, CMS cautions providers that this code only should be billed if the time and effort involved in care plan development is beyond the usual time and effort involved in the underlying E/M service. Also, the code may be billed only one time, at the outset of CCM services.
D. Non-Face-to-Face Prolonged E/M Services
Payment for CCM and complex CCM is intended to reimburse physicians for clinical staff time spent providing care management services, not time spent by physicians. For those cases in which a physician spends a significant amount of time outside the usual office visit addressing an individual patient’s needs, CMS will make payment under two codes beginning in 2017:
In discussing these services, CMS warns the time counted toward these codes must be separate and distinct from time spent providing any other service reimbursable under the MPFS including, but not limited to, new and established patient office visits, transitional or chronic care management services, or care plan development.
3. Implementation of Site-Neutral Payments for Off-Campus Hospital Outpatient Departments
The day before CMS released the 2017 MPFS Final Rule, the agency published the 2017 Medicare Outpatient Prospective Payment System (OPPS) Final Rule. Most notably, CMS has finalized its regulations implementing Section 603 of the Bipartisan Budget Act of 2015. Effective January 1, 2017, hospital off-campus provider-based departments other than emergency rooms that began furnishing services on or after November 2, 2015 (referred to as “new PBDs”), no longer will be eligible for payment under OPPS.
Instead, CMS will reimburse hospitals directly for items and services provided at new PBDs according to new MPFS payment rates. To accomplish this, CMS has established a mechanism by which hospitals will continue to submit claims for items and services furnished in a new PBD on the institutional claim form, but append a new “PN” modifier to line items for new PBD items and services. As a general rule, these new MPFS rates for new PBD services will be 50% of the OPPS rate with certain exceptions. Physicians and non-physician practitioners will continue to bill for professional services in the same manner as they do now, and will continue to be reimbursed at the existing MPFS facility rate.
As a result of these site-neutral payments, CMS has effectively leveled the playing field between physician practices and hospitals. Of course, the impact of this change has yet to be seen, but it will most likely impact hospitals’ decisions to acquire and operate physician practices and other off-campus outpatient ancillary services.
4. Payment for Telehealth Services
In 2017, CMS will add the following services to the list of those which may be furnished via telehealth:
- End-stage renal disease—related services for dialysis
- Advance care planning services
- Critical care consultations furnished via telehealth using new Medicare G-codes
While CMS continues to expand the list of telehealth-eligible services, there remains the statutory requirement that a telehealth service is reimbursable only if furnished to an individual located in a rural health professional shortage area, or a county not included in a metropolitan shortage area, and who is physically present at a specified healthcare facility (as opposed to the individual’s residence). So long as these restrictions remain in place, telehealth will remain underutilized even as the list of telehealth services grows.