Key Takeaways from CMS Medicare Physician Fee Schedule Final Rule

CMS has issued its final rule for the CY2018 Medicare Physician Fee Schedule. Most significantly, the new rule cuts payment rates for non-excepted off-campus hospital outpatient departments. What follows is a summary of the most important points from the rule.

Payment Cut to Certain Off-Campus Hospital Outpatient Departments

Non-excepted off-campus hospital departments (HOPDs opened on or after November 2, 2015) used to be reimbursed through the Hospital Outpatient Prospective Payment System (“OPPS”). CMS started reimbursing these facilities at a percentage of the OPPS rate in CY2017. In this final rule, for CY2018, CMS has set the reimbursement rate for non-excepted off-campus HOPDs at 40% of the OPPS rate, down from the previous rate of 50%. As a reminder, this payment cut only affects payments originating from institutional claims; payments resulting from professional claims remain the same under the final rule.

Dedicated emergency department services and off-campus provider-based departments that meet the 21st Century Cures “mid build” exception are excluded from the payment rate changes as well.

The 340B payment cut does not impact non-excepted off-campus HOPDs. The day before the release of the Medicare PFS Final Rule, CMS issued its OPPS/ASC Final Rule. In that rule, CMS cut the payment rate for drugs acquired through the 340B Program at Disproportionate Share Hospitals and Rural Referral Centers.

The combined reimbursement cuts to non-excepted off-campus HOPDs and affected facilities participating in the 340B Program has caused industry-wide concern. Advis recommends conducting a feasibility study to begin exploring various strategies to financially optimize your organization in light of these changes.

Slight Increase in Overall Medicare PFS Rate

CMS increased the Medicare Physician Fee Schedule rate by 0.41%, setting the final PFS conversion factor for 2018 at $35.99.

Telehealth: Services Added, Modifier Removed

The following services are added to the telehealth list:

  • HCPCS code G0296 (visit to determine low dose computer tomography eligibility)
  • CPT code 90785 (Interactive Complexity)
  • CPT codes 96160 and 96161 (Health Risk Assessment)
  • HCPCS code G0506 (Care Planning for Chronic Care Management)
  • CPT codes 90839 and 90840 (Psychotherapy for Crisis)

CMS is also eliminating the required use of the telehealth modifier “GT” for professional claims. The GQ modifier remains a prerequisite in order to maintain the distinction between synchronous and asynchronous telehealth services.

The telehealth originating site facility fee was also increased to $25.76 (up from $25.40).

Delay of Medicare Appropriate Use Criteria Program

Originally scheduled to take effect in January 2018, CMS has delayed the implementation of the AUC Program for Advanced Diagnostic Imaging. Implementation will now begin in 2020, at which time physicians will be required to start using and reporting AUCs on their claims.

Reduced Criteria for Physician Quality Reporting System

For CY2018, CMS has reduced reporting criteria for the Physician Quality Reporting System (PQRS) to only 6 measures with no domain or cross-cutting measure requirements. Previously, the PQRS criteria spanned 9 measures across 3 NQS domains.

In order to better align incentives and provide a smoother transition to MIPS under the Quality Payment Program, CMS is also reducing the automatic downward payment adjustment for not meeting the criteria from -4.0% to -2.0% for groups of ten or more clinicians. Adjustments for groups of less than ten clinicians or solo practitioners is reduced from -2.0% to -1.0%.

Reduced Requirements for ACOs in Medicare Shared Savings Program

Beginning performance year 2019 and beyond, in order to reduce the burden on Accountable Care Organizations participating in the Medicare Shared Savings Program, CMS is eliminating the requirement for ACOs to list each physician working in the FQHC or RHC on the ACO participant list. ACOs will no longer have to submit an initial Shared Savings Program application or the application for use of the SNF 3-Day Rule Waiver.

In addition, three new chronic care management (“CCM’) codes and four behavior health integration (“BHI”) codes were added to the definition of primary care services in the ACO assignment methodology.

  • Added CCM codes: 99487, 99487, G0506
  • Added BHI codes: G0502, G0503, G0504, G0507

For any questions regarding this rule, the CY2018 CMS OPPS/ASC Final Rule, or for assistance in any other health care regulatory and operational matters for your organization, please contact Advis through our website or give us a call at 708-478-7030.

  • This field is for validation purposes and should be left unchanged.