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Fee schedule: Conversion factor up but vaccine administration, cardio stress tests take payment hit

2018 final Medicare physician fee schedule
The slight increase in the conversion factor means little or no change in reimbursement for most of your E/M codes and other high volume services – with two exceptions.
In the fee schedule, the 2018 conversion factor is up to $35.9996 from $35.8887. For anesthesia providers, the 2018 anesthesia conversion factor is $22.1887 up from $22.0454.
But note payment decreases if your practice does immunization administration (90471), which is cut 19% to $20.88 next year from $25.84, or cardiovascular stress tests (93015), which drops 6% to $72.72 next year from the current $77.52.
  • No change to the E/M documentation guidelines in 2018. CMS says it agrees “with stakeholders that the E/M documentation guidelines should be substantially revised.” However, a comprehensive revision “would require a multi-year, collaborative effort among stakeholders,” the agency concluded. The agency plans to consider what the best approach would be for a collaborative revamp of the guidelines as it prepares to update office visit documentation rules in a future rule.
  • Non-exempt, provider-based outpatient departments will see reduced cut to facility rates. CMS will set payments for certain services performed by off-campus, provider-based departments at 40% of the hospital outpatient prospective payment system (OPPS) rate next year, down from 50% this year. The agency had proposed to cut next year’s payments to 25% of OPPS rates. The cuts affect payments to provider-based outpatient departments that were established after Nov. 2, 2015, or which do not meet other exemptions.
  • Fewer measures to meet 2016 physician quality reporting system (PQRS) minimum. CMS reduced from nine to six the minimum number of quality measures practices had to report to avoid a 2% penalty under PQRS. It also did away with the requirement that the measures had to span three National Quality Strategy domains. So if your practice reported at least six measures, your 2018 payments will not receive a PQRS penalty.
  • Value modifier takes a smaller bite in 2018. CMS says it will reduce the cut to Medicare pay that providers will suffer next year for failing to meet PQRS requirements in 2016. Groups of 10 or more physicians will see a 2% reduction instead of 4%, while provider groups of nine or fewer clinicians will see a 1% reduction down from 2% for noncompliance. Also, good news – your value modifier performance won’t appear with your other Medicare data in CMS’ Physician Compare database, though the agency says it will make that data available through public use and research identifiable files.
  • Medicare diabetes prevention program starts in April with two-year limit. Starting the program April 1 “allows a sufficient amount of time (90 days) for eligible suppliers to enroll in Medicare before furnishing and billing for MDPP services,” CMS says, though several commenters asked for a delay. The program for each participant will last no longer than two years: The initial “core” period, during which participants are working toward their weight targets, may be pursued at differing paces by different participants but the second “maintenance” period will last no more than one year. CMS will not allow for a 100%-virtual program in 2018, though participants can do “virtual make-up sessions” for missed sessions. CMS also reveals “currently over 1,500 organizations [are] actively pursuing or maintaining DPP recognition,” a 90% increase between September 2015 and March 2017.
  • CMS adds codes for telehealth, cuts GT modifier, unbundles 99091. CMS finalized seven new telehealth codes: G0296 (Visit to determine low dose computed tomography [LDCT] eligibility), 90785 (Interactive complexity), 96160 and 96161 (Health risk assessment), G0506 (Care planning for chronic care management) and 90839 and 90840 (Psychotherapy for crisis). Practices will not have to append the GT modifier to telehealth claims. CMS also is finalizing a separate payment for 99091 (Collection and interpretation of physiologic data [e.g., ECG, blood pressure, glucose monitoring]), which had previously been bundled. No changes were made to the originating site and other requirements that have limited telehealth utilization in the past.
  • Shared savings adds behavioral, CCM to beneficiary assignment codes. The biggest changes are in codes added to the primary care code set by which CMS assigns beneficiaries under Shared Savings. Seven codes that were added to the last fee schedule – the CCM service codes 99487, 99489 and G0506 and the behavioral health integration service codes G0502, G0503, G0504 and G0507 – will now be considered primary care service codes for assignment purposes. CMS hinted that it would consider adding the advance care planning codes 99497 and 99498 in future rulemaking. CMS also finalized other Shared Savings operational changes, including removing some restrictions on the three-day inpatient hospital stay waiver, establishing new routine audits to check data match rates between accountable care organization (ACO) quality reports and medical documentation and reserving the right to makes changes to CMS web interface measures reporting.
  • Appropriate Use Criteria (AUC) delayed again. Last year, CMS delayed the start date for AUC, under which ordering professionals in certain settings must consult specified applicable criteria via qualified decision support mechanisms for applicable imaging services related to certain conditions such as coronary artery disease and suspected pulmonary embolism. The date had been moved from 2018 to 2019 and now will be moved to Jan. 1, 2020 – though “early adopters” can start reporting “limited consultation information” on Medicare claims from July 2018 through December 2019.
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