Issue Brief

Issue Brief

FEDERAL ISSUE BRIEF

KEY POINTS Major proposed updates include the following. zz Medicare telehealth services zz improving payment accuracy for preventive services — diabetes self-management training zz payment incentive for the transition from traditional X-ray to digital radiography zz procedures subject to the multiple procedure payment reduction and the outpatient PPS cap zz appropriate use criteria for advanced diagnostic imaging services zz value-based payment modifier and physician feedback program zz physician self-referral updates

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July 11, 2016

CMS Issues Proposed Changes to the MPFS and Other Part B Services for CY 2017 The Centers for Medicare and Medicaid Services has issued a proposed rule regarding revisions to payment policies and payment rates under the Medicare Physician Fee Schedule for calendar year 2017. A copy of the document is available on the Federal Register website at: https://s3.amazonaws.com/public-inspection.federalregister.gov/2016-16097. pdf The rule is scheduled for publication on July 15. The above link will change upon publication. A 60-day comment period ending September 6 is provided. The PFS Addenda, along with other supporting documents and tables referenced, are available on CMS’ website at http://www.cms.gov/Medicare/ Medicare-Fee-for-Service-Payment/ PhysicianFeeSched/PFSFederalRegulation-Notices.html. Click on the link on the left side of the screen titled, ‘‘PFS Federal Regulations Notices,’’ for a chronological list of PFS Federal Register and other related documents. For the CY 2017 PFS Proposed Rule, refer to item CMS-1654-P. CMS says it is “proposing to establish RVUs for CY 2017 for the PFS, and other Medicare Part B payment policies, to ensure that our payment systems are updated to reflect changes in medical

practice and the relative value of services, as well as changes in the statute.” CMS’ table of contents basically divides the subject matter of the rule into two major categories — provisions for the physician fee schedule and other items. The PFS material encompass the following:

•• Determination of Practice Expense Relative Value Units

•• Determination of Malpractice Relative Value Units

•• Medicare Telehealth Services •• Potentially Misvalued Services Under the Physician Fee Schedule

•• Improving Payment Accuracy for Primary Care, Care Management Services, and Patient-Centered Services

•• Improving Payment Accuracy for Preventive Services: Diabetes SelfManagement Training

•• Target for Relative Value Adjustments for Misvalued Services

•• Phase-In of Significant RVU Reductions

•• Geographic Practice Cost Indices •• Payment Incentive for the Transition from Traditional X-Ray Imaging continued

ISSUE BRIEF | CMS Issues Proposed Changes to the MPFS and Other Part B Services for CY 2017

to Digital Radiography and Other Imaging Services

•• Procedures Subject to the Multiple Procedure Payment Reduction and the OPPS Cap

•• Valuation of Specific Codes The proposed rule for other items are:

•• Chronic Care Management and Transitional Care Management Health Centers

•• FQHC-Specific Market Basket •• Appropriate Use Criteria for Advanced Diagnostic Imaging Services

•• Reports of Payments or Other Transfers of Value to Covered Recipients: Solicitation of Public Comments

•• Release of Part C Medicare Advantage Bid Pricing Data and Part C and Part D Medical Loss Ratio Data

•• Prohibition on Billing Qualified Medicare Beneficiary Individuals for Medicare Cost-Sharing

•• Recoupment or Offset of Payments to Providers Sharing the Same Taxpayer Identification Number

•• Accountable Care Organization Participants Who Report Physician Quality Reporting System Quality Measures Separately

•• Medicare Advantage Provider Enrollment

•• Proposed Expansion of the Diabetes Prevention Program Model

•• Medicare Shared Savings Program •• Value-Based Payment Modifier and Physician Feedback Program

•• Physician Self-Referral Updates

therapy centers and independent diagnostic testing facilities. Payments are based on the relative resources typically used to furnish the service. Relative value units are applied to each service for physician work, practice expense and malpractice. These RVUs become payment rates through the application of a conversion factor, updated each year as specified in the statute.

COMMENT As always, the MPFS rule is a long, complex and detailed document. This version is 856 pages. Again, there is much history, too much history, being repeated in numerous sections. While the statute mandates a 0.5 percent increase in physician payments, other items are offsetting the increase. Further, there are numerous changes to the Resource Based Relative Values that have an impact on specific services and specialty groups. Most material does not easily identify the changes being proposed. This and most CMS rulemaking need a major overhaul in presentation format. In this rule, for example, there is much discussions about items that CMS is not acting or proposing changes. Such information just detracts and clouds the issues being changed. Perhaps these items could be placed in a separate section. Focus should be on changes being proposed within clearly identified sections.

CONVERSION FACTORS To calculate the proposed conversion factor for this year, CMS says it multiplies the product of the current year (CY 2016) conversion factor and updates as noted in the table below.

In addition to physicians, the physician fee schedule pays a variety of practitioners and entities, including nurse practitioners, physician assistants, physical therapists, as well as radiation continued


Conversion Factor in Effect in CY 2016

35.8043

Update Factor

0.50 percent (1.0050)

CY 2017 RVU Budget Neutrality Adjustment

-0.51 percent (0.9949)

CY 2017 Target Recapture Amount

0 percent (1.0000)

CY 2017 Imaging MPPR Adjustment

-0.07 percent (0.9993)

CY 2017 Conversion Factor

35.7751

The CY 2017 anesthesia conversion factor is as follows: CY 2016 National Average Anesthesia Conversion Factor

21.9935

Update Factor

0.50 percent (1.0050)

CY 2017 RVU Budget Neutrality Adjustment

-0.51 percent (0.9949)

CY 2017 Target Recapture Amount

0 percent (1.0000)

CY 2017 Imaging MPPR Adjustment

-0.07 percent (0.9993)

CY 2017 Conversion Factor

21.9756

I. PROVISIONS OF THE PROPOSED RULE FOR PFS Determination of Practice Expense Relative Value Units

Practice expense is the portion of the resources used in furnishing a service that reflects the general categories of physician and practitioner expenses, such as office rent and personnel wages, but excluding malpractice expenses. Some of CMS actions in this area are: (1) PE Inputs for Digital Imaging Services Would price the professional Picture Archiving and Communication System workstation (ED053) at $14,616.93. CMS is not proposing a change in price for the current technical PACS workstation (ED050), which would remain at $5,557.00. CMS is proposing to add the professional PACS workstation to many CPT codes in the 70000 series that use the current technical PACS workstation (ED050) and include professional work for which such a workstation would be used. CMS has identified approximately 426 codes to which it is proposing to add a professional PACS workstation. The rule’s Table 4 includes the full list of affected codes. (2) Standardization of Clinical Labor Tasks Would establish a range of appropriate standard minutes for the clinical labor activity. These standard minutes will be applied to new and revised codes that make use of this clinical labor activity. CMS is proposing 2 minutes as the standard for the simple case, 3 minutes as the standard for the intermediate case, and 4 minutes as the standard for the complex case. (3) Equipment Recommendations for Scope Systems Would approach standalone prices for each scope, and separate prices for the video systems that are used with scopes. Would define the scope video system as including: (1) a monitor; (2) a processor; (3) a form of digital capture; (4) a cart; and (5) a printer. continued


(4) Restoration of Inputs Would add the fiber optic headlight (EQ170) to CPT codes 30300, 31295, 31296, 31297 and 92511 at the same number of equipment minutes as the xenon light (EQ167). The PE RVUs are displayed in Addendum B on CMS’ website. Determination of Malpractice Relative Value Units

CMS is not proposing any changes with respect to the malpractice inputs. Medicare Telehealth Services

CMS proposes to add the following services to the telehealth list on a category 1 basis for CY 2017: CPT codes:

•• 90967 (End-stage renal disease related services for dialysis less than a full month of service, per day; for patients younger than 2 years of age;

•• 90968 (End-stage renal disease related services for dialysis less than a full month of service, per day; for patients 2-11 years of age;

•• 90969 (End-stage renal disease related services for dialysis less than a full month of service, per day; for patients 12-19 years of age); and

•• 90970 (End-stage renal disease related services for dialysis less than a full month of service, per day; for patients 20 years of age and older). Two advance care planning service codes:

•• CPT code 99497 (advance care planning including the explanation and discussion of advance directives such as standard forms (with completion of such forms, when performed), by the physician or other qualified health care professional; first 30 minutes,

face-to-face with the patient, family member(s), or surrogate); and

•• CPT code 99498 (advance care planning including the explanation and discussion of advance directives such as standard forms (with completion of such forms, when performed), by the physician or other qualified health care professional; each additional 30 minutes (list separately in addition to code for primary procedure)). Critical care consultation codes:

•• New codes, initial and subsequent, used to describe critical care consultations furnished via telehealth. [(GTTT1 and GTTT2)] Place of Service Code for Telehealth Services:

•• Physicians or practitioners furnishing telehealth services would be required to report the telehealth POS code to indicate that the billed service is furnished as a telehealth service from a distant site. Potentially Misvalued Services Under the Physician Fee Schedule

Section 1848(c)(2)(K) of the Act requires the Secretary to periodically identify potentially misvalued services using certain criteria and to review and make appropriate adjustments to the relative values for those services. CMS estimates the CY 2017 net reduction in expenditures resulting from proposed adjustments to relative values of misvalued codes to be 0.51 percent. If finalized, this amount would exceed the 0.5 percent target established by the Achieving a Better Life Experience Act of 2014. There would be no residual difference between the target for the year and the estimated net reduction in expenditures (the “Target Recapture continued


Amount”) by which to reduce payments made under the PFS. The rule’s Table 7 lists 83 codes that CMS is proposing as potentially misvalued for CY 2017. CMS is proposing to identify CPT codes 90963 through 90970 as potentially misvalued codes based on the volume of claims submitted for these services relative to those submitted for facility ESRD services. CMS is identifying existing CPT codes 11981 (Insertion, non-biodegradable drug delivery implant), 11982 (Removal, non-biodegradable drug delivery implant), and 11983 (Removal with reinsertion, non-biodegradable drug delivery implant) as potentially misvalued codes and is seeking comments and information regarding whether the current resource inputs in work and practice expense for these codes appropriately account for variations in the service relative to which devices and related drugs are inserted and removed. CMS is proposing a rigorous data collection effort to provide data needed to accurately value the 4,200 codes with a 10- or 90-day global period. Improving Payment Accuracy for Primary Care, Care Management and Patient-Centered Services

•• CMS is proposing several revisions to the physician fee-for-service billing code set to more accurately recognize the work of primary care and other cognitive specialties to accommodate the changing needs of the Medicare patient population that would:

•• Make separate payments for certain existing CPT codes describing nonface-to-face prolonged evaluation and management services.

•• Revalue existing CPT codes describing face-to-face prolonged services.

•• Make separate payments using new codes to describe the comprehensive assessment and care planning for patients with cognitive impairment (e.g., dementia).

•• Make separate payments using new codes to pay primary care practices that use inter-professional care management resources to treat patients with behavioral health conditions. Several of these codes describe services within behavioral health integration models of care, including the Collaborative Care model that involves care coordination between a psychiatrist or behavioral health specialist and the primary care clinician, which has been shown to improve quality.

•• Make separate payments using new codes to recognize the increased resource costs of furnishing visits to patients with mobility-related impairments. Like several of these proposed codes, this is especially relevant for the Medicare-Medicaid dually-eligible population.

•• Make separate payments for codes describing chronic care management for patients with greater complexity.

•• Make several changes to reduce administrative burden associated with the chronic care management codes to remove potential barriers to furnishing and billing for these important services. CMS says it is aware that CPT has approved a code to describe assessment and care planning for patients with cognitive impairment; however, it will not be ready in time for valuation in CY 2017. Therefore, CMS is proposing to make payment using a G-code (GPPP6—see below) for this service in 2017. CMS is also aware that CPT continued


has approved three codes that describe services furnished consistent with the psychiatric Collaborative Care Model, but that they will also not be ready in time for valuation in CY 2017. Proposed CY 2017 payment for services described by new coding are as follows:

•• GPPP1: Initial psychiatric collaborative care management, first 70 minutes in the first calendar month of behavioral health care manager activities, in consultation with a psychiatric consultant, and directed by the treating physician or other qualified health care professional.

•• GPPP2: Subsequent psychiatric collaborative care management, first 60 minutes in a subsequent month of behavioral health care manager activities, in consultation with a psychiatric consultant, and directed by the treating physician or other qualified health care professional.

•• GPPP3: Initial or subsequent psychiatric collaborative care management, each additional 30 minutes in a calendar month of behavioral health care manager activities, in consultation with a psychiatric consultant, and directed by the treating physician or other qualified health care professional (List separately in addition to code for primary procedure) (Use GPPP3 in conjunction with GPPP1, GPPP2).

•• GPPPX: Care management services for behavioral health conditions, at least 20 minutes of clinical staff time, directed by a physician or other qualified health care professional time, per calendar month.

•• GPPP6: Cognition and functional assessment using standardized instruments with development of recorded care plan for the patient with cognitive impairment, history obtained from patient and/or caregiver, by the

physician or other qualified health care professional in office or other outpatient setting or home or domiciliary or rest home.

•• GPPP7: 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 (billed separately from monthly care management services) (Add-on code, list separately in addition to primary service).

•• GDDD1: Resource-intensive services for patients for whom the use of specialized mobility-assistive technology (such as adjustable height chairs or tables, patient lifts, and adjustable padded leg supports) is medically necessary and used during the provision of an office/outpatient evaluation and management visit (Add-on code, list separately in addition to primary procedure). CMS is proposing separate payment for services under the psychiatric CoCM using three new G-codes, as detailed above: GPPP1, GPPP2 and GPPP3, which would parallel the CPT codes that are being created to report these services. CMS is proposing to more appropriately recognize and pay for other codes in the CPT family of CCM services (CPT codes 99487 and 99489 describing complex CCM). The CPT provision that CPT codes 99487, 99489 and 99490 may only be reported once per service period (calendar month) and only by the single practitioner who assumes the care management role with a particular beneficiary for the service period. That is, a given beneficiary would be classified as eligible to receive either complex or noncomplex CCM during a given service period (calendar month), not both, and continued


only one professional claim could be submitted to the PFS for CCM for that service period by one practitioner. The face-to-face visit included in transitional care management services (CPT 99495 and 99496) qualifies as a “comprehensive” visit for CCM initiation. CMS is proposing to require the initiating visit only for new patients or patients not seen within one year instead of for all beneficiaries receiving CCM services. RHCs and FQHCs have been authorized to bill for CCM services since January 1, 2016, and are paid based on the Medicare PFS national average non-facility payment rate when CPT code 99490 is billed alone or with other payable services on a RHC or FQHC claim. The RHC and FQHC requirements for billing CCM services have generally followed the requirements for practitioners billing under the PFS, with some adaptations based on the RHC and FQHC payment methodologies. CMS is proposing a G-code that would provide separate payment to recognize the work of a physician (or other appropriate billing practitioner) in assessing and creating a care plan for beneficiaries with cognitive impairment, GPPP6 (Cognition and functional assessment using standardized instruments with development of recorded care plan for the patient with cognitive impairment, history obtained from patient and/or caregiver, in office or other outpatient setting or home or domiciliary or rest home).

COMMENT This is section encompasses more than 50 pages. There is simply too much detailed information to convey in this limited space.

Improving Payment Accuracy for Services: Diabetes SelfManagement Training

DSMT includes, as applicable, instructions in self-monitoring of blood glucose; education about diet and exercise; an insulin treatment plan developed specifically for the patient who is insulin-dependent; and motivation for patients to use the new skills for self-management (see §410.144(a) (5)). DSMT services are reported under HCPCS codes G0108 (Diabetes outpatient self-management training services, individual, per 30 minutes) and G0109 (Diabetes outpatient self- management training services, group session (two or more), per 30 minutes). Target for Relative Value Adjustments for Misvalued Services

Section 1848(c)(2)(O) of the Act establishes an annual target for reductions in PFS expenditures resulting from adjustments to relative values of misvalued codes. The target that applies to calendar years 2017 and 2018 is calculated as 0.5 percent of the estimated amount of expenditures under the PFS for the year. For the CY 2017 final rule, CMS will be finalizing values (year 3) for codes that were interim final in CY 2016 (year 2).

COMMENT For a relatively short section (five pages), the material is confusing to say the least. This is another example of where CMS needs to better explain its actions.

Phase-In of Significant RVU Reductions

Section 1848(c)(7) of the Act specifies that for services that are not new or revised codes, if the total RVUs for a service for a year would otherwise be decreased by an estimated 20 percent or more as compared to the total RVUs continued


for the previous year, the applicable adjustments in work, PE and MP RVUs shall be phased in over a two-year period. The list of codes proposed to be subject to the phase-in and the associated proposed RVUs that result from this methodology are available on CMS’ website under downloads for the CY 2017 PFS proposed rule at: http://www.cms.gov/Medicare/MedicareFee-for-Service-Payment/PhysicianFeeSched/PFS-Federal-Regulation-Notices.html. Geographic Practice Cost Indices

CMS has completed a review of the GPCIs and is proposing new GPCIs in this proposed rule. CMS is continuing to use the current cost share weights for determining the PE GPCI values and locality GAFs. Expense Category

Current Cost Share Weight

Proposed CY 2017 Cost Share Weight

Work

50.866%

50.866%

Practice Expense

44.839%

44.839%

- Employee Compensation

16.553%

16.553%

- Office Rent

10.223%

10.223%

- Purchased Services

8.095%

8.095%

- Equipment, Supplies, Other

9.968%

9.968%

Malpractice Insurance

4.295%

4.295%

Total

100.000%

100.000%

There are no changes in the states identified as Frontier States for the CY 2017 proposed rule. The qualifying states are: Montana, Wyoming, North Dakota, South Dakota and Nevada. In accordance with statute, CMS would apply a 1.0 PE GPCI floor for these states in CY 2017. There are currently 89 total PFS localities; 34 localities are statewide areas (that is, only one locality for the entire state). Beginning in CY 2017, section 1848(e)(6)(A)(i) of the Act requires that the fee schedule areas used for payment in California must be metropolitan statistical areas as defined by the Office of Management and Budget as of December 31 of the previous year; and section 1848(e)(6)(A)(ii) of the Act requires that all areas not located in an MSA must be treated as a single rest-of-state fee schedule area. The resulting modifications to California’s locality structure would increase its number of localities from nine under the current locality structure to 27 under the MSA-based locality structure. Section 1848(e)(6)(B) specifies that the GPCI values used for payment in a transition area are to be phased in over 6 years, from 2017 through 2021. There are a total of 58 counties in California, 50 of which are in transition areas as defined in section 1848(e)(6)(D) of the Act. The eight counties that are not within transition areas are: Orange; Los Angeles; Alameda; Contra Costa; San Francisco; San Mateo; Santa Clara; and Ventura counties. continued


Payment Incentive for the Transition from Traditional X-Ray Imaging to Digital Radiography and Other Imaging Services

Effective for services furnished beginning January 1, 2017, section 1848(b)(9) (A) of the Act reduces by 20 percent the payment amounts under the PFS for the technical component (including the TC portion of a global service) of imaging services that are X-rays taken using film. Section 1848(b)(9)(B) of the Act provides for a 7 percent reduction in payments for imaging services made under the PFS that are X-rays (including the X-ray component of a packaged service) taken using computed radiology furnished during CY 2018, 2019, 2020, 2021 or 2022, and for a 10 percent reduction for such imaging services taken using computed radiology furnished during CY 2023 or a subsequent year. CMS is proposing to establish a new modifier (modifier “XX”). The use of this proposed modifier to indicate an X-ray taken using film would result in a 20-percent reduction for the technical component of the X-ray service. Procedures Subject to the Multiple Procedure Payment Reduction and the OPPS Cap

Effective January 1, 2012, CMS implemented an MPPR of 25 percent on the professional component of advanced imaging services.

Valuation of Specific Codes

CMS notes that establishing valuations for newly created and revised CPT codes is a routine part of maintaining the PFS. For CY 2017, CMS is proposing new values for the vast majority of new, revised, and potentially misvalued codes for which it received complete relative value update committee recommendations by February 10, 2016. The proposal’s Table 16 (on website) includes a list of codes for which CMS is proposing work RVUs; this includes all RUC recommendations received by February 10, 2016, and codes for which CMS established interim final values in the CY 2016 PFS final rule. The proposed work RVUs and other payment information for all proposed CY 2017 payable codes are available in Addendum B.

COMMENT This is a long section comprising more than 260 pages. CMS (1) responds to comments received in response to the CY 2016 PFS final rule with comments; (2) addresses 21 specific CY 2017 proposed codes that were also CY 2016 proposed codes; (3) addresses 45 CY 2017 proposed codes; (4) and includes significant other tables.

[Note the page numbers provided below are from the display copy of the rule. Each is the staring page of the subject matter Page numbers will change upon publication in the Federal Register.]

Section 502(a)(2)(A) of the Consolidated Appropriations Act of 2016 added a new section 1848(b)(10) of the Act which revises the payment reduction from 25 percent to 5 percent, effective January 1, 2017.

continued


Valuation of Specific Codes CY 2017 Proposed Codes That Also Were CY 2016 Proposed Codes

Page Number

1

Soft Tissue Localization (CPT codes 10035 and 10036

252

2

Repair Flexor Tendon (CPT codes 26356, 26357, and 26358)

253

3

Esophagogastric Fundoplasty Trans-Oral Approach (CPT code 43210)

256

4

Percutaneous Biliary Procedures Bundling (CPT codes 47531, 47532, 47533, 47534, 47535, 47536, 47537, 47538, 47539, 47540, 47541, 47542, 47543, and 47544)

257

5

Percutaneous Image Guided Sclerotherapy (CPT code 49185)

257

6

Genitourinary Procedures (CPT codes 50606, 50705, and 50706)

259

7

Laparoscopic Radical Prostatectomy (CPT code 55866)

263

8

Intracranial Endovascular Intervention (CPT codes 61645, 61650, and 61651) 266 For

9

Paravertebral Block Injection (CPT codes 64461, 64462, and 64463)

268

10

Implantation of Neuroelectrodes (CPT codes 64553 and 64555)

269

11

Ocular Reconstruction Transplant (CPT code 65780)

270

12

Trabeculoplasty by Laser Surgery (CPT code 65855)

271

13

Glaucoma Surgery (CPT codes 66170 and 66172)

273

14

Retinal Detachment Repair (CPT codes 67107, 67108, 67110, and 67113)

274

15

Fetal MRI (CPT codes 74712 and 74713)

276

16

Interstitial Radiation Source Codes (CPT codes 77778 and 77790)

277

17

Colon Transit Imaging (CPT codes 78264, 78265, and 78266)

278

18

Cytopathology Fluids, Washings or Brushings and Cytopathology Smears, Screening, and Interpretation (CPT codes 88104, 88106, 88108, 88112, 88160, 88161, and 88162)

279

19

Immunohistochemistry (CPT codes 88341, 88342, 88344, and 88350)

280

20

Morphometric Analysis (CPT codes 88364, 88365, 88367, 88368, 88369 and 88373)

283

21

Liver Elastography (CPT code 91200)

285

CY 2017 Proposed Codes

Page Number

1

Anesthesia Services Furnished in Conjunction with Lower Gastrointestinal (GI) Procedures (CPT codes 00740 and 00810)

286

2

Removal of Nail Plate (CPT code 11730)

287

3

Bone Biopsy Excisional (CPT code 20245)

289

4

Insertion of Spinal Stability Distractive Device (CPT codes 228X1, 228X2, 228X4, and 228X5)

289

5

Biomechanical Device Insertion (CPT codes 22X81, 22X82, and 22X83)

290

6

Closed Treatment of Pelvic Ring Fracture (CPT codes 271X1 and 271X2)

291

7

Bunionectomy (CPT codes 28289, 282X1, 28292, 28296, 282X2, 28297, 28298, and 28299)

292

8

Endotracheal Intubation (CPT code 31500)

293

9

Closure of Left Atrial Appendage with Endocardial Implant (CPT code 333X3) 294

10

Valvuloplasty (CPT codes 334X1 and 334X2)

294

11

Dialysis Circuit (CPT codes 369X1, 369X2, 369X3, 369X4, 369X5, 369X6, 369X7, 369X8, 369X9)

295

12

Open and Percutaneous Transluminal Angioplasty (CPT codes 372X1, 372X2, 303 372X3, and 372X4)

continued


CY 2017 Proposed Codes

Page Number

13

Percutaneous Biliary Procedures Bundling (CPT codes 47531, 47532, 47533, 47534, 47535, 47536, 47537, 47538, 47539, 47540, 47541, 47542, 47543, and 47544)

305

14

Flexible Laryngoscopy (CPT codes 31575, 31576, 31577, 31578, 317X1, 317X2, 317X3, and 31579)

309

15

Laryngoplasty (CPT codes 31580, 31584, 31587, and 315X1-315X6)

313

16

Mechanochemical Vein Ablation (MOCA) (CPT codes 364X1 and 364X2)

315

17

Esophageal Sphincter Augmentation (CPT codes 432X1 and 432X2)

315

18

Electromyography Studies (CPT code 51784)

316

19

Cystourethroscopy (CPT code 52000)

317

20

Biopsy of Prostate (CPT code 55700)

317

21

Hysteroscopy (CPT codes 58555-58563)

318

22

Epidural Injections (CPT codes 623X5, 623X6, 623X7, 623X8, 623X9, 62X10, 62X11, and 62X12)

322

23

Endoscopic Decompression of Spinal Cord (CPT code 630X1)

322

24

Retinal Detachment Repair (CPT codes 67101 and 67105)

323

25

Abdominal Aortic Ultrasound Screening (CPT code 767X1)

324

26

Fluoroscopic Guidance (CPT codes 77001, 77002, and 77003)

324

27

Radiation Treatment Devices (CPT codes 77332, 77333, and 77334)

325

28

Special Radiation Treatment (CPT code 77470)

326

29

Flow Cytometry Interpretation (CPT codes 88184, 88185, 88187, 88188, and 326 88189)

30

Mammography - Computer Aided Detection Bundling (CPT codes 770X1, 770X2 and 770X3)

330

31

Microslide Consultation (CPT codes 88321, 88323, and 88325)

335

32

Closure of Paravalvular Leak (CPT codes 935X1, 935X2, and 935X3)

338

33

Electroencephalogram (EEG) (CPT codes 95812, 95813, and 95957)

339

34

Parent, Caregiver-focused Health Risk Assessment (CPT code 961X0)

340

35

Reflectance Confocal Microscopy (CPT codes 96931, 96932, 96933, 96934, 96935, and 96936)

341

36

Evaluative Procedures for Physical Therapy and Occupational Therapy (CPT codes 97X61, 97X62, 97X63, 97X64, 97X65, 97X66, 97X67, 97X68)

342

37

Proposed Valuation of Services Where Moderate Sedation is an Inherent Part 352 of the Procedure and Proposed Valuation of Moderate Sedation Services (CPT codes 991X1, 991X2, 991X3, 991X4, 991X5, and 991X6; and HCPCS code GMMM1)

38

Prolonged Evaluation and Management Services (CPT codes 99354, 99358, and 99359)

367

39

Complex Chronic Care Management Services (CPT codes 99487 and 99489)

367

40

Prostate Biopsy, Any Method (HCPCS code G0416)

368

41

Behavioral Health Integration: Psychiatric Collaborative Care Model (HCPCS codes GPPP1, GPPP2, and GPPP3) and General Behavioral Health Integration (HCPCS code GPPPX)

369

42

Resource-intensive services (HCPCS code GDDD1)

370

43

Comprehensive Assessment and Care Planning for Patients with Cognitive Impairment (HCPCS code GPPP6)

371

44

Comprehensive Assessment and Care Planning for Patients Requiring Chronic Care Management (HCPCS code GPPP7)

372

45

Telehealth Consultation for a Patient Requiring Critical Care Services (HCPCS codes GTTT1 and GTTT2)

373

continued


Other information/ tables:

FQHC-Specific Marketbasket

•• Table 23: Proposed CY 2017

For CY 2017, CMS is proposing to create a 2013-based FQHC marketbasket. The proposed marketbasket uses Medicare cost report data submitted by freestanding FQHCs.

Work RVUs for New, Revised and Potentially Misvalued Codes [page 374]

•• Table 24: CY 2016 Proposed Codes with Direct PE Input Recommendations Accepted without Refinement [page 394]

•• Table 25: CY 2016 Proposed Codes with Direct PE Input Recommendations Accepted with Refinement [page 399]

•• Table 26: Invoices Received for Existing Direct PE Inputs [page 492]

•• Table 27: Invoices Received for New Direct PE Inputs [page 494]

II. OTHER PROVISIONS OF THE PROPOSED REGULATIONS Chronic Care Management and Transitional Care Management Supervision Requirements in Rural Health Clinics and Federally Qualified Health Centers

CMS proposes to revise §405.2413(a) (5) and §405.2415(a)(5) to state that services and supplies furnished incident to TCM and CCM services can be furnished under general supervision of a RHC or FQHC practitioner. The proposed exception to the direct supervision requirement would apply only to auxiliary personnel furnishing TCM or CCM incident to services, and would not apply to any other RHC or FQHC services. The proposed revisions for CCM and TCM services and supplies furnished by RHCs and FQHCs are consistent with §410.26(b)(5), which allows CCM and TCM services and supplies to be furnished by clinical staff under general supervision when billed under the PFS.

CMS would update the FQHC PPS base payment rate by 1.7 percent for CY 2017 based on the proposed 2013-based FQHC marketbasket. Appropriate Use Criteria for Advanced Diagnostic Imaging Services

Section 218(b) of the PAMA amended Title XVIII of the Act to add section 1834(q) of the Act directing CMS to establish a program to promote the use of appropriate use criteria for advanced diagnostic imaging services. The rule proposes requirements and processes for specification of qualified clinical decision support mechanisms under the Medicare AUC program; the initial list of priority clinical areas; and exceptions to the requirement that ordering professionals consult specified applicable AUC when ordering applicable imaging services. CMS says that “the number of clinicians impacted by the scope of this program is massive as it will apply to every physician or other practitioner who orders or furnishes applicable imaging services.” Under this proposal, the first list of qualified CDSMs will be posted no later than June 30, 2017, allowing ordering professionals to begin aligning themselves with a qualified CDSM. CMS anticipates that furnishing professionals could begin reporting AUC information starting as early as January 1, 2018, but will provide details in the CY 2018 PFS rulemaking for how to report that information on claims. continued


Reports of Payments or Other Transfers of Value to Covered Recipients: Solicitation of Public Comments

CMS says it does not intend to finalize any requirements related to Open Payments directly as a result of this proposed rule; rather, CMS expects to conduct future rulemaking. Release of Part C Medicare Advantage Bid Pricing Data and Part C and Part D Medical Loss Ratio Data

CMS is proposing to release to the public MA bid pricing data and Part C and Part D MLR data on a specific schedule and subject to specified exclusions. CMS proposes to add contract terms and expand the basis and scope of its regulations on MA bidding and Part C and Part D MLR submission to incorporate section 1106(a) of the Act (42 U.S.C. 1306(a)), which authorizes disclosure of information filed with CMS in accordance with regulations adopted by the agency. CMS is proposing to release the MLR data specified in this rule for each MA and Part D contract on an annual basis no earlier than 18 months after the end of the contract year to which the MLR data applies. CMS is proposing to follow the commercial MLR approach in making the data it receives in MLR Reports available to the public. Prohibition on Billing Qualified Medicare Beneficiary Individuals for Medicare Cost-Sharing CMS reminds all Medicare providers (including providers of services defined in section 1861 of the Act and physicians) that federal law prohibits them from collecting Medicare Part A and Medicare Part B deductibles, coinsurance, or copayments, from beneficiaries enrolled in the Qualified Medicare Beneficiaries Program (a Medicaid program which

helps certain low-income individuals with Medicare cost-sharing liability). Recoupment or Offset of Payments to Providers Sharing the Same Taxpayer Identification Number

CMS proposes to create a new paragraph (f) in §405.373 to state that §405.373(a) does not apply in instances where the Medicare Administrative Contractor intends to offset or recoup payments to the applicable provider of services or supplier to satisfy an amount due from an obligated provider of services or supplier when the applicable and obligated provider of services or supplier share the same Taxpayer Identification Number. Accountable Care Organization Participants Who Report Physician Quality Reporting System Quality Measures Separately

Current Shared Savings Program regulations at §425.504(c) do not allow eligible professionals billing through the Taxpayer Identification Number of an Accountable Care Organization participant to participate in PQRS outside of the Shared Savings Program, and these EPs and the ACO participants through which they bill may not independently report for purposes of the PQRS apart from the ACO. CMS is proposing to amend the regulation at §425.504 to permit EPs that bill under the TIN of an ACO participant to report separately for purposes of the 2018 PQRS payment adjustment when the ACO fails to report on behalf of the EPs who bill under the TIN of an ACO participant. Medicare Advantage Provider Enrollment

This proposed rule would require providers or suppliers that furnish health care items or services to a continued


Medicare enrollee who receives his or her Medicare benefit through an MA organization to be enrolled in Medicare and be in an approved status. Proposed Expansion of the Diabetes Prevention Program Model

CMS’ Office of the Actuary has determined that DPP is likely to reduce Medicare expenditures if made available to eligible Medicare beneficiaries based on historical evidence from evaluations of the Y-USA DPP and other DPPs in the CDC Diabetes Prevention Recognition Program. CMS proposes to expand the duration and scope of the DPP model test by expanding DPP under section 1115A(c) of the Act, and proposes to refer to this expanded model as the Medicare Diabetes Prevention Program (MDPP). In this section of the proposed rule, CMS proposes a basic framework for the MDPP. If finalized, CMS will engage in additional rulemaking, likely within the next year, to establish specific requirements of the MDPP. Medicare Shared Savings Program

The Medicare Shared Savings Program was established to promote accountability for a patient population, coordinate items and services under parts A and B, and encourage investment in infrastructure and redesigned care processes for high quality and efficient service delivery through provider and supplier participation in an ACO. The CY 2017 PFS proposed rule includes the following proposed policies specific to certain sections of the Shared Savings Program regulations:

•• Updates to ACO quality reporting, including changes to the quality measure set and the quality validation audit, revisions to terminology used

in quality assessment, revisions that would permit eligible professionals in ACOs to report quality apart from the ACO, and updates to align with the Physician Quality Reporting System and the proposed Quality Payment Program. CMS proposes to replace the Documentation of Current Medications in the Medical Record measure (ACO-39) by reintroducing Medication Reconciliation (ACO-12) in the Care Coordination/Patient Safety domain. CMS proposes to retire or replace the following measures in order to reduce provider reporting burden by reducing the number of measures that must be reported and because these measures do not align with the core measure set recommendations from the Core Quality Measures Collaborative and the measures that are proposed for reporting through the CMS web interface in the QPP proposed rule: –– ACO-39 Documentation of Current Medications in the Medical Record. –– ACO-21 Preventive Care and Screening: Screening for High Blood Pressure and Follow-up Documented. –– ACO-31 Heart Failure: BetaBlocker Therapy for Left Ventricular Systolic Dysfunction. –– ACO-33 Angiotensin-Converting Enzyme Inhibitor or Angiotensin Receptor Blocker (ARB) Therapy – for patients with CAD and Diabetes or Left Ventricular Systolic Dysfunction (LVEF