2016 Medicare Physician Fee Schedule Final Rule Released
2016 MPFS Conversion Factor
The Achieving a Better Life Experience (ABLE) Act of 2014 established a 1% target for adjustments to misvalued codes for 2016, and required that payments under the fee schedule must be reduced by the difference between the target for the year and the estimated net reduction in expenditures. In CY 2016, the net reduction in expenditures resulting from adjustments to relative values of misvalued codes is 0.23%.
Therefore, the CY 2016 MPFS conversion factor is $35.8279, which reflects the budget neutrality adjustment of -0.02%, the 0.5% update factor specified under Medicare Access and CHIP Reauthorization Act (MACRA), and the 0.77% target recapture amount required under ABLE Act.
Request for Information on Nonfacility Cataract Surgery
As we reported, CMS requested feedback on office-based surgical suite cataract surgery in the proposed rule. ASCRS surveyed our members, and provided pros and cons of office-based cataract surgery to CMS in our comments on the proposed rule.
CMS received 138 comments from stakeholders. Consistent with ASCRS' comments, the commenters suggested that while office-based cataract surgery would allow greater flexibility regarding scheduling and location where services are performed, there are also safety concerns involved in furnishing cataract surgery in the office setting.
In this final rule, CMS stated that they will use the information provided by groups such as ASCRS, as they consider whether to proceed with the development of Practice Expense Relative Value Units (RVUs) for nonfacility cataract surgery.
Improving the Valuation and Coding of the Global Package
In the 2015 MPFS Final Rule, CMS finalized transitioning all 10-day and 90-day global codes to 0-day codes, however, MACRA prohibited CMS from implementing this policy. MACRA requires that instead, CMS develop a process to gather information needed to value surgical services from a representative sample of physicians and data collection should begin no later than January 1, 2017. The collected information must include the number and level of medical visits furnished during the global period and other items and services related to the surgery as appropriate.
Therefore, CMS sought input from stakeholders on the kinds of objective data needed to increase the accuracy of the values for surgical services and the potential methods of valuing the individual components of the global surgical package in the proposed rule. CMS stated that, in general, commenters were supportive of the need to identify objective representative data, but many were not able to identify a specific source for such data. CMS noted in the final rule that they received many comments expressing strong support for potential open forums or town hall meetings to discuss this process and they will consider these methods for gathering the information they need as they develop proposals for inclusion in next year's PFS proposed rule.
Currently, the Physician Compare website has a section, which indicates whether providers participated in Medicare quality programs. CMS had proposed to expand this section to add a green check mark to include the names of those individual eligible professionals and group practices who received an upward adjustment for the Value Modifier, which ASCRS opposed. CMS did not finalize this proposal.
CMS previously planned to make all 2015 PQRS measures for individual eligible professionals available for public reporting, and finalizes in this rule to continue to make all PQRS measures available for public reporting annually.
Physician Quality Reporting System (PQRS)
For 2016 PQRS reporting, CMS is not making any major changes to reporting via claims or registry. Therefore, providers reporting via claims will be required to report 9 measures, covering at least 3 National Quality Strategy domains, and report each measure for 50% of their Medicare Part B Fee-for-Service patients seen during the reporting period. Providers reporting via registry will report 1 measures group on 20 patients (more than 50% of which must be Medicare Part B patients). CMS is finalizing adding Measure 19, Diabetic Retinopathy: Communication with the Physician Managing Ongoing Diabetes Care to the Diabetes Retinopathy Measures Group.
Value Based Payment Modifier (VBPM)
CMS will to continue to apply the VBPM to all physicians in 2016, and continue to set the maximum upward adjustment under the CY 2018 (based on 2016 reporting) VM at +4.0 times an adjustment factor. CMS also finalized the amount of payment at risk under the CY 2018 VM at -4% for groups with ten or more eligible professionals, and at -2.0% for groups with between 1 and 9 eligible professionals, and groups and solo practitioners that consist only of nonphysician eligible professionals. Quality tiering will apply to all providers that satisfactorily report PQRS in 2016, with only groups consisting of nonphysician eligible practitioners being held harmless from downward quality tiering adjustments. CMS will waive the VM for groups and solo practitioners, if at least one eligible professional who billed under the group's Tax Identification Number (TIN) participated in the Pioneer ACO Model or other similar Innovation Center Models during the performance period.
Potentially Misvalued Codes
The ACA required CMS to identify "misvalued codes" in the MPFS. CMS uses a high expenditure screen to identify codes that meet the high expenditure criteria as potentially misvalued codes.
Included in the 2016 potentially misvalued services for review in the proposed rule were 92002 Eye Exam New Patient, 92136 Ophthalmic Biometry, 92240 Icg Angiography, 92250 Eye Exam with Photos, and 92275 Electroretinography.
In the final rule, CMS noted that commenters believed that 92002 was an ophthalmological E/M code and as a result should be excluded for the same reasons other E/M codes are excluded. CMS agreed and is not including 92002 on the list of codes identified for review through the high expenditure screen.
Impact on CY 2016 Payment for Selected Procedures
CY 2016 Estimated Impact on Total Allowed Charges by Specialty
Impact of Work RVU Changes
Impact of PE RVU Changes
Impact of MP RVU Changes
Additional information will be detailed in upcoming editions of Washington Watch Weekly. For additional assistance, please contact Ashley McGlone, manager of regulatory affairs, at 703-591-2220 or firstname.lastname@example.org.