2015 MEDICARE PHYSICIAN FEE SCHEDULE (MPFS)
FINAL RULE RELEASED
This evening, ASCRS reviewed final changes to payment policies and rates under the 2015 Medicare Physician Fee Schedule (MPFS) final rule  from the Centers for Medicare and Medicaid Services (CMS). The final rule will be effective for services on or after January 1, 2015.
2015 MPFS Conversion Factor
The CY 2015 MPFS conversion factor is $35.8013 for January 1, 2015 through March 31, 2015--as a result of Congress passing a "fix" to the SGR in April 2014. The "fix" provided for a zero percent update for services furnished between January 1 and March 31, 2015.
If Congress does not intervene before April 1, 2015, the MPFS 2015 conversion factor for April 1, 2015 through December 31, 2015 will be $28.2239. This conversion factor reflects the the -21.2% update from the SGR as well as the budget neutrality adjustment of -0.06%. ASCRS will continue to advocate for a full repeal and replacement of the SGR before the end of 2014.
Transition of 10 and 90-day Global Packages into 0-day Global Packages
CMS finalized the proposal to refine bundles by transitioning over several years all 10 and 90-day global codes to 0-day global codes. Medically reasonable and necessary visits will be billed separately during the pre- and post-operative periods outside of the day of the surgical procedure. The transition for current 10-day global codes will occur in CY2017 and for the current 90-day global codes in CY2018.
Physician Quality Reporting System (PQRS) for 2015
CMS will continue implementing quality improvement initiatives for physicians via the PQRS. For 2015 PQRS reporting, CMS is requiring that eligible professionals (EPs) report at least 9 measures, cover at least 3 of the National Quality Domains and report each measure for at least 50 percent of the eligible professionals Medicare Part B FFS patients seen during the reporting period to which the measure applies to avoid the PQRS penalty. There is no PQRS incentive payment for reporting in CY 2015. CMS also noted that their intention is to eliminate the claims-based reporting mechanism in future rulemaking.
For claims or registry reporting, if the EP sees a least one Medicare patient in a face-to-face encounter, the EP must report on at least 1 broadly applicable measure contained in the cross-cutting measure set as 1 of their 9 measures.
CMS is Retaining Many Ophthalmology Measures for Claims-Based Reporting
CMS had proposed to remove many of the ophthalmology measures from claims-based PQRS reporting. ASCRS strongly opposed the elimination of these measures via claims reporting and CMS opted to retain many of the measures.
Specifically, they retained Measure 14: Age-Related Macular Degeneration: Dilated Macular Examination, Measure 140: Age-Related Macular Degeneration: Counseling on Antioxidant Supplement, Measure 12: Primary Open-Angle Glaucoma Optic Nerve Evaluation, Measure 19: Diabetic Retinopathy: Communication with the Physician Managing Ongoing Diabetes Care, Measure 117: Diabetes: Eye Exam, and Measure 141: Primary Open-Angle Glaucoma: Reduction of Intraocular Pressure by 15 Percent or Documentation of a Plan of Care. This will allow providers to continue to report via claims for CY 2015.
CMS did finalize their proposal to remove Measure 18: Diabetic Retinopathy: Documentation of Presence or Absence of Macular Edema and Level of Severity of Retinopathy.
For EPs reporting via registry, CMS is maintaining that for 2017 PQRS payment adjustment (based on the 2015 reporting year), EPs can report on one measures group via registry and report the measures for 20 patients. CMS increased the number of measures in a measures group from 4 to 6 measures.
Measure Group Increases to 6 Measures
CMS is finalizing their proposal to increase the number of measures in the measures group from 4 to 6 measures. A list of the measures added to the Cataract Measures Group will be posted on our website.
CMS is expanding public reporting via the Physician Compare website. Group level measures will be expanded to make all 2015 PQRS GRPO web interface, registry and EHR measures for group practices of 2 or more eligible professionals and ACOs available for public reporting on Physician Compare in 2016. In addition, all 2015 PQRS individual measures collected via registry, EHR or claims will be made available for public reporting on Physician Compare in late 2016 if technically feasible.
CMS finalized the proposal to change the process for establishing values for new, revised and potentially misvalued codes each year by including proposed values for them in the proposed rule. CMS noted that they will use CY 2016 as a transition year, and beginning with valuations for CY 2017, the new process will be applicable to all codes.
EHR / Meaningful Use
CMS is still requiring providers who report clinical quality measures electronically to use the most recent version of eCQMS, however, beginning in CY2015, EPs will not have to ensure that their CEHRT products are recertified to the most recent version of the electronic specifications for the CQMs.
Value Based Payment Modifier (VBPM)
CMS finalized applying the Value Based Payment Modifier beginning in CY 2017 to all physicians including physicians in groups with two or more eligible professionals and physicians who are solo practitioners. This will be based on required information reported in 2015. CMS estimates that this will affect an additional 900,000 physicians. CMS also finalized applying the VBPM to non-physician eligible professionals in groups with two or more eligible professionals and to non-physician eligible professionals who are solo practitioners beginning in CY 2018.
Penalties for Groups of 10 or More Eligible Professionals
CMS had initially proposed to increase the penalty under the VBPM from -2% in the CY 2016 payment adjustment period to -4% for all providers in the CY2017 payment adjustment period. However, in this rule they finalized increasing the penalty from 2% to 4% in CY 2017 only for groups with 10 or more eligible professionals. Therefore, in CY 2017, a -4% penalty will apply to groups of ten or more eligible professionals who do not successfully report PQRS.
CMS also is increasing the maximum downward adjustment under the quality-tiering methodology for groups with ten or more eligible professionals to -4% for those groups classified as low quality / high cost and setting the adjustment at -2% for groups of ten or more EPs classified as low quality / average cost or average quality / high cost. CMS is also increasing the maximum upward adjustment under quality tiering in CY 2017 to +4% for groups of ten or more eligible professionals that are high quality / low cost and +2% for groups that are average quality / low cost or high quality / average cost.
Penalties for Groups of 2-9 and Solo Practitioners
Groups of 2-9 eligible professionals and solo practitioners will have a maximum penalty of -2% if the group or practitioner does not successfully report for PQRS. The maximum upward adjustment for groups of 2 or more eligible professionals or solo practitioners is +2% and they will not be subject to negative adjustments under quality tiering in 2017.
Open Payments/Sunshine Act
The Open Payments program is continuing. CMS finalized removing the continuing education exclusion that currently exempts payments to speakers at certain accredited or certifying continuing medical education events.
Potentially Misvalued Codes
CMS had identified 65 codes as potentially misvalued in the proposed rule, including 6 ophthalmology codes. CMS used a high expenditure screen as a tool to identify potentially misvalued codes. In the final rule, CMS is finalizing the high expenditure screen as a tool to identify potentially misvalued codes. However, CMS stated that given the resources required over the next several years to revalue the services with global periods, they are going to concentrate their efforts on those valuations and therefore did not finalize the codes identified through the high expenditure screen as potentially misvalued at this time. They will re-run the high expenditure screen at a future date and will propose codes that meet the high expenditure criteria at that time to be reviewed.
Impact of Final Rule on Ophthalmology
The following Tables show the impact of this final rule on ophthalmology. Due to an error that CMS made in calculating the Malpractice RVUs for ophthalmology codes in the previous five year review during CY 2010, ophthalmology and optometry will be reduced by -2 and -1 percent overall.