Print Article

January 7, 2014
The essential resource for your practice
Volume XXI, Number 1
Table of Contents

  

Summary of the 2014 Medicare Physician Fee Schedule Final Rule

On December 26, 2013, President Obama signed into law the “Pathway for SGR Reform Act of 2013.” This new law prevented the scheduled 24 percent payment reduction under the 2014 Medicare Physician Fee Schedule (MPFS) from taking effect on January 1, 2014. Although the MPFS final rule released on November 27, 2013 called for a 20.1 percent reduction, largely as a result of the statutory sustainable growth rate (SGR) formula, when adjustments to the relative value scale are combined with the conversion factor, the net reduction is about 24 percent. The new law averts the 20.1 percent cut and replaces it with a 0.5 percent increase for services provided through March 31, 2014, resulting in a conversion factor of $35.8228 for calendar year (CY) 2014. The short-term fix will give lawmakers more time to permanently repeal the SGR and finalize other Medicare payment reforms. 

CMS is currently revising the 2014 MPFS to reflect the new law’s requirements as well as technical corrections identified since publication of the final rule in November. The new law also extends several provisions of the Middle Class Tax Relief and Job Creation Act of 2012, as well as provisions of the Affordable Care Act (ACA). Section 1102 of the new law extends the existing 1.0 floor on the physician work geographic practice cost index through March 31, 2014. As with the physician payment update, this extension will be reflected in the revised 2014 MPFS. While Medicare sequester cuts applicable to the MPFS remain at 2.00 percent for now, Section 1205 of the law realigns the sequester amount for fiscal year 2023, which will increase to 2.9 percent for the first six months, then drop to 1.1 percent for the remainder of the year.

Using Opps and Asc Rates in Developing PE RVUS

As mentioned in the December 3 edition of Health Policy Brief, in the final rule, CMS did not adopt its proposal to adjust relative values under the MPFS to cap practice expense payments for non-facility services at the hospital outpatient department (OPD) or ambulatory surgical center (ASC) facility rate. In the AUA’s comment letter on the proposed rule, several flaws in the proposed methodology were identified. Following strong opposition from the AUA and the medical community, CMS withdrew the proposal, but did note in the final rule that the agency is planning to take additional time to consider the points and questions raised in the public comments and to address the issue in future rulemaking.

Validating RVUs of Potentially Misvalued Codes

In recent years, CMS and the Relative Value Scale Update Committee (RUC) have implemented processes to identify and address potentially misvalued codes. Starting in 2011, CMS and the RUC began reviewing potentially misvalued codes on an annual basis, in lieu of the traditional 5-year review of relative value units (RVUs). In addition, the ACA requires CMS to periodically identify, review, and adjust values for potentially misvalued codes. To fulfill the ACA mandate, CMS entered into contracts with the RAND Corporation and the Urban Institute to develop validation models for RVUs. New time data for the following urology codes will be collected as part of the validation model to be developed for the study:

CPT Code

Descriptor

52000

Cystoscopy (separate procedure)

52224

Cystourethroscopy, with fulguration (including cryosurgery or laser surgery) or treatment of minor (less than 0.5 cm) lesion(s) with or without biopsy

52281

Cystoscopy, with calibration and/or dilation of urethral stricture or stenosis, with or without meatotomy, with or without injection procedure for cystography, male

52601

Transurethral electrosurgical resection of prostate, including control of postoperative bleeding, complete (vasectomy, meatotomy, cystourethroscopy, urethral calibration and/or dilation, and internal urethrotomy are included)

55700

Biopsy, prostate; needle or punch, single or multiple, any approach

55866

Laparoscopy, surgical prostatectomy, retropubic radical, including nerve sparing, includes robotic assistance, when performed

CMS anticipated the studies to be completed over a two-year period. In the interim, the AUA will request a greater level of transparency in the development process and the opportunity for stakeholder input on any proposed recommendations prior to implementation.

Contractor Medical Director Identified Potentially Misvalued Codes

As part of the ACA mandate to identify potentially misvalued codes, CMS reached out to Medicare contractor medical directors (CMDs) for input to increase identification of inappropriately valued codes. Among the codes identified as potentially misvalued are the following urology codes:

CPT Code

Descriptor

55845

Prostatectomy, retropubic radical, with or without nerve sparing; with bilateral pelvic lymphadenectomy, including external iliac, hypogastric, and obturator nodes

55866

Laparoscopy, surgical prostatectomy, retropubic radical, including nerve sparing, includes robotic assistance, when performed

64566

Posterior tibial neurostimulation, percutaneous needle electrode, single treatment, includes programming

76942

Ultrasonic guidance for needle placement (eg, biopsy aspiration, injection, localization device), imaging supervision and interpretation

Following the release of the final rule, the AUA submitted Action Plans to the RUC for review of these codes. In our comment letter on the proposed rule, we urged CMS to defer any action on these codes until after the RUC review process was completed. Despite our request to concede to RUC review, CMS finalized the proposal to review the services as potentially misvalued, but did note in the final rule that it will consider AMA RUC recommendations through the usual review of potentially misvalued codes.

In addition, CMS affirmed the proposal to reduce the procedure time for CPT code 76942 from 45 minutes to 10 minutes, and to reduce the total clinical labor and equipment time from 58 to 23 minutes. These changes will result in an overall drop in RVUs from 6.13 to 2.07. CMS also adopted the RUC recommendation, which the AUA supported, to change the practice expense inputs for ultrasound equipment services for CPT code 76942 from room, ultrasound, general, EL015 to ultrasound unit, portable, EQ250.

CPT codes 55845 and 76942 will be surveyed for consideration at the April 2014 RUC meeting. In the interim, the AUA will further comment on CMS’ decision to move forward with the review process prior to RUC review.

Establishing RVUs for CY 2014

The following CY 2013 interim final work values were finalized for CY 2014 as reflected in Table 24 of the final rule.

CPT Code

Descriptor

CY 2013 
Work RVU

CY 2014
Work RVU

CY 2014
Action

50590

Lithotripsy, extracorporeal shock wave

9.77

9.77

Finalized

52214

Cystourethroscopy, with fulguration (Including cryosurgery or laser surgery) of trigone, bladder neck, prostatic fossa, urethra, or periurethral glands

3.50

3.50

Finalized

52224

Cystourethroscopy, with fulguration (including cryosurgery or laser surgery) or treatment of minor (less than 0.5 cm) lesion(s) with or without biopsy

4.05

4.05

Finalized

52234

Cystourethroscopy, with fulguration (including cryosurgery or laser surgery) and/or resection of; small bladder tumor(s) (0.5 up to 2.0 cm)

4.62

4.62

Finalized

52235

Cystourethroscopy, with fulguration (including cryosurgery or laser surgery) and/or resection of; medium bladder tumor(s) (2.0 to 5.0 cm)

5.44

5.44

Finalized

52240

Cystourethroscopy, with fulguration (including cryosurgery or laser surgery) and/or resection of; large bladder tumor(s)

7.50

7.50

Finalized

52287

Cystourethroscopy, with injection(s) for chemodenervation of the bladder

3.20

3.20

Finalized

52351

Cystourethroscopy, with ureteroscopy and/or pyeloscopy; diagnostic

5.75

5.75

Finalized

52352

Cystourethroscopy, with ureteroscopy and/or pyeloscopy; with removal or manipulation of calculus (ureteral catheterization is included)

6.75

6.75

Finalized

52353

Cystourethroscopy, with ureteroscopy and/or pyeloscopy; with lithotripsy (ureteral catheterization is included)

7.50

7.50

Finalized

52354

Cystourethroscopy, with ureteroscopy and/or pyeloscopy; with biopsy and/or fulguration of ureteral or renal pelvic

8.00

8.00

Finalized

52355

Cystourethroscopy, with ureteroscopy and/or pyeloscopy; with resection of ureteral or renal pelvic tumor

9.00

9.00

Finalized

53850

Transurethral destruction of prostate tissue; by microwave thermotherapy

10.08

10.08

Finalized

In establishing interim final direct practice expense (PE) inputs for CY 2013, CMS finalized values for surgical pathology CPT codes 88300- 88309 and revised the descriptors for HCPCS G codes for microscopic examination for prostate biopsy from prostate needle saturation to biopsy sampling as follows:

  • G0416 (Surgical pathology, gross and microscopic examination for prostate needle biopsies, any method; 10-20 specimens),
  • G0417 (Surgical pathology, gross and microscopic examination for prostate needle biopsies, any method; 21-40 specimens),
  • G0418 (Surgical pathology, gross and microscopic examination for prostate needle biopsies, any method; 41-60 specimens); and
  • G0419 (Surgical pathology, gross and microscopic examination for prostate needle biopsies, any method; greater than 60 specimens).

The AUA will publish a separate Coding Corner article in the Health Policy Brief and issue an email alert to provide guidance on appropriate selection and application of the G codes for prostate biopsy.

Geographic Practice Cost Indices (GPCIs)

CMS is required to develop separate GPCIs to measure resource cost differences among localities compared to the national average for each of the three components (physician work, practice expense, and malpractice) of the physician fee schedule. The agency is required by statute to review and adjust the GPCIs as needed, at least every three years. The American Taxpayer Relief Act of 2012 (ATRA) extended the 1.0 Work floor GPCI through December 31, 2013 for all states except Alaska, which has a permanent 1.5 percent Work floor, and the frontier states (Montana, Wyoming, North Dakota, Nevada and South Dakota), have a 1.0 percent work floor through 2014. In the AUA’s comment letter on the proposed rule, we urged CMS to work with Congress to maintain the 1.0 work GPCI in 2014 for all states. As mentioned above, the Pathway for SGR Reform Act of 2013 extends the 1.0 percent GPCI through 2014.

Physician Quality Reporting System (PQRS)

In the final rule, CMS adopted several proposed changes for the PQRS. In 2014, the PQRS will include the addition of 57 new individual measures and 2 measures groups to fill existing measure gaps. For 2014, PQRS will contain a total of 287 measures and 25 measures groups. As proposed, CMS retired a number of measures (Table 54) from reporting in the PQRS in 2014.

The most significant change, which the AUA objected to in our comment letter, is that eligible professionals (EPs) who chose to report individual measures either via claims or registry must now report 9 (up from 3 measures) covering at least 3 domains of care in order to satisfactorily report in 2014 and qualify for the 0.5 percent bonus payment. Those wishing to solely avoid the 2016 two percent payment adjustment (penalty), which is based on 2014 reporting, must report on at least 3 individual measures via claims or registry for 50 percent or more eligible Medicare patients. After 2016, the penalty remains at 2 percent and will be applied depending on the provider’s performance for the reporting period. 

Reporting Period and Threshold: CMS will also maintain the current 12-month calendar year reporting period for the PQRS program but will eliminate the option to report on measures groups via claims. In the final rule, CMS affirmed the proposal to decrease the reporting threshold from 80 percent to 50 percent for applicable patients, which the AUA supported in our comment letter on the proposed rule.

Reporting Criteria for 2016 Payment Adjustment:  CMS also finalized changes to certain criteria for satisfactory reporting, as well as adopted new criteria, for group practices for the 2014 PQRS incentive and 2016 PQRS payment adjustment. The changes include:

  • Adopting a new reporting mechanism, the certified survey vendor reporting mechanism, under which a group comprised of 25 or more eligible EPs reports Group Consumer Assessment of Healthcare Providers and Systems (CG CAHPS) survey measures in conjunction with other PQRS reporting mechanisms.
  • Aligning the reporting criteria for group practices reporting individual measures via registry with the individual EPs reporting criteria for the 2014 PQRS incentive and 2016 PQRS payment adjustment.

Alignment of Reporting Requirements:  In 2014, CMS will align quality measures across quality reporting programs so that physicians and other EPs may report a measure once to receive credit in all quality reporting programs in which that measure is used. As previously reported, CMS is aligning PQRS measures with the National Quality Strategy (NQS) and meaningful use requirements, and transitioning away from process measures in favor of performance and outcome measures. Finally, certain data collected in 2012 for groups of 100 or more reporting certain PQRS measures under the Group Practice Reporting Option (GPRO) will be publicly reported on the CMS Physician Compare website in 2014.

Qualified Clinical Data Registries:  The ATRA provides EPs with an alternative to satisfy PQRS data submission requirements if the EP participates in a qualified clinical data registry (QCDR). In the final rule, for the 2014 PQRS incentive, EPs participating in a QCRD may meet the criteria for satisfactory participation by reporting at least 9 measures, at least one of which must be an outcome measure. Collectively, the measures must cover a minimum of 3 domains of care, and each measure must be reported for at least 50 percent of the EP's applicable patients. For the 2016 PQRS payment adjustment (based on 2014 reporting), EPs participating in QCDR need only report 3 measures covering 1 domain for at least 50 percent of the EP's applicable patients.

The AUA Board of Directors recently approved the development and launch of the AUA Quality (AQUA) Registry, which will initially focus on prostate cancer and gradually expand to other urological conditions. The AQUA Registry will be implemented in a phased manner over two years and will be built with electronic medical record (EMR) data integration capability to meet CMS regulatory requirements.

Value-Based Payment Modifier and Physician Feedback Program

The ACA calls for CMS to establish a value-based payment modifier (VBPM) that provides for differential payment to a physician or group of physicians under the MPFS based upon the quality of care furnished to Medicare beneficiaries compared to the cost of that care during a given performance period. In addition, the law requires CMS to begin applying the VBPM in 2015 to certain physicians and groups, and to apply it to all physicians and groups no later than January 1, 2017. The statute also requires that the VBPM be implemented in a budget neutral manner, meaning that upward payment adjustments for high performance will balance the downward payment adjustments applied for poor performance.

Group Size:  In the final rule, CMS affirmed its proposal to apply the VBPM to groups of physicians with 10 or more EPs, and to apply upward and downward payment adjustments based on performance to groups of physicians with 100 or more EPs. However, only upward adjustments based on performance (not downward adjustments) will be applied to groups of physicians with between 10 and 99 EPs. In our comments on the proposed rule, the AUA expressed concern about lowering the inclusion criteria to groups of 10 or more and requested additional time to test the system with larger group practices before extending to groups of 10 or more EPs.

Quality Tiering:  In addition, CMS finalized the proposal for mandatory quality-tiering for groups of physicians with 10 or more EPs and increased the maximum downward adjustment under the quality-tiering methodology to -2.0 percent for groups of physicians subject to CY 2016 VBPM that fall in Category 1 that are classified as low quality/high cost. For groups classified as either low quality/average cost or average quality/high cost, the adjustment will be set at -1.0. In our comments on the proposed rule, the AUA stated an adjustment of -2.0 is too much of an increase (decrease) by 2016 and recommended that CMS allow more time for physicians, particularly specialists, to adapt to quality tiering, mainly for smaller groups of 10-50 EPs.

For the 2016 VBPM, CMS will allow use of all PQRS measures available for reporting under various reporting mechanisms to calculate a group of physicians' VBPM in 2016. CMS also will allow groups of 25 or more EPs the option to elect to have the patient experience of care measures collected through the PQRS CG-CAHPS survey for 2014 included in their VBPM for 2016. The AUA supported CMS' proposal to provide physicians with flexibility in selecting the quality measures to report, as this would allow specialists to select measures that are meaningful to their practice rather than identifying a core set of measures.

Two-Category Approach:  CMS finalized the proposed two-category approach for establishing the 2016 VBPM based on whether a group of physicians meets the criteria to avoid the PQRS payment adjustment in 2016. Category 1 will include groups of physicians with 10 or more EPs that meet the satisfactory reporting criteria through the PQRS GPRO for the 2016 PQRS payment adjustment. Groups of physicians with 10 or more EPs that do not meet the criteria for inclusion in Category 1 will fall into Category 2 and will be subject to an automatic downward payment adjustment under the VBPM. In our comment letter on the proposed rule, the AUA supported the proposed two-category approach for establishing the 2016 VBPM to allow groups of 10-99 EPs the opportunity to learn and adapt to the VBPM without fear of penalty.

Inclusion of the Medicare Spending per Beneficiary Measure in the VBPM Cost Composite:  In the final rule, CMS confirmed inclusion of the Medicare Spending Per Beneficiary (MSPB) measure in the cost composite of the VBPM beginning in 2016. The MSPB measure includes all Medicare Part A and Part B payments during an MSPB episode. This measure will be included in the total per capita costs for all attributed beneficiaries domain along with the total per capita cost measure, and each measure will be weighted equally in the domain. The AUA recommended against use of the MSPB measure for the VBPM cost composite in our comment letter, as we believe it does not provide a clear link between specialist resource use and patient quality of care.

Refinements to the Cost Measure Composite Methodology:  In the proposed rule, CMS put forward two methods (Specialty Adjustment vs. Comparability Peer Grouping) to refine the cost measure composite methodology for physician specialty groups because the 2011 data indicated that the current peer grouping methodology could have varied impacts on specialties. In the final rule, CMS adopted the proposal to refine the current peer group methodology to account for physician specialty composition of the group prior to computing the standardized score for each cost measure. The AUA supported the specialty adjustment method because the comparability peer grouping raises concerns about identifying a comparable specialty mix on which to develop the benchmark.

Performance Period:  In addition, CMS finalized the proposal to use 2015 as the performance period for the application of the 2017 VBPM, although the AUA commented in favor or closing the gap between the end of the performance period and the beginning of the payment adjustment period to allow for EPs to make improvements in quality of care provided in a timely manner in response to feedback received.

Quality and Resource Use Reports (QRURs):  In September 2013, CMS made QRURs available to all groups of 25 or more EPs nationwide, based on 2012 data. In the final 2014 MPFS, CMS anticipates providing QRURs to all groups of EPs and solo practitioners to explain how the VBPM would affect payment under the MPFS. In our comments on the proposed rule, the AUA supported gradual implementation of the QRURS, but cautioned CMS to proceed cautiously in expanding the Physician Feedback Program and QRURs.

Feedback Reports:  In the proposed rule, CMS sought public comment on whether to merge feedback reports for the VBPM with PQRS. While the AUA supported the proposal to combine PQRS and performance data for the VBPM into a single report, CMS did not finalize any changes to the annual QRURs. Instead, CMS will continue to develop and refine the reports in an iterative manner. In the late summer of CY 2014, CMS plans to disseminate the QRURs based on CY 2013 data to all physicians (that is, TINs of any size) even though groups of physicians with fewer than 100 EPs will not be subject to the VBPM in CY 2015. The reports will contain performance on quality and cost measures used to score the composites and additional information to help physicians coordinate care and improve the quality of care furnished. The reports will be based on the VBPM policies finalized in the rule that will take effect January 1, 2014 and that will affect physician payment starting January 1, 2016.

Medicare Electronic Health Records (EHR) Incentive Program

To minimize the burden of reporting, CMS proposed two additional options (Qualified Clinical Data Registry Reporting Option or the Group Reporting Option – Comprehensive Primary Care Initiative) for EPs to report clinical quality measures (CQMs) for the Medicare EHR Incentive Program for CY 2014 and subsequent years. In the final rule, CMS finalized the option for EPs to submit CQMs based on the following criteria:

  1. EPs must use CEHRT as required under the Medicare EHR Incentive Program;
  2. CQMs reported must be included in the Stage 2 final rule and use the same electronic specifications established for the EHR Incentive Program;
  3. EPs must report 9 CQMs covering at least 3 domains;
  4. If an EP's Certified EHR technology (CEHRT) does not contain patient data for at least 9 CQMs covering at least 3 domains, then the EP must report the CQMs for which there is patient data and report the remaining CQMs as “zero denominators” as displayed by the EP's CEHRT; and
  5. EPs must have CEHRT that is certified to all of the certification criteria required for CQMs, including certification of the qualified clinical data registry itself for the functions it will fulfill (for example, calculation, electronic submission).

This option would only be open to those EPs who have completed their first year demonstrating meaningful use. EPs who do not wish to report CQMs electronically using the most recent version of the electronic specifications (for example, if their CEHRT has not been certified for that particular version) would be allowed to report CQM data to CMS by attestation for the Medicare EHR Incentive Program.

Physician Compare Website

The ACA requires that CMS develop a Physician Compare website with information on physicians enrolled in the Medicare program as well as information on other EPs who participate in the Physician Quality Reporting System (PQRS).

In the rule, CMS finalized the proposal to publically report measures performance rates collected through the Group Practice Reporting Option (GPRO) web interface for groups of all sizes participating in the 2014 PQRS GPRO and for Accountable Care Organizations (ACOs) participating in the Medicare Shared Savings Program (MSSP). In our comment letter, we recommended CMS allow patients to have a say on to which physician their service is attributed, as we believe this approach would underscore the importance that CMS places on patients and their involvement in their healthcare experience.

CMS also finalized the 30-day preview period to allow group practices and ACOs to view their data prior to publication on the Physician Compare website. The AUA objected to the 30-day preview period in our comment letter and expressed concern about the accuracy of the underlying database. We believe a 30-day preview period is insufficient and will continue to advocate for a longer preview period to ensure that quality measure performance data are accurate prior to posting on the Physician Compare website.

In addition, CMS finalized its proposal to post performance on the patient experience survey-based measures for groups that elect to report the CG-CAHPS Measures, although CG-CAHPS is not typically used by urology practices to report patient satisfaction. In our comment letter to CMS, we suggested that CMS clarify that the lack of reported data for some practices is not a negative finding; rather, this measure is not meaningful for those providers who collect and report patient satisfaction via another mechanism.

Medicare Shared Savings Program (MSSP)

CMS continues to align the MSSP with the PQRS. ACOs will report the ACO GPRO measures through a CMS web interface on behalf of EPs and must meet the criteria for the 2014 PQRS incentive to avoid the 2016 PQRS payment adjustment.

CMS also finalized the proposals to use fee-for-service data, including data submitted by the MSSP and Pioneer ACOs, to set the performance benchmarks for the 2014 and subsequent reporting periods. CMS did not finalize the proposal to use Medicare Advantage data alone or in combination with fee-for-service data in the short-term to set ACO performance benchmarks. Additionally, CMS will set benchmarks based on flat percentages when the 60th percentile is equal to or greater than 80.0 percent.

Finally, CMS affirmed the proposal to increase the scoring for the CG-CAHPs survey measure modules within the patient experience of care domain that transition to pay-for-performance in the second year of an ACO's agreement period. Although the weight of some measure modules within the domain will increase, the domain itself will continue to represent 25 percent of the total quality performance score.

Although most provisions in the final rule are effective January 1, 2014, CMS will accept public comments until January 27. The AUA remains concerns with several of the provisions adopted in the final rule and intends to comment further on the issues of most concern to our members. If you have questions about the final rule, please contact the AUA at R&R@AUAnet.org.