On October 31, 2014, the Centers for Medicare & Medicaid Services (CMS) issued the final rule with corresponding fact sheets updating policies and payment rates for physician and other health care provider services paid under the Medicare Physician Fee Schedule (MPFS) for calendar year (CY) 2015. The final rule also makes several changes to the Physician Quality Reporting System (PQRS), Medicare Shared Savings Program, and Medicare Electronic Health Record (EHR) Incentive Program, as well as changes to the Physician Compare website. Finally, the rule continues the phased-in implementation of the physician value-based payment modifier created by the Affordable Care Act, which would affect payments to physicians and physician groups, as well as other eligible professionals, based on the quality and cost of care they furnish to beneficiaries enrolled in the traditional Medicare fee-for-service program.
Select Highlights from the PFS Final Rule
The Protecting Access to Medicare Act of 2014 (PAMA) provided a 0.5 percent update in the conversion factor (CF) through the end of this year. The current CF is $35.8228; however, the law provides a 0 percent update for services furnished on or after January 1, 2015 through March 31, 2015. At that time, the CF will decrease slightly to $35.8013. Under current law, the CF is scheduled to drop again to $28.2239 on April 1, 2015.
Sustainable Growth Rate (SGR)
In most prior years, Congress has taken action to avert fee schedule cuts before the cuts take effect. If Congress fails to act, the SGR will be -21.2 percent. When final relative value scale adjustments are combined with the respective 2015 CFs, the net reductions in payment rates will be substantially different.
Open Payments (Physician Payment Sunshine Act)
As proposed – and over the objections of the AUA and many other stakeholders – CMS is finalizing its proposal to revise the Open Payments Final Rule published on February 8, 2013 to eliminate the language that expressly excluded from reporting any payments to speakers at certain accredited or certified Continuing Education (CE) events. CMS states that some payments or transfers of value made to support a CE event may still be excluded from reporting requirements as "indirect payments", and provides examples of circumstances where CE payments may satisfy – or fail to satisfy – this indirect payments exclusion. The AUA, the American Medical Association, and the Council of Medical Specialty Societies opposed the policy change, concerned that eliminating the existing CE exclusion for accredited and certified groups under the Open Payments program would have an unintended outcome, as it would open the door for unapproved standards that are not part of the universally accepted continuing medical education accreditation system. learn more about the final rule policy change.
Improving the Valuation and Coding of the Global Package
CMS confirmed its proposal to transform all codes with 10- and 90-day global periods to 0-day global codes starting in CY 2017 and 2018, respectively. The agency will actively assess whether there is a better construction of a bundled payment for surgical services that incentivizes care coordination and care redesign across an episode of care as they begins to revalue services. The AUA, along with many other specialty societies, and the American Medical Association opposed this proposal. The AUA believes the proposal to transition all global surgical codes is premature. Rather than deconstruct the current global payment structure, the AUA recommended that CMS develop a more effective mechanism to increase accuracy of physician fee schedule payments within the global structure.
Enhanced Transparency in Rate Setting
CMS will adopt a new process for valuing new, revised and potentially misvalued codes for CY 2016, so that payment for the vast majority of codes undergo notice and comment rulemaking prior to being adopted. CMS initially proposed to adopt the new process for 2016. Instead, CMS is finalizing the proposal with a transition in CY 2016 and full implementation in CY 2017. CMS made several adjustments in the policy to minimize the need for Medicare-specific G-codes. The AUA supported a new process that would allow CMS to publish the proposed RVUs for CPT codes in the MPFS proposed rule instead of the MPFS Final Rule for 2017; however, the AUA disagreed with the proposed timeline to implement this change in 2016, as it would impact code changes already underway.
Summary of PQRS Measures
For 2015, CMS will add 20 new individual measures and two measures groups to fill existing measure gaps. CMS will remove 50 measures from reporting for the PQRS, bringing the individual measure set to 255 total measures. Generally, eligible professionals (EPs) need only report nine measures covering three National Quality Strategy (NQS) domains.
Individual EPs and Group Practices Reporting PQRS Measures Under the Group Practice Reporting Option (GPRO)
To avoid a payment adjustment in 2017, EPs and group practices reporting via claims or registry who see at least one Medicare patient in a face-to-face encounter must report on at least one measure from a newly cross-cutting measures set in addition to any other measures that the EP is required to report. All group practices of 25 or more EPs using the GPRO web interface must report measures on a beneficiary sample of 248 patients. In addition, all group practices of 100 or more EPs that are registered for the GPRO must report on the Consumer Assessment of Healthcare Provider and Systems survey (CAHPS) for PQRS regardless of the reporting mechanism the group practice chooses. The group practices will bear the cost of administering CAHPS for PQRS.
Most provisions of the final rule are effective January 1, 2015. CMS will accept comments on the final rule until December 30, 2014. To learn more about how the proposed rule policies will affect reimbursement rates for urology services, view the conversion tables below.
AUA staff is currently analyzing the final rule and the implications for urology services. A detailed analysis will be provided in a separate update. If you have questions about the final payment and policy changes, please contact the AUA at R&R@AUAnet.org.