On October 31, 2014, CMS released the CY 2015 Physician Fee Schedule (PFS) final rule. CMS calculated the conversion factor using the Sustainable Growth Rate (SGR). Due to the Protecting Access to Medicare Act of 2014, there will be a 0.0 percent update (that is, no cuts) through March 2015. However, barring Congressional action, there will be a 21.2 percent cut effective April 1, 2015 mandated by the SGR formula. CMS implores Congress for a permanent SGR fix stating, “While Congress has provided temporary relief from these reductions every year since 2003, a long-term solution is critical. We will continue to work with Congress to fix this untenable situation . . . .”
In addition to updating the RVUs, the rule also updated a number of other items related to physician payment and quality reporting.
Medicare Telehealth Services
For CY 2015, CMS updated the list of telehealth services eligible for coverage under Medicare. Telehealth encounters for annual wellness visits, psychoanalysis, psychotherapy, and prolonged evaluation and management services will now be covered under Medicare.
Valuing New, Revised, and Potentially Misvalued CPT Codes
Beginning in CY 2016, with full implementation in CY 2017, CMS will annually identify CPT codes that are potentially misvalued. In the subsequent year, new, revised, and misvalued codes will be reviewed and revalued, if appropriate, via notice and comment rulemaking. CMS will also consider recommendations by the Relative Value Update Committee (RUC) and other relevant stakeholders in making its final determination. In the CY 2015 final rule, CMS identified several potentially misvalued services to be reviewed, including hip and knee replacements, radiation therapy, and epidural pain injections
Chronic Care Management
The final rule established CY 2015 payment for chronic care management (CCM)—$40.39 per patient/per 30 days, reduced from the $41.92 proposed amount. This payment accounts for non-face-to-face coordination services such as revision of a patient’s care plan, communication with other treating practitioners, and medication management.
To be eligible for payment, CCM services must be furnished using EHR certification criteria required by the prior year’s PFS payment year. For CY 2015, practitioners may use technology certified to either the 2011 or 2014 criteria. Furthermore, the electronic care plan must be accessible at all times to practitioners within the practice, and available to be shared electronically with care team members outside the practice.
Outpatient Therapy Caps
The therapy cap—a limitation on the expenses incurred for outpatient therapy services under Part B—are updated yearly based on the Medicare Economic Index (MEI). For CY 2015, the therapy cap amount is $1,940.
Definition of Colorectal Cancer Screening
The CY 2015 rule revises the definition of screening colonoscopy, such that anesthesia provided by a separate anesthesia practitioner does not trigger coinsurance and deductible payment obligations on the part of beneficiaries.
The final rule increases the ambulance fee schedule amount for ground ambulance transportation originating in rural areas by 3 percent. So-called “super rural” areas (the lowest 25th percentile of all rural populations by population density) will receive a 22.6 percent bonus. All other covered ground ambulance transportation fees will be increased by 2 percent.
Services “Incident To” Rural Health Clinics and Federally Qualified Health Center
To provide greater flexibility to staff Rural Health Clinics (RHCs) and Federally Qualified Health Centers (FQHCs), the final rule removes the requirement that incident to services furnished during an RHC or FQHC visit be furnished by an employee of the provider.
Manufacturer Payments to Physicians and Hospitals
Manufacturers of covered drugs, devices, biological, and medical supplies must annually submit information about payments or other transfers of value made to physicians and teaching hospitals under the “Open Payments” program. The CY 2015 final rule requires new disclosures: reporting of the marketed name and therapeutic area of the item, unless the payment or transfer of value was not related to a specific item, as well as reporting of stocks, stock options, and other ownership interests as payment. The final rule removes the Continuing Education Exclusion—that is, payments for speakers at certain educational events are no longer exempt from the Open Payments reporting requirements.
Physician Quality Reporting System (PQRS)
Starting in 2015, the PQRS will dictate payment adjustments based on whether practitioners and group practices satisfactorily report data on quality measures. Measures reported in 2015 will affect payments in 2017, and each reporting period will run for 12 months. The final rule outlines individual and group practice measures, and the various available reporting mechanisms.
Physician Compare Website
Public reporting on physician performance on the Physician Compare website continues under the final rule. The website will now include data from the 2015 PQRS measures for individuals and group practices, as well as Shared Savings Program ACO measures. The website will also include a notation for physicians successfully participating in the Medicare EHR Incentive Program.
While CMS still requires that eligible professionals who report quality measures for the Medicare EHR Incentive Program use the most recent version of the electronically specified clinical quality measures (eCQMs), they are not required to ensure that their Certified EHR Technology (CEHRT) are recertified to the most recent version of the electronic specifications for the CQMs.
Medicare Shared Savings Program
Under the Shared Savings Program, eligible groups of providers and suppliers can form Accountable Care Organizations (ACOs), subject to quality performance standards. The CY 2015 final rule includes a number of additions, deletions, and other revisions to required quality measures. New quality measures include depression remissions, diabetes measures for eye exams, and documentation of current medication in the medical record.
The full text of the rule is available by clicking here. This rule will be published in the Federal Register on November 13, 2014.