Medicare Physician Fee Schedule for Calendar Year (CY) 2017 Released

On July 7, 2016, the Centers for Medicare & Medicaid Services (CMS) issued a proposed rule that updates payment policies, payment rates, and quality provisions for services furnished under the Medicare Physician Fee Schedule (PFS) on or after January 1, 2017. This year, CMS is proposing a reduction in the conversion factor for fee-for-service payment from 35.8279 to 35.7751. The change has resulted in slight decreases in payment rates for skilled nursing facility (SNF) visits as is reflected in the table below.

SNF Visit Payment Rates with 2017 Conversion Factor of 35.7751

The CY 2017 proposed MPFS conversion factor is $35.7751, which reflects a budget neutrality adjustment of -0.51% and the 0.5% update factor specified under MACRA.

CMS has also released an updated look at the visit rates in skilled nursing facilities.

Using 2015 utilization rate released by CMS. Practitioner visits have continued to increase but at a slower rate compared to all other sites of service:

2015 Physician Visit Rates

The visits by Internists, Family Practitioners, and Geriatricians have remained the same from 2009 – 2015. The overall increase in visits are due to others such as NP, PA, PMR, and Psychiatry which are up 50% from 2009 to 2015. In 2013, NP/PA visits constituted 30% of all PALTC visits while in 2015 they constituted 32.7% of all visits. The data further shows that in 2015, 40% of all 99309 visits were made by NP/PA, and 45% of all 99310 visits were made by NP/PA.

Improving Payment Accuracy for Primary Care, Care Management, and Patient-Centered Services

CMS is proposing a number of coding and payment changes to better identify and value primary care, care management, and cognitive services. As a result of the Society’s advocacy along with colleagues from many primary care specialties, CMS has proposed making payment for a number of services provided to chronically ill older adults—changes which dramatically improve current payment for chronic care management and management of people transitioning from hospital care to the home. These proposals include:

• Make separate payments for certain existing Current Procedural Terminology (CPT) codes describing non-face-to-face prolonged evaluation and management services.
• Revalue existing CPT codes describing face-to-face prolonged services.
• Make separate payments using new codes to describe the comprehensive assessment and care planning for patients with cognitive impairment (e.g., dementia).
• Make separate payments using new codes to pay primary care practices that use interprofessional care management resources to treat patients with behavioral health conditions. Several of these codes describe services within behavioral health integration models of care, including the Collaborative Care model that involves care coordination between a psychiatrist or behavioral health specialist and the primary care clinician, which has been shown to improve quality.
• Make separate payments using new codes to recognize the increased resource costs of furnishing visits to patients with mobility-related impairments. Like several of these proposed codes, this is especially relevant for the Medicare-Medicaid dually-eligible population.
• Make separate payments for codes describing chronic care management for patients with greater complexity.
• Make several changes to reduce administrative burden associated with the chronic care management codes to remove potential barriers to furnishing and billing for these important services.

Medicare Telehealth Services: End-Stage Renal Disease (ESRD) and Advanced Care Planning

CMS is proposing to add several codes to the list of services eligible to be furnished via telehealth. These include:

• End-stage renal disease (ESRD) related services for dialysis;
• Advance care planning services;
• Critical care consultations furnished via telehealth using new Medicare G-codes

. CMS is also proposing payment policies related to the use of new place of service code specifically designed to report services furnished via telehealth.

Medicare Shared Savings Program

The CY 2017 PFS proposed rule includes the following proposed policies specific to certain sections of the Shared Savings Program regulations:

• Updates to Accountable Care Organization (ACO) quality reporting, including changes to the quality measure set and the quality validation audit, revisions to terminology used in quality assessment, revisions that would permit eligible professionals in ACOs to report quality apart from the ACO, and updates to align with the Physician Quality Reporting System and the proposed Quality Payment Program;
• Modifications to the assignment algorithm to align beneficiaries to an ACO when a beneficiary has designated an ACO professional as responsible for their overall care;
• Establishing beneficiary protection policies related to use of the SNF 3-day waiver; and,
• Technical changes to certain rules related to merged and acquired TINs and for reconciliation of ACOs that fall below 5,000 beneficiaries, and other program refinements

Other Proposals

• Proposing modifications to the Medicare Shared Savings Program to update the quality measures set and align with the proposals for the Quality Payment Program, changes to take beneficiary preferences for ACO assignment into consideration, and changes that would improve beneficiary protections when ACOs are approved to use the skilled nursing facility (SNF) 3-day waiver rule;
• Requiring health care providers and suppliers to be screened and enrolled in Medicare in order to contract with Medicare Advantage health plans to provide Medicare-covered items and services to beneficiaries enrolled in Medicare Advantage;
• Increasing transparency of Medicare Advantage pricing data and medical loss ratio (MLR) data from Medicare health and drug plans, and;
• Continuing to implement Appropriate Use Criteria for advanced diagnostic imaging services, including proposals for priority clinical areas and clinical decision support mechanism (CDSM) requirements, among other proposals as detailed in this fact sheet.
• CMS will accept comments on the proposed rule until September 6, 2016, and the Society will review and prepare comments for submission.

For More Information:

• Proposed Rule (CMS-1654-P): Comments due no later than 5 pm on September 6, 2016
• Fact Sheet
• Blog
• Diabetes Prevention Program