Sustainable Growth Rate (SGR)
The Protecting Access to Medicare Act of 2014 provides for a zero percent update from the CY 2014 rates for services furnished between January 1, 2015, and March 31, 2015.
Adjusting by .06 percent to achieve required budget neutrality, the conversion factor for this period
Under current law, the conversion fact or will be adjusted on April 1, 2015. In the final rule CMS announced a conversion factor of $28.2239 for this period, resulting in an average reduction
of 21.2 percent from the CY 2014 rates. In most prior years, Congress has taken action to avert large across-the-board reductions in PFS rates before they went into effect. The Administration supports legislation to permanently change SGR to provide more stability for Medicare beneficiaries and providers while promoting efficient, high quality care.
Screening and Diagnostic Digital Mammography
To ensure that the higher resources needed for 3D mammography are recognized, Medicare will
pay for 3D mammography using add-on codes that will be reported in addition to the 2D mammography codes when 3D mammography is furnished.
Primary Care and Chronic Care Management
Medicare continues to emphasize primary care by making payment for chronic care management (CCM) services — non-face-to-face services to Medicare beneficiaries who have two or more chronic conditions — beginning January 1, 2015. CCM services include regular development and revision of a plan of care, communication with other treating health professionals, and medication management. CCM can be billed once per month per qualified beneficiary, provided the minimum level of services is furnished.
CMS is finalizing its proposal to allow greater flexibility in the supervision of clinical staff providing CCM services. The proposed application of the “incident to” supervision rules was widely supported by the commenters.
Payment for CCM is only one part of a multi-faceted CMS initiative to improve Medicare beneficiaries’ access to primary care. Models being tested through the Innovation Center will continue to explore other primary care innovations.
Finally, CMS will require that in order to bill CCM, a practitioner must use a certified electronic
health record (EHR) that meets the requirements for the EHR Incentive Program as of December 31
of the prior calendar year.
Application of Beneficiary Cost Sharing To Anesthesia Related To Screening Colonoscopies
The Medicare statute waives the Part B deductible and coinsurance applicable to screening colonoscopy. In the CY 2015 final rule, CMS revised the definition of a “screening colonoscopy” to
include separately provided anesthesia as part of the screening service so that the coinsurance and
deductible do not apply to anesthesia for a screening colonoscopy, reducing beneficiaries’ cost-
sharing obligations under Part B.
Enhanced Transparency in Setting PFS Rates
Since the beginning of the physician fee schedule in 1992, CMS adopted rates for new and revised
codes for the following calendar year in the final rule on an interim basis subject to public comment. This policy was necessary because CMS did not receive the codes in time to include in the PFS proposed rule. Until recently, the only services that were affected by this policy were services with new and revised codes. In recent years, CMS began receiving new and revised codes and revaluing existing services under the misvalued codes initiative. Establishing payment in the final rule for misvalued codes often led to implementation of payment reductions before the public had the opportunity to comment.CMS finalized its proposal to change the process for valuing new, revised and potentially misvalued codes for CY 2016, so that payment for the vast majority of these codes goes through notice and comment rulemaking prior to being adopted. After a transition in CY 2016, the process will be fully implemented in CY 2017.
Potentially Misvalued Services
Consistent with amendments to the Affordable Care Act, CMS has been engaged in a vigorous effort
over the past several years to identify and review potentially misvalued codes, and to make adjustments where appropriate. The following are major misvalued code decisions for 2015:
• Radiation Therapy and Gastroenterology: Consistent with the final rule policy and in response to public comments, CMS is not adopting the Procedure coding changes for CY 2015 for gastroenterology and radiation therapy services so that CMS can propose and obtain comments on the revised coding prior to using them for payment. As a result, CMS will not recognize some new Procedure codes, and reate
d G-codes in place of changed and new Procedure codes.
• Radiation Treatment Vault: CMS proposed to refine the way it accounts for the infrastructure costs associated with radiation therapy equipment, specifically to remove the radiation treatment vault as a direct expense when valuing radiation therapy services. After considering public comments, CMS did not finalize this proposal.
• Epidural Pain Injections: CMS reduced payment for these services in 2014 under the misvalued code initiative. In response to concerns from pain physicians regarding the accuracy of the valuation, CMS proposed to raise the values in 2015 based on their prior resource inputs before adopting further changes after considering RUC recommendations. However, because the inputs for these services
included those related to image guidance, CMS also proposed to prohibit separate billing for image guidance for CY 2015. CMS finalized the policy as proposed to avoid duplicate payment for image guidance. CMS has asked the RUC to further review this issue and make recommendations to us on how to value epidural pain injections.
• Film to Digital Substitution: CMS finalized its proposal to update the practice expense inputs for X-ray services to reflect that X-rays are currently done digitally rather than with analog film.
The U.S. Department of Health and Human Services (HHS), Office of Inspector General (OIG)
has identified a number of surgical procedures that include more visits in the global period than are being furnished. CMS is also concerned that post-surgical visits are valued higher than visits that were furnished and billed separately by other physicians such as general internists or family physicians.
CMS finalized a proposal to transform all 10- day and 90-day globals to 0-day globals, beginning with 10-day global services in CY 2017 and following with the 90-day global services in 2018. As
CMS revalues these services as 0-day global periods, CMS 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.
Access to Telehealth Services
CMS is adding the following services to the list of services that can be furnished to Medicare beneficiaries under the telehealth benefit:
• Annual wellness visits,
• Psychotherapy, and
• Prolonged evaluation and management services.