Practice Economics
Officials at the Centers for Medicare & Medicaid Services have issued the final 2016 fee schedule for physicians, making modifications to the Physician Quality Reporting System (PQRS) and loosening requirements for its controversial two-midnight rule.
The fee schedule – the first since repeal of the Sustainable Growth Rate (SGR) formula and enactment of the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) – includes changes to payment policies, modifications to misvalued codes, and updates to quality performance metrics under the PQRS, the Medicare Shared Savings Program, and Physician Compare, among others.
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As part of the final fee schedule rule, released Oct. 30, CMS is relaxing its two-midnight rule to allow doctors greater flexibility when determining whether hospital stays are subject to the regulation.
For hospital stays for which physicians expect the patient will need less than two midnights of hospital care, an inpatient admission may still be payable under Medicare Part A on a case-by-case basis based on the admitting physician’s judgment, according to the final rule. Additionally, the agency does not plan to send recovery auditors after doctors suspected of violating the two-midnight rule. Instead, CMS plans to use Beneficiary and Family Centered Care Quality Improvement Organizations to conduct initial medical reviews of claims for short-stay inpatient admissions. The claim reviews will focus on educating physicians and hospitals about the policy for inpatient admissions.
Only physicians with questionable practice patterns, such as high rates of claims denial after medical review, will be referred to auditors, according to CMS.
“These changes continue CMS’ long-standing emphasis on the importance of a physician’s medical judgment in meeting the needs of Medicare beneficiaries,” CMS officials stated in a fact sheet.
CMS also finalized two new advance care planning codes that will pay physicians for time spent discussing patient options for advance directives. The first code will cover an initial 30 minutes of the physicians’ time, and the second code will cover additional 30-minute blocks as necessary.
The AMA Current Procedural Terminology (CPT) Editorial Panel and the AMA Relative Value Update Committee (RUC) created the new CPT codes and recommended the associated payments for calendar year 2015, but CMS delayed the codes’ enactment until collecting public comment.
Modifications to quality programs include a new reporting option under the PQRS that will allow group practices to report quality measure data using a Qualified Clinical Data Registry. In 2016, there will be 281 measures in the PQRS measure set and 18 measures in the Group Practice Reporting Option (GPRO) Web Interface, according to the final rule.
The 2018 payment adjustment will be the last adjustment under the PQRS. Starting in 2019, adjustments to payment for quality reporting and other factors will be made under the Merit-Based Incentive Payment System (MIPS), as required by MACRA.
Changes to the Value-Based Payment Modifier program are also coming in 2016:
• CMS will apply the quality-tiering methodology to all groups and solo practitioners that meet the criteria to avoid the downward adjustment under the PQRS. Groups and solo practitioners would be subject to upward, neutral, or downward adjustments derived under the quality-tiering methodology.
• CMS will continue to set the maximum upward adjustment under the quality-tiering methodology for the CY 2018 value modifier at four times an adjustment factor for groups of physicians with 10 or more eligible professionals, and two times an adjustment factor for groups of physicians with between two and nine eligible professionals and physician solo practitioners.
• CMS will use calendar year 2016 as the performance period for the calendar 2018 value modifier and continue to apply the 2018 value modifier based on participation in the PQRS by groups and solo practitioners.
The fee schedule also includes modifications to the Medicare Shared Savings Program including a new measure on statin therapy for the prevention and treatment of cardiovascular disease in the “preventive health domain” of the Shared Savings Program quality measure set. The final rule also clarifies how PQRS-eligible professionals participating within an Accountable Care Organization can meet reporting requirements.
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