Medicare Compliance & Reimbursement

The biggest bonus the Centers for Medicare & Medicaid Services (CMS) has for physicians in the new year is reimbursement for advance care planning. Get set to collect for your practitioners’ services in talking about end-of-life decisions with Medicare beneficiaries starting Jan. 1, 2016.

CMS released its Final Rule on Oct. 30, outlining how it will pay for services under the Medicare Physician Fee Schedule in 2016, which included comments and explanations of how CMS set payments for both old and new services.

“CMS is establishing separate payment and a payment rate for two advance care planning services provided to Medicare beneficiaries by physicians and other practitioners,” the agency said in a Fact Sheet about the decision. “The Medicare statute currently provides coverage for advance care planning under the ‘Welcome to Medicare’ visit available to all Medicare beneficiaries, but they may not need these services when they first enroll. Establishing separate payment for advance care planning codes to recognize additional practitioner time to conduct these conversations provides beneficiaries and practitioners greater opportunity and flexibility to utilize these planning sessions at the most appropriate time for patients and their families.”

The CPT^® codes that describe these services are as follows:

• 99497: Advance care planning including the explanation and discussion of advance directives such as standard forms [with completion of such forms, when performed], by the physician or other qualified health care professional; first 30 minutes, face-to-face with the patient, family member[s], and/or surrogate
• +99498: ... each additional 30 minutes ...

Payment is set: The agency assigned 1.50 work RVUs to 99497 and 1.40 RVUs to 99498. Officials noted that this will translate into payments of about $86 for 99497 and $75 for the add-on code 99498.

According to the Final Rule, you can report 99497 and 99498 on the same date as other E/M services, transitional care management and chronic chare management, and you can even bill them during global surgical periods. You cannot, however, report 99497 and 99498 on the same date as certain critical care services including neonatal and pediatric critical care, the Final Rule indicates.

Look for Conversion Factor to Drop

On the negative side, doctors who were looking for a 0.5 percent pay boost — as promised as part of MACRA, which was passed earlier this year — will be disappointed. Although MACRA said that payments would increase by 0.5 percent every year from 2016 through 2019, the Final Rule suggests otherwise.

The conversion factor is actually dropping from the current level of 35.9335 to 35.8279, the Final Rule says. Although CMS did increase the conversion factor by 0.5 percent, the agency then cut it by -0.02 percent due to a “budget neutrality adjustment” and another -0.77 percent attributed to a “target recapture amount,” resulting in a total cut of 0.3 percent instead of the 0.5 percent raise that doctors had expected.

Gastroenterologists Will See Deeper Pay Cuts

Although most specialists will see overall reimbursement remain fairly stable in 2016, gastroenterologists will take a four percent hit to their payments effective Jan. 1, due to adjustments in endoscopic lower GI procedures, including colonoscopies. For example, payment for 44394 (Colonoscopy through stoma…) will drop from 4.42 RVUs this year to 4.13 RVUs starting in January. Other gastroenterology services will follow suit.

Although CMS projects overall cuts of four percent, the actual damage could be higher, depending on the mix of services that your doctors perform. For instance, the final rule notes that CMS will lower the work RVUs for code 45380 (Colonoscopy, flexible; with biopsy, single or multiple) to 3.66 from its current level of 4.43, resulting in more than a 17-percent hit to this service.

Societies React: The American Gastroenterological Association noted that it was “outraged” at the “inappropriately deep” cuts, which the association had urged CMS not to adopt when the proposed rule came out last summer. Many medical societies are contacting Congress and CMS executives to explain how severely these cuts will impact gastroenterologists.

Pathologists See Boost

Pathologists are the winners among specialists listed in the Final Rule, with CMS noting that pathology practices will see pay rise by eight percent in 2016. This is largely due to adjustments in RVUs for specific pathology procedures. For instance, pay for the professional component of 88305 (Tissue exam by pathologist) will go up two percent, while new code 88350 (Immunofluorescent study;each additional single antibody stain procedure) will get 0.56 work RVUs effective Jan. 1. 

Resource: To read the entire Final Rule, visit https://s3.amazonaws.com/public-inspection.federalregister.gov/2015-28005.pdf  or read the Fact Sheet at https://www.cms.gov/Newsroom/MediaReleaseDatabase/Fact-sheets/2015-Fact-sheets-items/2015-10-30.html?DLPage=1&DLEntries=10&DLSort=0&DLSortDir=descending .