Medicare Compliance & Reimbursement

E/M services, chronic coordination, telehealth at the heart of the finalized policies.

CMS issued its Final Rule for the 2017 Medicare Physician Fee Schedule (MPFS) on Nov. 2, 2016. With payment policies and rates slated to begin on Jan. 1, 2017, CMS continued to center its adjustments around primary care and coordination across healthcare platforms. Read the Final Rule here: https://s3.amazonaws.com/public-inspection.federalregister.gov/2016-26668.pdf.

Boost to Those That Provide Primary and Cognitive Care

As MACRA pushes primary care to the heart of healthcare, CMS reforms key elements to encourage primary care providers who are considered the foundation of Medicare. In the past, primary and cognitive care have been “bundled” in with E/M services across specialties, but the final rule suggests a move away from that practice.

“This has meant that payment for these services has been distributed equally among all specialties that report the visit codes, instead of being targeted toward practitioners who manage care and/or primarily provide cognitive services,” the MPFS Final Rule fact sheet says. “To improve payment accuracy for such care, in recent years, CMS created new codes that separately pay for chronic care management and transitional care management services, and solicited public comment on additional policies the Agency should pursue.”

CMS Pledges Extra Pay for Non-Face-to-Face Prolonged E/Ms

According to the final fee schedule, CMS plans to start providing separate payment for some E/M services that fall under non-face-to-face, prolonged care with CPT® codes 99358-99359. In the past, it was extremely difficult to collect for these services unless the physician saw the patient face-to-face. “We stress that we intend these codes to be used to report extended non-face-to-face time that is spent by the billing physician or other practitioner (not clinical staff) that is not within the scope of practice of clinical staff,” the MPFS says. “And, that is not adequately identified or valued under existing codes or the 2017 finalized new codes.”

Importantly, CMS also makes clear that the prolonged, non-face-to-face services needn’t take place the same day as the accompanying E/M service. “Our final policy will adopt the CPT® guidance that allows the prolonged time to be reported for time on a different day than the companion E/M code, along with the rest of the CPT® prefatory language for CPT® codes 99358 and 99359,” the agency says in the final rule.

In a nutshell. Here is a quick overview of other primary and cognitive care changes:

• Existing CPT® codes that covered non-face-to-face prolonged care will be revalued. »
• The new code G0505 (Cognition and functional assessment using standardized instruments with development of recorded care plan for the patient with cognitive impairment, history obtained from patient and/or caregiver, in office or other outpatient setting or home or domiciliary or rest home) offers better “comprehensive assessment and care planning” for cognitive issues like dementia.
• New codes (99487-99489) are introduced to allow for greater clarity in CCM.
• Separate pay for primary care physicians who utilize behavioral health specialists will be offered with new codes G0502-G0504 in an effort to better coordinate care between primary care physicians and behavioral specialists.
• In a nod to the MACRA final rule, CMS opts to lessen the reporting burden with these CCM codes, making it easier for providers and encouraging patient-focused care.

Telehealth Expands with New Code Options

CMS will invest in telehealth with new code options as Medicare moves beyond the traditional venues to more alternative settings for enhanced patient care. The highlights include codes for End-stage renal disease (ESRD)-related services for dialysis (90967); advanced care planning services (99497-99498); and critical care consultations (G0508-G0509).

Global Services Data Collection See Revisions

The way global services are reported and data collected will be made easier to “significantly reduce the burden on practitioners,” the MPFS Final Rule suggests. After Jan. 1, providers will need only report on post-op procedures that are high volume/high cost and use CPT® code 99024 (Postoperative follow-up visit, normally included in the surgical package, to indicate that an evaluation and management service was performed during a postoperative period for a reason[s] related to the original procedure) versus the proposed G-codes. Also, only a sampling of providers from specified states with practices of 10 or more will be required to submit their global services data, but other clinicians are welcome to voluntarily offer their reports as well.

Diabetes Prevention Program Benefits Realized

The Medicare Diabetes Prevention Program (MDPP) is set to expand in 2018 but keep its original focus, allowing providers to be paid for non-medical counseling in regard to diabetes control, reduction, and prevention.

The original model “led to approximately 5 percent reduction in weight and saved Medicare an estimated $2,650 for each person enrolled in the Diabetes Prevention Program model test over a 15-month period, more than enough to cover the cost of the program,” Andy Slavitt, CMS acting administrator and Patrick Conway, MD, MSc, CMS acting principal deputy administrator and chief medical officer, said in a Nov. 2, 2016 blog post about the MPFS Final Rule.

AMA Weighs In

The American Medical Association (AMA) found much to be happy with in the 2017 MPFS Final Rule. As CMS plans to implement MACRA on Jan. 1, 2017, the core values of its healthcare manifesto and its fee schedule initiatives—affordable care that is easier and more efficient for physicians to perform while focusing on the patient’s needs—were consistent with pleas the AMA had made to help providers out.

“This annual policy fine-tuning is an opportunity for CMS to improve treatment options for patients and streamline bureaucratic demands on physicians” said Andrew W. Gurman MD, AMA president, in a Nov. 3, 2016 press release. “By expanding coverage of the Medicare Diabetes Prevention Program (DPP) and revising data collection efforts, CMS is ensuring that patients and physicians will benefit from better care and more rational directives.”

For a look at the Medicare Physician Fee Schedule Final Rule fact sheet, visit https://www.cms.gov/Newsroom/MediaReleaseDatabase/Fact-sheets/2016-Fact-sheets-items/2016-11-02.html.

To read the American Medical Association’s press release, visit https://www.ama-assn.org/ama-applauds-cms-final-rule-physicians-payment-fee-schedule.