Medicare Compliance & Reimbursement

Massive PFS proposed rule also aims to make 10 other significant changes.

Get ready to enjoy Medicare Part B reimbursement increases — especially for primary care. The Centers for Medicare & Medicaid Services (CMS) has released a sneak peek at the Physician Fee Schedule (PFS) for next year, and it’s looking pretty good.

On July 7, CMS issued a proposed rule that updates payment policies, reimbursement rates, and quality provisions under the PFS for calendar year 2017. These key changes aim to boost Medicare payments for primary care provider services to beneficiaries with multiple chronic conditions, mental and behavioral health issues, cognitive impairment, and mobility-related disabilities.

1. Chronic Care Management & Care Coordination Get Increases

The proposed rule would revise chronic care management payments, including payment for new codes and for extra care management that a physician or practitioner furnishes following the initiating visit for patients with multiple chronic conditions.

CMS would make separate payments for codes describing chronic care management for patients with greater complexity. The proposed rule would also make several changes to reduce administrative burdens associated with the chronic care management codes to remove possible barriers to furnishing and billing for these services.

What to expect: The proposals would increase payments to geriatricians and family practice physicians, who provide core services for Medicare beneficiaries. CMS estimates that these clinicians would receive a 2-percent pay increase for providing care the proposed rule would recognize under the PFS. Over time, CMS estimates the payment increase could be as much as 30 percent for geriatricians and 37 percent for family practice physicians.

2. Mental & Behavioral Health Model Could Expand

The proposed rule would allow payments for specific behavioral health services furnished using the Collaborative Care Model. In this model, patients receive a team approach to care, involving a primary care practitioner, behavioral healthcare manager, and a psychiatric consultant. The rule also proposes paying more broadly for other approaches to behavioral health integration services.

According to CMS, the behavioral health Collaborative Care Model has demonstrated benefits in a variety of settings to improve patient outcomes. The proposed rule also would pay for other approaches to behavioral health integration.

3. Enjoy More Pay for Cognitive Impairment Assessment & Care Planning

The proposed rule includes a new code to pay for cognitive and functional assessment and care planning for patients with cognitive impairment, such as Alzheimer’s disease and dementia. CMS would make separate payments using new codes to describe the comprehensive assessment and care planning for such patients.

“We are delighted that CMS included these services in the 2017 proposed Physician Fee Schedule. Their inclusion is a key component of better care,” says Nancy Lundebjerg, MPA, CEO of the American Geriatrics Society. “In proposing these codes, CMS is recognizing the importance of supporting healthcare professionals who provide high-quality, person-centered care to older adults with complex illness.”

4. CMS Looks at Care for Patients with Mobility Problems

CMS proposes paying physicians more accurately for furnishing services to beneficiaries with mobility-related impairments. CMS aims to improve care quality and access to such beneficiaries through increasing payments.

Payoff: Under the proposed rule, Medicare would pay $119 for these visits. This is a significant increase from the current payment of approximately $73. The pay increase would account for patients who often need to spend more time with the physician or require more physical and staff support during the visit.

Pay Attention to 10 Other Areas

Additionally, CMS estimates the conversion factor for 2017 to be $35.7751, “which is slightly lower than the 2016 conversion factor of $35.8043,” notes Kent Moore, Senior Strategist for Physician Payment for the American Academy of Family Physicians.

“However, CMS expects that the provisions of the proposed rule will generate an estimated 3-percent increase in Medicare allowed charges for family physicians,” Moore says. “That would be the largest estimated update for a given specialty.”

What’s more: In addition to these primary care-related payment changes, the PFS proposed rule contains a myriad of other important changes. The proposed rule would also:

• Modify the Medicare Shared Savings Program (MSSP) to update the quality measures set and align with proposals for the Quality Payment Program;
• Take beneficiary preferences for Accountable Care Organization (ACO) assignment into consideration and improve beneficiary protections when ACOs are approved to use the skilled nursing facility three-day waiver rule;
• Require healthcare providers and suppliers to be screened and enrolled in Medicare to contract with Medicare Advantage (MA) health plans for providing Medicare-covered items and services to beneficiaries;
• Increase transparency of MA pricing data and medical loss ratio (MLR) data from Medicare health and drug plans;
• Continue to implement Appropriate Use Criteria for advanced diagnostic imaging services, including proposals for priority clinical areas and clinical decision support mechanism (CDSM) requirements;
• Set values for the new CPT^® moderate sedation codes and propose a uniform methodology for valuation of the procedural codes that currently include moderate sedation and an inherent part of the procedure;
• Augment the new moderate sedation CPT^® codes with an endoscopy-specific moderate sedation code;
• Add several codes to the list of eligible telehealth services, including end-stage renal disease (ESRD) related services for dialysis, advance care planning services, and critical care consultations furnished via telehealth using new Medicare G-codes;
• Create new CPT^® codes for mammography services that reflect the current technology used; and
• Revise the methodology CMS uses to calculate Geographic Practice Cost Indices (GPCI), which would increase overall PFS payments in Puerto Rico.

Understand CMS’ Underlying Strategies

These proposals are part of CMS’ efforts to redirect Medicare payments from costly institutions, nursing homes, and hospitals, instead to better primary care. “We should reinvest in what we value — primary care — as a practice, as a profession, and as an abundant resource for patients,” stated a July 7 blog posting by CMS Acting Administrator Andy Slavitt and Acting Principal Deputy Administrator and Chief Medical Officer Patrick Conway, MD, MSc.

Slavitt and Conway identified a four-part strategy to emphasize primary care:

1. Improve how CMS pays for valued care. The Medicare PFS proposed rule would improve how Medicare pays for primary care, care coordination, and mental healthcare. CMS estimates that the changes in the proposed rule would result in approximately $900 million in additional pay to physicians and practitioners in 2017, and up to $5 billion in the future.

2. Provide more opportunities for primary care providers to practice the way they think is best. CMS is aiming to transition Medicare to policies that reduce the burdens on both patients and clinicians by better rewarding coordinated, high-quality care. The new advanced primary care Medical Home Model called the Comprehensive Primary Care Plus (CPC+) model will support primary care providers’ efforts to spend more time with patients, better coordinate care with specialists, and serve patients’ needs outside office visits.

3. Reduce practice expenses associated with operating a primary care or other small practice. CMS has been meeting with physician practices across the country to identify ways to reduce reporting and compliance burdens, while at the same time increasing support to their practices. The new Quality Payment Program contains components that aim to reduce clinicians’ reporting burdens, and the Transforming Clinical Practice Initiative supports more than 140,000 clinicians in sharing, adapting, and further developing their comprehensive quality improvement strategies.

4. Encourage far-reaching innovations to connect people with primary care in new ways. CMS highlights its inclusion of telemedicine in several care models. Also, the Rural Health Council is helping to promote a focus on access, economics, and innovation issues.

Resources: To read the PFS proposed rule, go to www.federalregister.gov/articles/2016/07/15/2016-16097/medicare-program-revisions-to-payment-policies-under-the-physician-fee-schedule-and-other-revisions. A fact sheet on the proposed rule is also available at www.cms.gov/Newsroom/MediaReleaseDatabase/Fact-sheets/2016-Fact-sheets-items/2016-07-07-2.html.