Medicare Compliance & Reimbursement

CMS putting its money where its mouth is, Slavitt says.

Prevention, wellness, and appropriate management of chronic conditions and mental health are the main focus areas of the 2017 Physician Fee Schedule proposals. Cost cutting, revaluation of old CPT^® codes, and working further on refining existing codes round off the proposals.

Patient-focused Initiatives Are Front and Center

The importance of primary care cannot be understated, and with the newest set of proposals and PFS code revisions, the Centers for Medicare & Medicaid Services (CMS) seeks to reward both primary and transitional care providers who manage chronic care issues and offer cognitive support.

“Today’s proposals are intended to give a significant lift to the practice of primary care and to boost the time a physician can spend with their patients listening, advising and coordinating their care — both for physical and mental health,” said Andy Slavitt, CMS acting administrator, in a July 7 press release. “If this rule is finalized, it will put our nation’s money where its mouth is by continuing to recognize the importance of prevention, wellness, and mental health and chronic disease management.”

Takeaway: The standouts on the delivery of these services pertain to the creation of new codes, the revaluation of old CPT^® codes, and expanding and clarifying services for existing CPT^® codes.

CMS fielded comments from the public, many of whom requested that Medicare should separately pay for specific CPT^® codes that addressed chronic care management until CMS was able to “address deficiencies in the current E/M code set,” the proposed 2017 Fee Schedule indicated.

Putting the Nation’s Health First

In an unprecedented move toward investing in the country’s long-term health maintenance, CMS hopes to add the Diabetes Prevention Program to Medicare’s lineup starting Jan. 1, 2018. (See story on page 115.)

The U.S. Department of Health & Human Services’ (HHS’) ambitious initiative includes a 16-part intervention program designed to help Medicare beneficiaries lose weight through diet and exercise. The Diabetes Prevention Program hopes to align with providers to identify those most at risk and refer them to suppliers of this outreach service.

“If phased in, the rule contemplates whether the Medicare Diabetes Prevention Program would be offered initially for a period in certain geographic markets or regions or to a subpopulation of provider/suppliers,” the proposed 2017 Fee Schedule suggests. Payment structures, supplier enrollment, and IT safety and security are still in the design phases as CMS is taking public insight into account until Sept. 6.

Look for Potential Modifier 25 Overhaul

Global services news: CMS is taking a look at 83 zero-day global services codes usually billed for E/M services with modifier 25 (Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service) with the suggestion that the codes are “potentially misvalued” and should be reevaluated.

In the 2017 fee proposal, CMS is recommending a claims-based plan for the collection of data on 10- to 90-day global codes that includes surveying over 5,000 practitioners about their activities and services related to the codes. This plan, which originated with a 2015 MACRA ruling, could possibly revalue the codes and services.

Telehealth turnaround: With the rise and necessity of telehealth, CMS intends to allow several codes under this growing service. Those areas affected will be advanced care planning, end-stage renal disease (ESRD) related services for dialysis, and critical care consultations, introducing new Medicare G-codes for the consultations.

Sedation services revised: Past rules brought about new sedation codes created by the AMA’s CPT^® editorial panel at CMS’ request. Now, CMS wants to add values for the new CPT^® moderate sedation codes while streamlining the process of valuation for the procedural codes that utilize moderate sedation. These changes will likely affect the way you both code and are paid for claims of moderate sedation.

Endnote: Keep in mind these are but a few of the many proposals that CMS is looking at for CY 2017. As always, the public’s input is key to the eventual final rulings and changes to the proposals.

Resource: To read the complete Proposed Policy, Payment, and Quality Provisions Changes to the Medicare Physician Fee Schedule for Calendar Year (CY) 2017, visit https://s3.amazonaws.com/public-inspection.federalregister.gov/2016-16097.pdf.