2016 Medicare Physician Fee Schedule (MPFS) Proposed Rule Released

Proposed 2016 Conversion Factor $36.1096

2016 MPFS Conversion Factor

The CY 2016 proposed MPFS conversion factor is $36.1096, which reflects a budget neutrality adjustment of 0.9999 and the 0.5 percent update factor specified under MACRA.  

Request for Information on Nonfacility Cataract Surgery

CMS is requesting feedback on office-based surgical suite cataract surgery. CMS states advancements in technology have significantly reduced operating time and improved both the safety of the procedure and patient outcomes. CMS believes it is now possible for cataract surgery to be furnished in an in-office surgical suite, especially for routine cases. CMS believes there are advantages for furnishing cataract surgery in nonfacility settings, including lower Medicare expenditures for cataract surgery, if the nonfacility payment rate were lower than the sum of the Physician Fee Schedule facility payment rate and the payment to either the ASC or HOPD. CMS is also soliciting comments from the RUC and other stakeholders on the direct practice expense inputs involved in furnishing cataract surgery in the nonfacility setting.

Improving the Valuation and Coding of the Global Package

In the 2015 MPFS Final Rule, CMS finalized transitioning all 10-day and 90-day global codes to 0-day codes, however, the Medicare Access and CHIP Reauthorization Act (MACRA) prohibited CMS from implementing this policy. MACRA requires that instead, CMS develop a process to gather information needed to value surgical services from a representative sample of physicians and data collection should begin no later than January 1, 2017. The collected information must include the number and level of medical visits furnished during the global period and other items and services related to the surgery as appropriate. Therefore, CMS is seeking input from stakeholders on the kinds of objective data needed to increase the accuracy of the values for surgical services. CMS is also seeking comments on the potential methods of valuing the individual components of the global surgical package, including the procedure itself, and the pre- and post-operative care. CMS notes they plan to provide further opportunities for public feedback, and seek comments on stakeholder interest in an open door forum or town hall meetings.

Physician Compare

Currently, the Physician Compare website has a section which indicates whether providers participated in Medicare quality programs. CMS is proposing to expand this section to add a green check mark to include the names of those individual eligible professionals and group practices who received an upward adjustment for the Value Modifier. For the 2018 Value Modifier, this information would be based on 2016 data and included on the site no later than late 2017. CMS previously planned to make all 2015 PQRS measures for individual eligible professionals available for public reporting, and proposes in this rule to continue to make all PQRS measures available for public reporting annually. CMS also proposes to include benchmarks for PQRS measures based on PQRS performance rates, using the Achievable Benchmark of Care methodology.  CMS also seeks comment on adding Medicare Advantage data, and additional Value Modifier cost and quality data to the Physician Compare website.  

Physician Quality Reporting System (PQRS)

For 2016 PQRS reporting, CMS is not proposing to make any major changes to reporting via claims or registry.  Therefore, providers reporting via claims would be required to report 9 measures (including one cross-cutting measure), covering at least 3 National Quality Strategy domains, and report each measure for 50% of their Medicare Part B Fee-for-Service patients seen during the reporting period.  Providers reporting via registry would report 1 measures group on 20 patients (more than 50% of which must be Medicare Part B patients). 

CMS is proposing to add Measure 19, Diabetic Retinopathy: Communication with the Physician Managing Ongoing Diabetes Care to the Diabetes Retinopathy Measures Group and remove it from claims or registry PQRS reporting.  

Value Based Payment Modifier (VBPM)

CMS proposes to continue to apply the VBPM to all physicians in 2016, and continue to set the maximum upward adjustment under the CY 2018 (based on 2016 reporting) VM at +4.0 times an adjustment factor. CMS also proposes to set the amount of payment at risk under the CY 2018 VM at -4% for groups with ten or more eligible professionals, and at -2.0% for groups with between 1 and 9 eligible professionals, and groups and solo practitioners that consist only of nonphysician eligible professionals. Quality tiering will apply to all providers that satisfactorily report PQRS in 2016, with only groups consisting of nonphysician eligilbe practitioners being held harmless from downward quality tiering adjustments. CMS proposes to waive the VM for groups and solo practitioners if at least one eligible professional who billed under the groups Tax Identification Number (TIN) participated in the Pioneer ACO Model or other similar Innovation Center Models during the performance period.  

Potentially Misvalued Codes

The ACA required CMS to identify "misvalued codes" in the MPFS. Subsequent legislation set a 2016 target reduction of 1%. If the net reductions in misvalued codes in 2016 are not equal or greater than 1% of the estimated expenditures under the fee schedule, a reduction equal to the percentage difference between 1% and the estimated net reduction in expenditures resulting from misvlaued code reductions must be made to all PFS services. Inthis proposed rule, CMS is proposing a methodology for the implementation of this provision. Based on that methodology, CMS has identified changes that achieve a 0.25% reduction. Further misvalued code changes may be made in the final rule to reach the 1% target. Included in the 2016 potentially misvalued services for review are 92002 Eye Exam New Patient, 92136 Ophthalmic Biometry, 92240 Icg Angiography, 92250 Eye Exam with Photos, and 92275 Electroretinography.

Impact of Proposed Rule on CY 2016 Payment for Selected Procedures

Additional information will be detailed in upcoming editions of Washington Watch Weekly. For additional assistance, please contact Ashley McGlone, manager of regulatory affairs, at 703-591-2220 or amcglone@ascrs.org.