Summary: 2017 Medicare Physician Fee Schedule (MPFS)

News | Published: Friday, November 11, 2016 4:30 am

by MedAxiom


The Medicare Physician Fee Schedule (MPFS) Final Rule was published on November 2nd. In order to keep you informed with the latest on this important information, we have created a summary that highlights major policy changes, including those impacting cardiology. We encourage you to review this summary carefully and trust that you will let us know if you have questions or comments related to the content.  Want the detailed spreadsheet? Become a member! Contact your regional representative here. 

Medicare Physician Fee Schedule

Overall Payments
  • The conversion factor used to determine physician payment increased 0.2% compared to 2016
  • The FY 2017 conversion factor is $35.8887
Medicare Telehealth Services
  • CMS added new procedures that can be provided via telehealth:
    • ESRD services (4 CPT codes)
    • Advance care planning codes (2 CPT codes)
    • Critical care consultations (2 new G codes)
  • A new place of service code (POS 02) will now be required to report all telehealth services
 Moderate Sedation
  • CMS was concerned that due to practice pattern changes, various procedures including moderate sedation may be overvalued
  • Six new moderate sedation codes (CPT 99151-99157) are available to report these services separately when performed
  • The RVUs for the procedures that include moderate sedation have been adjusted downward to reflect that this service is no longer being performed – the new CPT codes can be billed when moderate sedation is utilized
  • A new G code (G0500) is also required for certain gastrointestinal endoscopy procedures, but this code does not apply to any cardiovascular procedure when moderate sedation is utilized
Global Packaging
  • CMS has been directed to evaluate post-surgical care visits – however, CMS has no data on these services as they aren’t services that are billed
  • CMS is initiating data collection for post-operative visits associated with ~270 procedures within the 10- and 90-day global period of these procedures 
  • Reporting is mandatory effective July 1, 2017 using existing CPT 99024
  • Only physicians in groups of sufficient size and in 9 states (FL, KY, LA, NV, NJ, ND, OH, OR, RI) will be required to report this information
    • Other physicians are encouraged to report voluntarily
  • The final list of codes subject to required reporting will be available on the CMS website
  • CMS finalized new GPCIs using updated data to be phased in over CY 2017 and CY 2018 – these updates are required by law
  • California
    • Beginning in 2017, CMS is required by law to use new locality definitions based on a combination of MSAs and the current locality structure
    • This provision is not budget neutral – payments to physicians in California will increase in the aggregate without reductions in physician services elsewhere
    • The new locality structure will increase payment to many physicians in urban parts of California without causing any reductions in specified counties that the law “holds harmless” from such effects
      • In a few other areas, the new locality structure may decrease Medicare PFS payments
 Payment Incentive for Digital X-Ray
  • Effective January 1, 2017, the technical component payment amounts under the MPFS will be reduced by 20% for X-rays that are taken using film
  • For X-rays utilizing film, a modifier “FX” must be included on the claim
 Advanced Imaging Multiple Procedure Payment Reduction (MPPR)
  • Effective in 2012, CMS implemented a MPPR of 25% on the professional component of advanced imaging services when multiple imaging procedures are furnished by the same physician to the same patient in the same session on the same day
  • By law, effective January 1, 2017, the payment reduction is reduced from 25% to 5%
  • The codes that the MPPR apply to are available on the CMS website
Appropriate Use Criteria (AUC) for Advanced Diagnostic Imaging
  • CMS is required to develop a program whereby physicians will need to consult AUC when deciding to utilize advanced diagnostic imaging services in the hospital outpatient, ASC or office places of services
  • In the 2016 MPFS, definitions of AUC and the processes to develop them were provided
  • Eight priority clinical areas will initially be targeted for these requirements, including coronary artery disease (suspected or diagnosed) and suspected pulmonary embolism
  • This final rule defines the requirements of qualified clinical decision support mechanisms (CDSMs) that will be the primary tool to consult AUC
    • 12 criteria
    • Approved by CMS via an application process
    • CMS is accepting applications for CDSMs through March 1, 2017 – the earliest that a CDSM can be approved is July 1, 2017
  • Exceptions to reporting
    • Emergency services
    • Inpatient services covered under Part A
    • Hardship (reviewed on a case-by-case basis)
  • CMS expects that furnishing professionals will be required to begin reporting January 1, 2018
    • Thus, there are no reporting requirements for 2017
    • CMS will adopt procedures for capturing this information on claims forms and the timing of reporting requirements through PFS rulemaking for CY 2018
Medicare Advantage (Part C) Provider and Supplier Enrollment
  • Providers and suppliers will now need to be screened and enrolled in Medicare to contract with Medicare Advantage organizations
  • CMS states this policy creates consistency with their current requirements for other areas of the Medicare program (Parts A, B and D)
  • These requirements will be included in CMS contracts with the designated plans and programs, and will begin two years from now, and will be effective on the first day of the plan year
Medicare Shared Savings Program
  • CMS updated ACO quality reporting requirements, including:
    • Changes to the quality measure set and the procedures for quality validation audits
    • Revisions to terminology used in quality assessment
    • Revisions that would permit eligible professionals in ACOs to report quality separately from the ACO
    • Updates to align with the Physician Quality Reporting System and the final Quality Payment Program
  • Modifications to the assignment algorithm to align beneficiaries to an ACO when a beneficiary has designated an ACO professional as responsible for their overall care
  • Establishment of beneficiary protection policies related to use of the Skilled Nursing Facility 3-day waiver
Primary Care, Care Management and Patient-Centered Services
CMS is finalizing several coding and payment changes to better identify and value primary care, care management, and cognitive services:
  • Make separate payments for certain existing CPT codes describing non-face-to-face prolonged evaluation and management services
  • Revalue existing CPT codes describing face-to-face prolonged services
  • Make separate payments using a new code to describe the comprehensive assessment and care planning for patients with cognitive impairment (e.g., dementia)
  • Make separate payments using new codes to pay primary care practices that use inter-professional care management resources to treat patients with behavioral health conditions
  • Make separate payments for codes describing chronic care management for patients with greater complexity
  • Make several changes to reduce administrative burden associated with the chronic care management codes to remove potential barriers to furnishing and billing for these important services
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