2018 CMS Physician Fee Schedule (PFS) Final Rule Overview

News | Published: Friday, November 10, 2017 7:00 am


MedAxiom and the Cardiology Advocacy Alliance have summarized the major provisions of the 2018 final PFS rule that was published on November 2. The summary highlights major policy changes, focusing on those impacting cardiology. Members get access to payment tables associated with various procedures identified by MedAxiom as most relevant for its CV community. 

Medicare Physician Fee Schedule (PFS)

The CMS fact sheet on the rule can be found at https://www.cms.gov/Newsroom/MediaReleaseDatabase/Fact-sheets/2017-Fact-Sheet-items/2017-11-02.html

Conversion Factor

  • The conversion factor (CF) is $35.9996, an increase of 0.3% compared to 2017
  • CMS estimates that the specialty of Cardiology will be impacted -1% on total allowed charges by all the policies in the proposed rule

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 PFS, 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
    • Qualified clinical decision support mechanisms (CDSMs) that will be the primary tool to consult AUC, and CMS has published the approved CDSMs athttps://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Appropriate-Use-Criteria-Program/CDSM.html
    • CMS will establish a set of G codes, one for each approved CDSM and one generic G code for approved CDSMs that CMS hasn’t yet developed a specific G code
  • Exceptions to reporting
    • Emergency services
    • Inpatient services covered under Part A
    • Hardship (reviewed on a case-by-case basis)
  • CMS is delaying implementation of reporting the consultation of AUC until January 1, 2020
    • CMS will adopt procedures for capturing this information on claims forms and the timing of reporting requirements through PFS rulemaking for CY 2018
    • CMS is proposing to treat 2020 as an education period – reporting will be available, but professionals will get paid regardless

Determination of Malpractice (MP) RVUs

  • CMS had proposed to change MP RVUs due to updated malpractice premium data, Medicare payment and utilization data, GPCIs and proposed work and clinical RVUs
  • The calculation includes a risk factor for each specialty, split for surgical and non-surgical procedures – for Cardiology, the risk factor for both surgical and non-surgical services was proposed to be the same (1.90)
  • Based on comments, CMS did not move forward with this proposal, and will update MP premium data and MP GPCIs once every three years
    • CMS did not the next update must occur by 2020

Off Campus Provider Based Departments (PBDs) of a Hospital

  • CMS finalized a reduction in the PFS relativity adjuster for non-excepted services furnished in non-excepted off-campus PBDs to 40% of the OPPS payment rate
    • For 2017, the PFS relativity adjuster was 50%, which means the adjustment for 2018 is a 20% decrease in payment
  • CMS is collecting claims data via the “PN” modifier on these services, and will update payment rates as appropriate when this information is available.

Remote Patient Monitoring

  • CMS sought comments on whether to make separate payment for CPT codes that describe remote patient monitoring, particularly CPT 99091
    • Based on comments received, CMS is activating separate payment for CPT 99091 with certain requirements – this code has 1.63 RVUs in the Facility setting ($58.68)
  • CPT 93299 (Implantable cardiac monitor/loop recorder, remote, technical services) is currently carrier priced with the payment amount determined by each MAC
    • CMS had proposed to value this code at 0.73 RVUs
    • Based on comments received, CMS did not move forward with this proposal and the code will remain carrier priced

Work and Practice Expense RVU Refinement

  • CMS is proposing RVU refinements on various codes
  • Cardiology related proposals – see payment tables below
    • TTE (CPT 93306-8) – CMS proposed higher work RVU values and decreased PE RVUs for CPT 93306 – these were finalized without adjustment
    • Stress Echo (CPT 93350-1) – CMS proposed slightly lower PE RVU values for these 2 codes, which was finalized

E&M Guidelines and Care Management Services

  • CMS utilized criteria from 1995 and 1997 guidelines to distinguish between E&M levels, and documentation requirements
  • CMS requested comments on revising/updating guidelines to reduce the administrative burden and align with current medical practice
    • Initial changes to guidelines for the history and physical exam as CMS believes these are more significantly outdated
    • Medical decision making and time are more significant factors in distinguishing visit levels
    • Based on comments of various positions on this, CMS finalized no changes at this time, and will revisit in future rulemaking
  • CMS is adopting new CPT codes to replace current G codes for care management services

Practice Expense (PE) Inputs for Digital Imaging Services

  • CMS includes the use of a professional PACS workstation used for interpretation of digital images to address costs related to the use of film that had previously been incorporated as direct PE inputs
  • Based on comments, CMS added professional PACS workstation PE RVUs to the following codes:
    • CPT 93880, 93882, 93886, 93888, 93890, 93892-3, 93925-6, 93930-1, 93965, 93970-1, 93975-6, 93978-819, 93990, 76706

Standardization of Clinical Labor Tasks

  • Preservice clinical labor times for CPT codes with 0 and 10-day global periods is assumed to be 0 minutes, unless the physician specialty can provide evidence otherwise
    • 65% of these codes that CMS reviewed included some pre-service time
    • Based on comments, CMS did not move forward with the proposal to apply 0 minutes for 0-day and 10-day global codes going forward – they will be evaluated at the code level
  • CMS did not move forward with its proposal to to assign 5 minutes of clinical labor time for all codes that include the “obtain vital signs” task regardless of when the code was last reviewed

Scope System PE Inputs

  • CMS considered creating a single scope equipment code for each of 5 categories of scopes – this would replace the many existing scope codes
  • Based on comments, CMS did not finalize this proposal and will evaluate creating scope equipment codes on a per-speciality basis by category

Telehealth Services

  • CMS finalized its proposal, adding the following services to the telehealth list
    • HCPCS:  G0296, G0506
    • CPT: 90785, 90839, 90840, 96160, 96161
  • CMS finalized its proposal to eliminate the required use of the GT modifier on professional claims, as it is redundant with the new POS code for telehealth services

Payment Incentive for Transition from Traditional X-Ray Imaging to Digital X-Ray Radiography

  • CMS finalized the requirement for a 7% reduction in TC payments for imaging services that are X-rays taken using computed radiography technology for 2018-2022 (increases to 10% in 2023 and beyond)
  • CMS established a new modifier ( “FY”) for filing on these claimsg

Medicare Diabetes Prevention Program Expanded Model (MDPP)

  • CMS is implementing the MDPP expanded model effective January 1, 2018
  • CMS is finalized additional policies necessary to begin providing these services
    • Payment structure
    • Enrollment requirements
    • Supplier compliance standards

PQRS Criteria for 2018 PQRS Adjustment

  • CMS finalized that no new data is being collected, and will analyze the data differently:
    • Lower current requirements of 9 measures across 3 NQS domains, to 6 measures with no domain requirements
    • Aligns more closely with MIPS quality metric requirements
    • Individuals and Groups reporting via claims or quality registry no longer are required to report a cross-cutting measure
    • Physician data on the Value Modifier will not be posted to Physician Compare website as originally planned

Clinical Quality Measurement for Eligible Professionals in EHR Incentive Program for 2016

  • CMS finalized that no new data is being collected, and will analyze the data differently:
    • Lower current requirements of 9 measures across 3 NQS domains, to 6 measures with no domain requirements
  • CMS is not changing previously finalized requirements for Medicaid EHR incentive program

Medicare Shared Saving Program

  • CMS finalized refinement to its assignment methodology
    • Assign Medicare FFS beneficiaries to an ACO based on their utilization of primary care services furnished by RHCs or FQHCs
    • Addition of new chronic care management and BHI service codes to the definition of primary care services
      • Complex CCM services – CPT 99487, 99489, G0506
      • Behavior Health – G0502-4, G0507
  • SNF 3-Day Rule Waiver Requirements
    • CMS removed the requirement to submit a narrative describing any financial relationship between the ACO, SNF affiliates and acute care hospitals is burdensome
    • CMS removed the requirement that the ACO must submit documentation demonstrating that each SNF on their list of affiliates has an overall rating of 3 or higher under the CMS Quality Rating System
  • Initial Application
    • CMS removed the requirement to submit supporting documents – CMS will request them if needed

Value-Based Payment Modifier

  • CMS finalized its proposal to align the VM payment adjustments in 2018 to be closer aligned with MIPS
    • Reduce the automatic downward adjustments for groups and solo practitioners in Category 2 from -2% to -1%
    • Hold all groups and solo Practitioners in Category 1 harmless from downward payment adjustments under quality tiering for the last year of program
    • Reduce the maximum upward adjustment under the quality-tiering methodology to 2x an adjustment factor (+2.0x) for groups with 10 or more EPs

MACRA Patient Relationship Categories and Codes


Proposed HCPCS Modifier

Patient Relationship Categories



Continuous/broad services



Continuous/focused services



Episodic/broad services



Episodic/focused services



Only as ordered by another clinician











  • The use of these codes is voluntary, and will be available for reporting beginning January 1, 2018




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