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2018 Medicare Physician Fee Schedule (MPFS) Proposed Rule Overview
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Appropriate Use Criteria Program Implementation

CMS proposes a delay in implementation of the Medicare Appropriate Use Criteria (AUC) Program for Advanced Diagnostic Imaging.  Specifically, CMS proposes to begin with an educational and operations testing year in 2019, which means physicians would be required to start using AUCs and reporting this information on their claims. During this first year, CMS proposes to pay claims for advanced diagnostic imaging services regardless of whether they contain information on the required AUC consultation. CMS notes this is to allow both providers and CMS to prepare for the new program. 

CMS seeks comments on whether the AUC program should be delayed beyond the proposed start date of January 1, 2019, and how long the educational and operations testing period should be available.


Request for Comment on Evaluation and Management Codes

CMS notes that most physicians and other practitioners bill patient visits to the MPFS under Evaluation and Management (E/M) codes.  These codes describe the level of complexity, site of care, and in some cases whether the patient is new or established. Billing practitioners must maintain information in the medical record that documents that they have reported the appropriate level of E/M visit code. CMS maintains guidelines that specify the kind of information that is required to support Medicare payment for each level. There are three key components to selecting the appropriate level:

  • History of Present Illness (History);
  • Physical Examination (Exam); and
  • Medical Decision Making (MDM). 

CMS believes its guidelines are potentially outdated and need to be revised, especially the history and exam components.  CMS seeks comment on specific changes that CMS should make to update the guidelines, reduce burdens on providers, and to better align E/M coding and documentation with the current practice of medicine.


Payment Rates for Non-Excepted Off-campus Provider-Based Hospital Departments Paid Under the MPFS

Statute requires that certain items and services furnished by off-campus hospital outpatient provider-based departments be no longer paid under the Hospital Outpatient Prospective Payment System (OPPS) beginning January 1, 2017. For Calendar Year (CY) 2017, CMS finalized the MPFS as the applicable payment system for most of these items and services.

For CY 2018, CMS is proposing to reduce current MPFS payment rates for these items and services by 50 percent. CMS currently pays for these services under the MPFS based on a percentage of the OPPS payment rate. The proposal would change the MPFS payment rates for these services from 50 percent of the OPPS payment rate to 25 percent of the OPPS rate. CMS believes that this adjustment will encourage competition between hospitals and physician practices by promoting greater payment alignment.



2018 Hospital Outpatient Prospective Payment System (OPPS) Proposed Rule Overview


Restructuring of Imaging Ambulatory Payment Classification (APC) Groups

For 2017, CMS implemented a significant restructuring of the imaging Ambulatory Payment Classification groups, resulting in the consolidation of such groups from 17 in 2016 to seven imaging APCs for 2017.  CMS stated the purpose of this restructuring was to more adequately reflect resource costs and clinical characteristics of services assigned to the various APCs.  This restructuring translated to a negative impact on technical component (TC) reimbursement for many imaging procedures.   However, cardiac CT services saw an increase of approximately $30 under this restructuring.  For 2018, CMS proposes to add an additional imaging APC – Level 5 Imaging without contrast - for low volume, high cost services.  Preliminary review indicates the TC of CPT codes 75572, 75573 and 75574, would be cut by $30 under the proposed rule for 2018.  Please see the attached reimbursement chart for effects of the proposed rules on professional and technical component reimbursement for cardiac CT services.


Request for Information on Flexibilities and Efficiencies – Hospital Outpatient Prospective Payment System

CMS issued a Request for Information (RFI) to solicit ways to improve transparency, flexibility, program simplification and innovation. CMS suggests this will inform the discussion on future regulatory action related to outpatient services performed at hospitals and services performed at ambulatory surgical centers.

CMS notes that ideas could include:  recommendations regarding payment system re-design; elimination or streamlining of reporting, monitoring and documentation requirements; operational flexibility; feedback mechanisms and data sharing, etc.


Comment Solicitation on Packaging

CMS seeks comments on packaging policies under the OPPS, including those related to drugs that function as a supply in a diagnostic test, diagnostic procedure, or surgical procedure. In addition, CMS requests feedback on common clinical scenarios involving separately payable items and services for which payment would be most appropriately packaged under the OPPS.


The above summary is a preliminary analysis of important provisions of the proposed Medicare Physician Fee Schedule and Hospital Outpatient Prospective Payment System rules for 2018.  SCCT will continue to review these rules and comment on provisions that will affect patient care and the provision of cardiac CT services.  Comments will be accepted by CMS until September 11, 2017.