- Advance Care Planning: CMS is establishing a payment rate for two advance care planning services, in addition to establishing payment for such services included as an optional element of the “Annual Wellness Visit.” CMS notes the decision to cover the services is “consistent with recommendations from the American Medical Association (AMA) and a wide array of stakeholders.”
- Biosimilar Payment: CMS finalizes its proposal to clarify that payment for a biosimilar biological product “is based on the ASP of all biosimilar biological products included within the same billing and payment code” effective on Jan. 1, 2016. On pharmacovigilance issues in the absence of distinct codes for biosimilars, CMS says “we are developing an approach for using manufacturer-specific modifiers on claims to assist with pharmacovigilance” and adds guidance is expected in the near future.
- Review of Potentially Misvalued Codes; Target Reductions: Pursuant to statutory directives in the Protecting Access to Medicare Act (PAMA) and Achieving a Better Life Experience (ABLE) Act, CMS finalizes a methodology for implementing targeted reductions and how net reductions would be calculated. CMS has identified changes that achieve a 0.23 percent reductions of MPFS expenditures resulting from changing misvalued codes. CMS notes that this will require a 0.77 percent reduction to all MPFS services.
- Misvalued Codes for Rad Onc: CMS opts not to finalize its proposal to “implement the new code set for payment of radiation therapy treatment under the PFS and will continue work to address the radiation therapy codes and pricing in future years.” However, it does finalize the change in the utilization rate assumption affecting the per minute cost of the capital equipment used for radiation therapy (70 percent versus 50 percent), which will be implemented over two years. The agency notes that it seeks comment on “additional sources of accurate data regarding the price of the linear accelerators used in radiation therapy and how often the machines are in use.”
- Phase-In of Significant RVU Reductions : CMS finalizes the proposal that, pursuant to a PAMA requirement to phase-in RVU reductions of 20 percent or more, it will adopt a 19 percent cut in year 1, followed by the additional percent in year 2. The agency says it believes “this approach avoids differential treatment among related codes that would occur due to the 20 percent phase-in cutoff.”
- Physician Self-Referral Updates: CMS finalizes several updates to the current physician self-referral regulations, many of which were recently revamped pursuant to the ACA (e.g., sec. 6001 re: additional requirements of physician-owned hospitals; and sec. 6049 re: the establishment of a Medicare self-referral disclosure protocol (SRDP)). Following stakeholder comment that “additional clarification of certain provisions of the physician self-referral law would be helpful,” CMS establishes new policies and revises certain existing policies pertaining to recruitment assistance and retention, including by clarifying certain requirements for federally qualified health centers (FQHCs) and rural health clinics (RHCs) for purposes of determining geographic areas they serve. CMS also delineates updates to existing restrictions of physician-owned hospitals (including relative to website and advertising requirements, as well as other conforming changes), in addition to a number of updates to terminology and guidance related to the SRDP process, which allows CMS to settle overpayments resulting from physician self-referral law violations. Please refer to the CMS fact sheet for information about the breadth of these finalized policies.
- Medicare Shared Savings Program: The final rule adds statin therapy measure and finalizes policies “[p]reserving flexibility to maintain or revert measures to pay for reporting if a measure owner determines the measure no longer aligns with updated clinical practice or causes patient harm.” The rule also clarifies how PQRS-eligible professionals participating within an ACO meet their PQRS reporting requirements, and amends the definition of primary care services to include claims submitted by Electing Teaching Amendment hospitals.
- Value Based Modifier Changes: The rule finalizes updates to the Value-based Payment Modifier (Value Modifier), authorized under the Affordable Care Act (ACA), which applies a Value Modifier (based on performance on quality and cost metrics) under the MPFS to physicians in groups of 100 or more Eligible Professionals (EPs). The Value Modifier is slated to expire in CY 18, in light of the agency’s broader transition to a Merit-based Incentive Program (MIPS) in CY 2019, pursuant to MACRA. To ultimately ease the transition to MIPS, CMS implements a number of policy changes to the Value Modifier. The policies include designating CY 2016 as the base performance period for the CY 2018 Value Modifier; and the application of the Value Modifier to non-physician EP-only groups (e.g., Physician Assistants (PAs) and others) beginning in CY 18. The rule also stipulates the maximum upward/downward adjustments under the CY 18 Value Modifier at +4.0 times an adjustment factor (and -4.0%, respectively) for groups of 10 or more EPs; +2.0 times (and -2.0%, respectively) for groups between 2-9 EPs and physician solo practitioners; and +2.0 times (and -2.0%, respectively) an adjustment factor for groups and solo practitioners that consist only of non-physician EPs.
- Physician Compare; Benchmark: CMS notes the final rule continues “the phased approach to public reporting on Physician Compare.” Finalized proposals include the addition of a publicly reported indicator for EPs who satisfactorily report the PQRS Cardiovascular Prevention measure group, which is aligned with Million Hearts, and for group practices that attain an upward adjustment under the value modifier. CMS also finalizes a policy, to “include in the downloadable database the Value Modifier tiers for cost and quality, noting if the group practice or EP is high, low, or neutral on cost and quality; a notation of the payment adjustment received based on the cost and quality tiers.” CMS notes that it is not finalizing the proposal to include a visual indicator on profile pages for group practices and individual EPs who receive an upward adjustment for the Value Modifier.
- Physician Quality Reporting System: Noting that beginning in 2019 adjustments to payment for quality reporting and other factors will be made under the Merit-Based Incentive Payment System (MIPS), as required by MACRA, CMS said there will be 281 measures in the PQRS measure set and 18 measures in the GPRO Web Interface for 2016. The agency also finalizes a MARCA-driven addition of a metric-reporting option for group practices via a qualified clinical data registry.
- Appropriate Use of Advanced Diagnostic Imaging; Additional Imaging Provisions: CMS is implementing the first component of a program to establish appropriate use criteria for advanced diagnostic imaging services program by establishing “which organizations are eligible to develop or endorse appropriate use criteria, the evidence-based requirements for AUC development and the process CMS will follow for qualifying provider-led entities.”
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