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CMS releases Quality Payment Program final rule, physician fee schedule

The Centers for Medicare and Medicaid Services (CMS) released last Thursday a final rule with comment period for the Quality Payment Program (QPP), as well as the 2018 Medicare Physician Fee Schedule (PFS) rule.

Established by the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), the QPP is a quality payment incentive program for physicians and other eligible clinicians that aims to reward value and outcomes through the Merit-based Incentive Payment System (MIPS) or the Advanced Alternative Payment Models (APMs). Society staff is currently reviewing the details of the 1,653-page rule and their implication for members. Meanwhile, CMS has made available this 26-page overview of the rule.

2018 Medicare Physician Fee Schedule
The 2018 PFS final rule includes a +0.31 percent payment adjustment, and also addresses the following:

  • Physician Work and Practice Expense: Includes resource estimates for new/revised CPT codes and services identified as potentially misvalued.
  • Physician Quality Reporting System (PQRS) and Meaningful Use (MU) Quality Reporting: Aligns calendar year 2016 PQRS and MU quality reporting requirements with those under MIPS.
  • Value Modifier (VM):
    • Holds all groups and solo practitioners who met 2016 PQRS reporting requirements harmless from any negative VM payment adjustments in 2018.
    • Halves penalties for those who did not meet PQRS requirements to -2 percent for groups with 10 or more eligible professionals, and to -1 percent for smaller groups and solo practitioners.
    • Reduces the maximum upward payment adjustment to 2 times an adjustment factor that is set at the rate needed to keep penalties and bonuses budget neutral.
    • Drops its earlier proposal to publicly report 2016 value modifier data on its Physician Compare website.
  • Patient Relationship Categories: Finalizes the use of level II HCPCS modifiers.
  • Diabetes Prevention Program: Reduces from $810 the maximum payment per beneficiary to $670 over three years. Also establishes two-year limit on Medicare coverage for ongoing maintenance sessions and new G-codes for reporting services.
  • Digital Medicine/Remote Patient Modeling: finalizes several proposed expansions of telehealth and remote patient monitoring; also includes development of new CPT codes.
  • Appropriate Use Criteria: creates an educational and operations testing period during which CMS will pay claims for advanced diagnostic imaging services regardless of whether they correctly contain information on the required AUC consultation.
  • Biosimilars: Provides for separate coding and payment for each approved biosimilar product. (Biosimilars are lower-cost alternative to certain types of drugs knows as biologicals.)
  • Payment Rates for Items and Services Furnished by Nonexcepted Off-Campus Provider-Based Departments (PBDs) of a Hospital: reduces the current payment rate of 50 percent of the Hospital Outpatient Prospective Payment System (OPPS) to 40 percent.
  • Medicare Shared Savings Program: reduces document submission requirements for skilled nursing facilities, rural health clinics and federally qualified health centers.

CMS also has released changes to the Hospital Outpatient Prospective Payment System (OPPS), the Ambulatory Surgical Center Payment System and Quality Reporting Programs for 2018. Changes include a 1.35 percent OPPS payment rate increase, a change based on the hospital market basket increase of 2.7 percent minus both a 0.6 percentage point adjustment for multifactor productivity and a 0.75 percent adjustment required by law. This rule is available here and a CMS fact sheet outlining changes is posted here.

The Society submitted comments on each of these proposed rules last summer and staff is currently reviewing details of the final rules.

For a more comprehensive analysis of these rules and their implications, the Society is offering “2018 Quality Payment Program Updates Under MACRA: Impacts for MIPS and APMs.” Presented by Society Policy Specialist H.J. Waukau, this webinar will be streamed live Wednesday, Dec. 13 at noon and will also be available on demand a few days later. Registration information will be available soon.

Back to November 9, 2017 Medigram