CMS effectuated this provision in the CY12 Physician Fee Schedule Final Rule and continues to identify misvalued codes for review.
On July 8, 2013, CMS released its CY14 Medicare Physician Fee Schedule (MPFS) proposed regulation, which delineates proposed payment changes to physician payments, in addition to effectuating ACA-authorized requirements consistent with these statutory provisions of the law. Comments on the underlying proposed regulation are due by September 6. A CMS press release is available here.
On November 27, 2013, CMS issued the CY14 Medicare Physician Fee Schedule (MPFS) final rule, in which it decided not to finalize proposed cuts to potentially misvalued codes with higher reimbursement rates than in the hospital outpatient setting. The rule did make some RVU changes that cut some specialties, however, and added a separate payment for non-face-to-face chronic care management services. Comments on the rule are due by January 27.
Note that section 220 of P.L. 113-93, the Protecting Access to Medicare Act of 2014 (i.e., the “doc fix”), which was signed into law on April 1, as noted in the CRS summary here, “[r]evises and expands the list of codes which the Secretary must examine to identify potentially misvalued codes,” among other changes.
On July 2, CMS issued its CY15 Medicare Physician Fee Schedule (MPFS) proposed rule delineating a number of payment policies impacting over one million physicians and other practitioners paid under the MPFS each year. The proposed rule also sets payment policies for the Clinical Laboratory Fee Schedule (CLFS) and other Part B payments for the upcoming year. These key ACA provisions are addressed in the underlying rule. See also: CMS’ accompanying facts sheets on the rule (here and here). Comments are due by September 2, 2014.
On Oct. 31, CMS posted the CY 15 Medicare Physician Fee Schedule (MPFS) final rule with comment (fact sheet) addressing a number of ACA provisions related to physician payment and quality. Citing the April 1 doc fix, the Protecting Access to Medicare Act (PAMA) of 2014, CMS notes that a 0.0% update applies between Jan. 1, 2015, and March 31, 2015, for a conversion factor (CF) of $35.8013 during that period (after budget neutrality adjustments). The SGR calculation applies thereafter (April 1, 2015-Dec. 31, 2015), with the final rule conveying a 21.2% payment reduction for this period relative to the CY14 CF, with a CF of $28.2239.
On May 21, GAO released a report on Medicare physician payment rates, concluding that better data and greater transparency could improve accuracy.
On July 8, CMS posted its CY 16 Medicare Physician Fee Schedule (MPFS) proposed rule, which delineates payment policies impacting over one million physicians and other practitioners paid under the MPFS each year (see fact sheet here). Citing the latest doc fix (P.L. 114-10), the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), CMS effectuates the statutory 0.5% increase. The proposed rule addressed this provision of the ACA. Comments are due Sept. 8
On July 7, CMS released its calendar year (CY) 2017 Medicare Physician Fee Schedule (MPFS) proposed rule delineating wide-ranging Medicare Part B policies that would take effect on Jan. 1, 2017. The proposed rule also would expand the Medicare Diabetes Prevention Program Model, require transparency of certain Medicare Advantage (MA) data, continue the implementation of appropriate use criteria for advanced diagnostic imaging services, and make selected refinements to the Medicare Shared Savings Program, among other policies.
On Aug. 2, CMS released the FY 2017 inpatient prospective payment system (IPPS) and long-term care hospital (LTCH) PPS and policy final rule. The final rule governs FY 2017 payments to approximately 3,330 acute care hospitals and 430 LTCHs through the IPPS and LTCH PPS, respectively, and effectuates key policy changes. Under the rule, net payments to inpatient hospitals will increase by 0.95 percent on average compared with FY 2016. For the IPPS, the rule finalizes the 1.5 percent documentation and coding recoupment cut, as proposed, and delays the proposed incorporation of S-10 data into uncompensated care calculations. LTCH PPS payments will decrease by 7.1 percent under the LTCH PPS amid the ongoing implementation of site neutrality and will increase by 0.7 percent for cases qualifying for the higher standard rate. The aforementioned provisions are addressed in this regulation.
On Nov. 2, CMS released its CY) 2017 Medicare Physician Fee Schedule (MPFS) final rule delineating wide-ranging Medicare Part B payment policies. CMS finalized a fee schedule conversion factor of 35.89 for physicians participating in Medicare Part B. CMS further notes that the policies contained in the rule would improve how Medicare pays for services for patients with multiple chronic conditions and mental and behavioral health issues.
SEC. 3134. MISVALUED CODES UNDER THE PHYSICIAN FEE SCHEDULE. (a) IN GENERAL.—Section 1848(c)(2) of the Social Security Act (42 U.S.C. 1395w–4(c)(2)) is amended by adding at the end the following new subparagraphs: ‘‘(K) POTENTIALLY MISVALUED CODES.— ‘‘(i) IN GENERAL.—The Secretary shall— ‘‘(I) periodically identify services as being potentially misvalued using criteria specified in clause (ii); and ‘‘(II) review and make appropriate adjustments to the relative values established under this paragraph for services identified as being potentially misvalued under subclause (I). ‘‘(ii) IDENTIFICATION OF POTENTIALLY MISVALUED CODES.—For purposes of identifying potentially misvalued services pursuant to clause (i)(I), the Secretary shall examine (as the Secretary determines to be appropriate) codes (and families of codes as appropriate) for which there has been the fastest growth; codes (and families of codes as appropriate) that have experienced substantial changes in practice expenses; codes for new technologies or services within an appropriate period (such as 3 years) after the relative values are initially established for such codes; multiple codes that are frequently billed in conjunction with furnishing a single service; codes with low relative values, particularly those that are often billed multiple times for a single treatment; codes which have not been subject to review since the implementation of the RBRVS (the so-called ‘Harvard-valued codes’); and such other codes determined to be appropriate by the Secretary. ‘‘(iii) REVIEW AND ADJUSTMENTS.— ‘‘(I) The Secretary may use existing processes to receive recommendations on the review and appropriate adjustment of potentially misvalued services described in clause (i)(II). ‘‘(II) The Secretary may conduct surveys, other data collection activities, studies, or other analyses as the Secretary determines to be appropriate to facilitate the review and appropriate adjustment described in clause (i)(II). ‘‘(III) The Secretary may use analytic contractors to identify and analyze services identified under clause (i)(I), conduct surveys or collect data, and make recommendations on the review and appropriate adjustment of services described in clause (i)(II). ‘‘(IV) The Secretary may coordinate the review and appropriate adjustment described in clause (i)(II) with the periodic review described in subparagraph (B). ‘‘(V) As part of the review and adjustment described in clause (i)(II), including with respect to codes with low relative values described in clause (ii), the Secretary may make appropriate coding revisions (including using existing processes for consideration of coding changes) which may include consolidation of individual services into bundled codes for payment under the fee schedule under subsection (b). ‘‘(VI) The provisions of subparagraph (B)(ii)(II) shall apply to adjustments to relative value units made pursuant to this subparagraph in the same manner as such provisions apply to adjustments under subparagraph (B)(ii)(II). ‘‘(L) VALIDATING RELATIVE VALUE UNITS.— ‘‘(i) IN GENERAL.—The Secretary shall establish a process to validate relative value units under the fee schedule under subsection (b). ‘‘(ii) COMPONENTS AND ELEMENTS OF WORK.—The process described in clause (i) may include validation of work elements (such as time, mental effort and professional judgment, technical skill and physical effort, and stress due to risk) involved with furnishing a service and may include validation of the pre-, post-, and intra-service components of work. ‘‘(iii) SCOPE OF CODES.—The validation of work relative value units shall include a sampling of codes for services that is the same as the codes listed under subparagraph (K)(ii). ‘‘(iv) METHODS.—The Secretary may conduct the validation under this subparagraph using methods described in subclauses (I) through (V) of subparagraph (K)(iii) as the Secretary determines to be appropriate. ‘‘(v) ADJUSTMENTS.—The Secretary shall make appropriate adjustments to the work relative value units under the fee schedule under subsection (b). The provisions of subparagraph (B)(ii)(II) shall apply to adjustments to relative value units made pursuant to this subparagraph in the same manner as such provisions apply to adjustments under subparagraph (B)(ii)(II).’’. (b) IMPLEMENTATION.— (1) ADMINISTRATION.— (A) Chapter 35 of title 44, United States Code and the provisions of the Federal Advisory Committee Act (5 U.S.C. App.) shall not apply to this section or the amendment made by this section. (B) Notwithstanding any other provision of law, the Secretary may implement subparagraphs (K) and (L) of 1848(c)(2) of the Social Security Act, as added by subsection (a), by program instruction or otherwise. (C) Section 4505(d) of the Balanced Budget Act of 1997 is repealed. (D) Except for provisions related to confidentiality of information, the provisions of the Federal Acquisition Regulation shall not apply to this section or the amendment made by this section. (2) FOCUSING CMS RESOURCES ON POTENTIALLY OVERVALUED CODES.—Section 1868(a) of the Social Security Act (42 U.S.C. 1395ee(a)) is repealed.