CMS Releases Proposed 2018 Medicare Physician Fee Schedule (MPFS) and Outpatient Prospective Payment System (OPPS)

July 2017 ~

On July 25, CMS released two proposed rules regarding Medicare reimbursement and requirements. The 2018 Proposed Medicare Physician Fee Schedule (MPFS) Proposed Rule addresses Medicare payment and quality provisions for physicians in 2018 and the 2018 Proposed Update to the Outpatient Prospective Payment System (OPPS) will update the requirements for the Hospital Outpatient Quality Reporting (OQR) Program and the ASC Quality Reporting (ASCQR) Program.

The 815-page 2018 Medicare Physician Fee Schedule (MPFS) Proposed Rule includes several issues relevant to anesthesia and pain medicine.

The Proposed Conversion Factor is subject to change pending CMS decisions in the final rule to be posted this fall. The adjustments include the positive 0.5% adjustment under the Medicare Access and CHIP Reauthorization Act (MACRA) as well as other required adjustments. The anesthesia conversion factor also includes an additional adjustment for practice expense and malpractice updates.

• The Proposed Conversion Factor for 2018 is as follows:
  • RBRVS – $35.9903
  • Anesthesia – $22.0353

Concerning Anesthesia for GI Endoscopy, Anesthesia codes 00740 and 00810 will be deleted for CY2018 and replaced with five new codes to more specifically describe this anesthesia care. Anesthesia for upper GI endoscopy will hold steady and see an increase for anesthesia for ERCP. CMS is proposing a value above the survey’s 25^th percentile for anesthesia for screening colonoscopy and is specifically seeking comments on whether it should value 008X2 at 4 base units or adopt the RUC recommendation of 3 base units.

• The code changes for Anesthesia for GI Endoscopy and proposed base unit values are as follows:
  • Deleted – Code 00740 – Anesthesia for upper gastrointestinal endoscopic procedures, endoscope introduced proximal to duodenum
    • Current Base Unit Value: 5
  • Deleted – Code 00810 – Anesthesia for lower intestinal endoscopic procedures, endoscope introduced distal to duodenum
    • Current Base Unit Value: 5
  • New – Code 007X1 – Anesthesia for upper gastrointestinal endoscopic procedures, endoscope introduced proximal to duodenum; not otherwise specified
    • Proposed Base Unit Value: 5
  • New – Code 007X2 – Anesthesia for upper gastrointestinal endoscopic procedures, endoscope introduced proximal to duodenum; endoscopic retrograde cholangiopancreatography (ERCP)
    • Proposed Base Unit Value: 6
  • New – Code 008X1 – Anesthesia for lower intestinal endoscopic procedures, endoscope introduced distal to duodenum; not otherwise specified
    • Proposed Base Unit Value: 4
  • New – Code 008X2 – Anesthesia for lower intestinal endoscopic procedures, endoscope introduced distal to duodenum; screening colonoscopy
    • Proposed Base Unit Value: 4
  • New – Code 008X3 – Anesthesia for combined upper and lower gastrointestinal endoscopic procedures, endoscope introduced both proximal to and distal to the duodenum
    • Proposed Base Unit Value: 5

For Intravascular Catheterization Procedures, placement of a non-tunneled centrally inserted central venous catheter in patients age 5 or older CPT code 36556) was flagged as potentially misvalued due to high expenditures. CMS concerns about the value of code 36556 has led to review of this code and three others as they were considered part of the same code family.

• CMS is proposing the following work RVUs for the above codes:
  • Code 36555 – Insertion of non-tunneled centrally inserted central venous catheter; younger than 5 years of age
    • Current Work RVU:2.43
    • Proposed Work RVU:1.93
  • Code 36556 – Insertion of non-tunneled centrally inserted central venous catheter; age 5 years or older
    • Current Work RVU:2.50
    • Proposed Work RVU:1.75
  • Code 36620 – Arterial catheterization or cannulation for sampling, monitoring or transfusion (separate procedure); percutaneous
    • Current Work RVU:1.15
    • Proposed Work RVU:1.00
  • Code 93503 – Insertion and placement of flow directed catheter for monitoring purposes
    • Current Work RVU:2.91
    • Proposed Work RVU:2.00

Percutaneous Implantation of Neurostimulator Arrays have been under review and CMS has proposed significant increases to the work RVUs assigned to these services.

• Proposed changes for Percutaneous Implantation of Neurostimulator Arrays include:
  • Code 64553 – Percutaneous implantation of neurostimulator electrode array; cranial nerve
    • Current Work RVU:2.36
    • Proposed Work RVU: 6.13
  • Code 64555 – Percutaneous implantation of neurostimulator electrode array; peripheral nerve (excludes sacral nerve)
    • Current Work RVU:2.32
    • Proposed Work RVU: 5.76

For the 2018 payment year, CMS is proposing to change the current PQRS program policy that requires reporting of 9 measures across 3 National Quality Strategy domains to only require reporting of 6 measures for the PQRS. This is significant for many practices who have previously struggled to reach the higher threshold.

Additionally, CMS has proposed to ease downward adjustments in the value-based payment modifier. As written the proposal reduces the automatic downward payment adjustment for not meeting minimum quality reporting requirements from -4% to -2.0% for groups of ten or more clinicians; and from negative two percent to negative one percent -1.0% for physician and non-physician solo practitioners and groups of two to nine clinicians. As well, the proposal would hold harmless all physician groups and solo practitioners who met minimum quality reporting requirements from downward payment adjustments for performance under quality-tiering for the last year of the program.

The Medicare Access and CHIP Reauthorization Act (MACRA) requires establishment of codes and modifiers to define clinician/patient relationships and to be used as part of determining cost attribution. CMS is proposing the following MACRA Patient Relationship Categories and Code modifiers to be used on claims for services provided on/after January 1, 2018:

• Proposed Modifier: X1
  • Patient Relationship Category: Continuous/broad services
• Proposed Modifier: X2
  • Patient Relationship Category: Continuous/focused services
• Proposed Modifier: X3
  • Patient Relationship Category: Episodic/broad services
• Proposed Modifier: X4
  • Patient Relationship Category: Episodic/focused services
• Proposed Modifier: X5
  • Patient Relationship Category: Only as ordered by another clinician

According to CMS, the 2018 Proposed Update to the Outpatient Prospective Payment System (OPPS) and Ambulatory Surgical Center Payment Systems Proposed Rule if finalized would revise the Medicare hospital outpatient prospective payment system (OPPS) and the Medicare ambulatory surgical center (ASC) payment system for CY 2018 to implement changes arising from our continuing experience with these systems and certain provisions under the 21^st Century Cures Act (Pub. L. 114-255).

Proposed changes to the amounts and factors used to determine the payment rates for Medicare services paid under the OPPS and those paid under the ASC payment system include:

• Proposed CY 2018 OPPS Conversion Factor: $76.483
  • CMS says this change is based on the projected hospital market basket increase of 2.9% minus both a 0.4% point adjustment for multi-factor productivity and a 0.75 percentage point adjustment required by law
  • The effective update is 1.75%
• Proposed CY 2018 ASC Conversion Factor: $44.976
  • CMS projects the CPI-U update to be 2.3%. The MFP adjustment is projected to be 0.4, resulting in a proposed MFP-adjusted CPI-U update factor of 1.9%.
• Modifications to the ASC Quality Reporting (ASCQR) Program
  • CMS is proposing to delay the mandatory implementation of the Consumer Assessment of Healthcare Providers and Systems Outpatient and Ambulatory Surgery Survey (OAS CAHPS) under the ASCQR Program for CY 2018 data collection.
• Modifications of Hospital Outpatient Department Quality Reporting Program
  • Proposals include formalized chart-abstracted measures validation, educational review procedures, updates to include a corrections process and corresponding regulatory updates to reflect these proposals, as well as changes to the Notice of Participation deadline and alignment of the naming of the Extraordinary Circumstances Exceptions policy with other quality reporting programs and corresponding regulatory updates to reflect these proposals

Comments on both rules are due on September 11, 2017.

For more details on these proposed changes, see CMS’ fact sheets on the MPFS and OPPS proposed rules.

Source(s): Emergency Department Practice Management; American Society of Anesthesiologists (ASA); CMS Fact Sheet; CMS Press Release; CMS Hospital Outpatient PPS; Hospital Outpatient Prospective Payment – Final Rule with Comment and Final CY2017 Payment Rates;