On October 31, the Centers for Medicare & Medicaid Services (CMS) released the Calendar Year 2015 Physician Fee Schedule (MPFS) final rule. This rule outlines changes to policies and payment rates for services rendered on and after January 1, 2015. After CMS posted its proposed rule in July, ASA submitted formal comments.
ASA continues to review the full 1,185 page final rule and its impact on anesthesiologists. After initial review, ASA wants to make you aware of the following points:
Epidural Injections and Fluoroscopic Guidance as Potentially Misvalued Services
When CMS announced dramatic cuts to interlaminar epidural injections, ASA and other specialties whose members provide these services advocated very strongly that CMS reverse its decision. CMS put that action forward as part of the proposed rule published in July. We are pleased to see that CMS finalized its proposal to return to the pre-2014 Work Relative Value Units (RVUs) and Practice Expense (PE) resources even though it stood by its position that the services remain classified as potentially misvalued. ASA reaffirmed its commitment to work via the CPT® (Current Procedural Terminology) process to ensure that the codes are revised to accurately describe the services performed and address CMS concerns about use of imaging guidance. ASA will continue to work via the RUC (AMA/Specialty Society Relative Value Scale Update Committee) process to determine values that accurately and fully capture all the work, resources and risks associated with providing this important care.
CMS announced its intention to follow through with its proposal to prohibit separate reporting of imaging guidance for these injections stating that the resources required to provide the imaging are part of the PE resources that have been returned to the value of the injections.
Definition of Colorectal Screening Tests
ASA is pleased to see that CMS will extend the essential benefits provisions associated with screening colonoscopy to anesthesia for these procedures. As an essential benefit, Medicare beneficiaries will not be responsible for any deductible or copayment for this anesthesia service. Claims for anesthesia for screening colonoscopy are to be reported with anesthesia CPT code 00810 – Anesthesia for lower intestinal endoscopic procedures, endoscope introduced distal to duodenum – with modifier 33 – Preventive services – appended to the anesthesia code. If the procedure begins as a screening but further services such as polyp removal are performed, the same anesthesia code is reported but modifier PT – Colorectal cancer screening test; converted to diagnostic test or other procedure – should be used instead of modifier 33.
In our comment letter, ASA stated that “As an essential benefit, Medicare should pay the anesthesia provider for the service; payment should not be conditioned on the presence or other specified diseases, conditions, or situations.” We are pleased that CMS has responded by noting that “This final rule with comment period establishes national policy and takes precedence over any local coverage policy that limits Medicare coverage for anesthesia services furnished during a screening colonoscopy by an anesthesia professional.” While this final rule confirms coverage of anesthesia care for screening colonoscopy, it includes no mention of any change in the method used to determine the payment amount.
2015 Anesthesia and Resource Based Relative Value System (RBRVS) Conversion Factors
Because the current patch to the Sustainable Growth Rate (SGR) formula expires on March 31, 2015, CMS provides the conversion factors that will be used to determine payments for services provided from January 1 – March 31, 2015 and a separate conversion factor for services provided on or after April 1, 2015 pending any further Congressional action. Differences in the conversion factors for 2014 and for the first quarter of 2015 are a result of budget neutrality adjustments and PE adjustments.
Jan 1 – Mar 31, 2015 On/After Apr 1, 2015
Anesthesia $22.5550 $17.7913
RBRVS $35.8013 $28.2239
Physician Quality Reporting System
Regarding the Physician Quality Reporting Program (PQRS), there will be several changes to the claims-based and registry-based reporting options for Calendar Year 2015. CMS finalized the removal of PQRS #30 (Timing of Prophylactic Antibiotic – Administering Physician) as an official PQRS measure as well as the Back Pain Measures Group from the traditional registry reporting option (PQRS #148-151). Reporting via claims will become increasingly burdensome in future years as CMS, beginning in 2015, will require eligible professionals (EPs) who report via the claims-based and registry reporting options to report on at least one of 19 available cross-cutting measures. More details on reporting via the claims-based and traditional registry reporting options will be available in upcoming weeks.
The Qualified Clinical Data Registry (QCDR) option for PQRS reporting, available for EPs, also received significant attention in the rule. To satisfactorily participate in the QCDR, CMS will require that an EP report nine measures across three NQS domains using the QCDR option. Of these measures, the EP must “report on at least 2 outcome measures (or, in lieu of 2 outcome measures, at least 1 outcome measure and 1 of the following other types of measures – resource use, patient experience of care, efficiency/appropriate use, or safety).” CMS also finalized their proposal that a QCDR may submit quality measures data for a maximum of 30 non-PQRS measures beginning next year.
Value-Based Payment Modifier
Over the objections of ASA and many other stakeholders, CMS will increase the amount at risk under the Value-Based Payment Modifier program for 2017. The amount at risk for the 2016 program is 2 percent of Medicare allowed charges. For 2017, this will increase to 4 percent of allowed charges for groups with 10 or more eligible professionals (EPs); it will remain at 2 percent for groups with 2-9 EPs and for solo practitioners.
ASA will continue to evaluate this rule and will update ASA members with additional information.
Review ASA's comments on the proposed rule.