CMS Issues Final Rule for CY 2017 Medicare Physician Fee Schedule

ASA members will see some good news in the 2017 Medicare Physician Fee Schedule, which was released on Wednesday, November 2.  While staff continues to review the 1,401-page rule, there are several issues where physician anesthesiologists will see improvements from what the Centers for Medicare and Medicaid Services (CMS) cited in its proposed rule on the 2017 fee schedule. Key provisions include:

Increase in Anesthesia Conversion Factor:

Both the Anesthesia and the Resource Based Relative Value System (RBRVS) conversion factors (CF) as finalized are higher than what was in the proposed rule and represent an increase from the 2016 CFs:

In addition to the positive update to the CFs, there is also good news on the values for specific services of note to ASA members:

Preservation of Values for Anesthesia Services Furnished in Conjunction with Lower Gastrointestinal GI Procedures (CPT Codes 00740 and 00810)

These two anesthesia codes had been identified a potentially misvalued and were the subject of an AMA/Specialty Society Relative Value Update Committee (RUC) survey earlier this year. The RUC recommended maintaining the current value of five base units for each of these codes on an interim basis as it works with ASA to address some concerns about the surveys. In its proposed rule, CMS expressed agreement with that recommendation noting that it was “premature to propose any changes to the valuation of CPT codes 00740 and 00810.”

In its official comment letter on the proposed rule, ASA stated: “We appreciate the agency’s fair-minded proposal to maintain current value for codes 00740 and 00810 and will continue to work with CPT, the RUC and CMS to address concerns about the valuation of these anesthesia services.”

In its Final Rule, CMS expressed appreciation for comments it received and indicated it will take them and any further feedback into consideration for future rulemaking.

Increase in Value for Paravertebral Block Injection (CPT Codes 64461, 64462 and 64463)

Codes specific to paravertebral blocks were new for CY2016. Following the process that was in place at the time, CMS assigned interim values to them for CY2016 and proposed finalizing those values in this final rule. ASA did not agree with the value assigned to code 64463 - Paravertebral block (PVB) (paraspinous block), thoracic; continuous infusion by catheter (includes imaging guidance, when performed).  CMS assigned a work value of 1.81 relative value units (RVUs) rather than ASA’s recommendation of 1.90 to code 64463.

In its official comment letter on the proposed rule, ASA stated: “We request CMS implement a work RVU of 1.90 for code 64463.” ASA is grateful that in its Final Rule, CMS revised its stance and will increase the work RVUs assigned to code 64463 for CY2017 to 1.90.

Increase in Value for Endotracheal Intubation (CPT Code 31500)

This service was reviewed after CMS identified it as potentially misvalued. RUC survey results supported ASA’s view that the service was in fact undervalued and both CMS and the RUC agreed. CMS initially proposed an increase that was lower than what ASA’s surveys supported and that the RUC had recommended.

In its official comment letter on the proposed rule, ASA stated: “We request CMS adopt the RUC recommended work RVU of 3.00 for code 31500.”  ASA is pleased that in response to this comment, CMS decided to increase the work value of this service beyond the increase it had originally proposed.

Stabilize Values for Epidural Injections (CPT Codes 62320 through 62327)

After more than five years of review, CMS proposed to stabilize the values assigned to interlaminar epidural injections.  As part of that process, existing codes 62310 through 62319 will be deleted and replaced with new codes effective January 1, 2017. These new codes address CMS’s concerns about use of imaging with these procedures. CMS proposed accepting the RUC recommended work RVUs for the new codes but also proposed removing two supplies from the practice expenses associated with these services.

In its official comment letter on the proposed rule, ASA stated: “ASA requests that CMS accept the RUC recommended practice expense supplies for codes 62320 – 62327.” The Final Rule indicates that CMS was receptive to these concerns and is restoring the supplies in question to all eight of the new codes.

Preserved Values for Fluoroscopic Guidance (CPT Codes 77001, 77002 and 77003)

The work values for codes 77002 and 77003 have been the subject of several recent RUC surveys. For CY 2017, these codes will become add on codes rather than standalone codes. CMS proposed lowering the work values for these services stating that these procedures were comparable to code +77001 - Fluoroscopic guidance for central venous access device placement, replacement (catheter only or complete), or removal (includes fluoroscopic guidance for vascular access and catheter manipulation, any necessary contrast injections through access site or catheter with related venography radiologic supervision and interpretation, and radiographic documentation of final catheter position) (List separately in addition to code for primary procedure)

In its official comment letter on the proposed rule, ASA stated: “ASA believes that CMS should acknowledge the increased risk and complexity associated with codes 77002 and 77003 as compared with code 77001 and assign a work RVU of 0.54 to code 77002 and 0.60 to code 77003.” After consideration of comments including those submitted by ASA, CMS changed its proposal and finalized higher values than it originally proposed for codes 77002 and 77003.

Modification of List of Potentially Misvalued Services

In a continuation of its efforts to identify potentially misvalued services, CMS proposed to review codes that have a zero-day global period that are billed more than 50% of the time with an evaluation and management (E/M) service. Priority would be placed on codes that had not been reviewed in the last five years and that have more than 20,000 allowed services.  The proposed rule included a list of 83 codes that could be identified as potentially misvalued under this new screen – 11 of which are often reported by ASA members.

In its official comment letter on the proposed rule, ASA stated: “ASA recommended that 10 of those codes be removed from the CMS list of potentially misvalued services under this new filter as they did not meet stated criteria.”

In the Final Rule, the list of services identified as potentially misvalued through this filter has been reduced to 19 services and it includes only one code that has any significant reporting by ASA members (64405 - Injection, anesthetic agent; greater occipital nerve).

Relief from Certain Requirement for Collecting Data on Resources Used in Furnishing Global Services:

The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) overturned a previous CMS decision to eliminate the surgical global period. However, MACRA did impose certain data collection efforts to determine the number and level of services provided in conjunction with procedures that have a 10 or 90-day global period. Some of the pain medicine procedures performed by ASA members have a 10-day global period.

CMS proposed a three-pronged approach. One prong was a requirement that all physicians and practitioners report all services within the global period with newly created G-codes for all services they provide that have a 10 or 90-day global period. This reporting requirement would become effective on January 1, 2017.

CMS received significant feedback from ASA and other stakeholders strongly objecting to this approach to claims based data collection. In its official comment letter on the proposed rule, ASA stated: “The claims based data collection process as proposed will be complex, burdensome and a distraction from patient care. If CMS finalizes its proposal, physicians will have to develop and implement new and complex processes to comply. This will result in increased costs and diversion of resources away from important patient-focused priorities.”

In the Final Rule, CMS finalized its claims based reporting proposal with significant changes that align with ASA’s concerns, including:

• Reporting will be via existing CPT code 99024 - Postoperative follow-up visit, normally included in the surgical package, to indicate that an evaluation and management service was performed during a postoperative period for a reason(s) related to the original procedure - instead of new G-codes.
• Code 99024 should be used to report post-operative visits within the global period. It will be used for informational purposes and will not have any payment implications.
• Reporting will be required only for services that are furnished by more than 100 practitioners and are either reported more than 10,000 times or have allowed charges greater than $10M annually. CY2014 claims data will be used to identify services that meet these criteria for 2017.
• CMS encourages reporting to start on January 1, 2017 but the reporting will not become mandatory until July 1, 2017.
• Reporting will be required only for practitioners in groups of 10 or more in the following states: FL, KY, LA, NV, NJ, ND, OH, OR and RI. CMS encourages those smaller groups or from other states to report data if feasible.

Medicare Telehealth Services:

As part of the proposed rule, CMS sought stakeholder feedback on a request that it consider including critical care services on its list of procedures that may be done via telehealth.  Previous requests had been denied but CMS has since found reasons to recognize that critical visits done remotely may have potential clinical benefit.  Therefore, CMS proposed to create new G-codes to describe these consultations and to include those new codes on the telehealth list.

In its official comment letter on the proposed rule, ASA stated: “While critical care medicine requires face-to-face care by critical care physicians, there are some clinical situations in which a patient may benefit from a telemedicine consultation with a critical care physician.  We support establishment of G-codes to describe these specific consultation services and adding those codes to the telehealth list.”

In response, in the Final Rule, CMS is creating two new G-codes for intensive telehealth consultations and adding them to the telehealth list.  The codes may be reported once per day per patient. Reporting will be subject to existing telehealth restrictions.

Summary:

ASA is grateful for CMS’ consideration of ASA comments during the proposed rule comment period.  CMS heard ASA’s concerns and took many of ASA’s suggested adjustments into consideration in drafting the Final Rule.  CMS responded positively to the issues ASA raised in response to the proposed rule for the CY 2017 Medicare Physician Fee Schedule. The higher values that will be assigned to the services noted above combined with the positive updates to the conversion factors will increase the accuracy of the fee schedule and benefit ASA members and the patients they serve.

Read the proposed rule.

Read ASA’s comments on the proposed rule.

Read the final rule.