CMS Releases Final Rule for 2018 Medicare Physician Fee Schedule

Correction (Monday, November 13, 2017): Posting corrected to display proper table in anesthesia GI endoscopy section. We apologize for any confusion the omission of this table may have caused.

On November 2, 2017, the Centers for Medicare & Medicaid Services (CMS) released its final rule for the CY2018 Medicare Physician Fee Schedule. This 1,250-page rule includes many issues relevant to anesthesia and pain medicine.

2018 Medicare Conversion Factors - Modest Increase in Anesthesia CF:

The calculations that result in these figures include the positive 0.5% adjustment under the Medicare Access and CHIP Reauthorization Act (MACRA) as well as other statutorily required adjustments. The anesthesia conversion factor also includes an additional adjustment for practice expense and malpractice updates.

A portion of a proposed – now rejected - decrease to the anesthesia conversion factor was due to a CMS proposal to update the malpractice component of the fee schedule . ASA and others objected to CMS’s proposed method and convinced CMS to not implement their proposal which would have negatively impacted every anesthesia service provided to Medicare beneficiaries.

Anesthesia for GI Endoscopy - New Codes include Base Unit Increases and Reductions:

Anesthesia codes 00740 - Anesthesia for upper gastrointestinal endoscopic procedures, endoscope introduced proximal to duodenum and 00810 - Anesthesia for lower intestinal endoscopic procedures, endoscope introduced distal to duodenum have been under review since 2016 based on a significant growth in utilization. These anesthesia codes will be deleted for CY2018 and replaced with five new codes to more specifically describe this anesthesia care. ASA worked in support of appropriate values for each of the new codes.

The new codes and CMS’s decision on their assigned base unit values are as follows:

These new codes replace the following anesthesia codes for services provided on/after January 1, 2017:

Deleted codes 00740 and 00810 each previously had a base unit value of 5. For CY 2018, the base unit value for anesthesia for ERCP increases from 5 to 6 base units and anesthesia for other upper GI endoscopy procedures holds its value at 5 base units.

CMS is finalizing a reduction in the base unit value for lower GI endoscopy procedures, going beyond the reduction that appeared in its Proposed Rule for anesthesia for screening colonoscopy. ASA strongly disagrees with this decision, again noting that CMS itself recognized the importance of screening colonoscopy and took actions that included eliminating beneficiary co-pays and deductibles in many cases for both the procedure and associated anesthesia care to encourage patients to undergo these procedures. ASA stressed in multiple venues that increased utilization was not driven by a valuation anomaly but rather by a recognition that these services are so important that patients are encouraged to undergo them through CMS’ own payment policies.

Intravascular Catheterization Procedures – Decreases for Work Values:

Placement of a non-tunneled centrally inserted central venous catheter in patients age 5 or older (CPT code 36556) was flagged by CMS as potentially misvalued due to high expenditures. CMS concerns about the value of code 36556 resulted in review of this code and three others as they were considered part of the same code family. CMS is finalizing the following work RVUs for these codes.

Percutaneous Implantation of Neurostimulator Arrays - Increases for Work Values:

These services have also been under review and CMS is finalizing significant increases to the work RVUs assigned to these services.

Overall Impact on Allowed Charges:

CMS estimated impacts on allowed charges for all specialties and specifically for anesthesiology and interventional pain management are as follows:

Source: CMS-1676-F, Table 50: CY 2018 PFS Estimated Impact on Total Allowed Charges by Specialty

(Note: Final column may not equal sums of previous columns due to rounding. Rounding may also prevent display of values other than whole numbers)

CMS Finalizes Changes to the 2018 PQRS Payment Adjustment and Value-Based Payment Modifier:

For the 2018 payment year, CMS reduced the criteria for satisfactory reporting for the Physician Quality Reporting System (PQRS) for CY 2016 reporting period. The requirement was lowered from 9 measures across 3 NQS domains, where applicable, to only 6 measures with no domain or cross-cutting measure requirement. This is significant for many practices who have previously struggled to reach the higher threshold.

In addition, CMS eased downward adjustments in the value-based payment modifier (VM). Individuals and practices that satisfactorily participated in PQRS will be exempt from any negative VM that could have occurred via quality-tiering. CMS has reduced the automatic downward payment adjustment for those individuals and practices not meeting minimum PQRS criteria from negative four percent to negative two percent (-2.0 percent) for groups of ten or more clinicians; and from negative two percent to negative one percent (-1.0 percent) for physician and non-physician solo practitioners and groups of two to nine clinicians. Positive payments adjustments under the VM are available for those practices that demonstrated lower costs and higher quality care.

ASA is exploring how CMS intends to notify practices of these rule changes and will produce guidance for members on how to assess the impact of this portion of the rule on practices.

MACRA Patient Relationship Categories and Codes:

The Medicare Access and CHIP Reauthorization Act requires establishment of codes and modifiers to define clinician/patient relationships and to be used as part of determining cost attribution. CMS proposed the following modifiers to be used on claims for services provided on/after January 1, 2018.

However, in this final rule, CMS states, “Our plan is not to tie the collection of the codes with payment until we are sure clinicians have gained ample experience and education in using these modifiers. Therefore, there is no impact to CY 2018 physician payments under the PFS.”

The full rule is available at https://www.federalregister.gov/documents/2017/11/15/2017-23953/medicare-programs-revisions-to-payment-policies-under-the-physician-fee-schedule-and-other-revisions

A CMS Fact Sheet can be viewed at https://www.cms.gov/Newsroom/MediaReleaseDatabase/Fact-sheets/2017-Fact-Sheet-items/2017-11-02.html