Outpatient Prospective Payment System
The Centers for Medicare & Medicaid Services (CMS) today released the proposed outpatient prospective payment system (PPS) rule for CY15. Premier will provide a detailed summary of the final rule in the coming days.
The proposed rules will be published in the Federal Register on July 14, 2014. CMS will accept comments until September 2, 2014.
The proposed rule with comment period will increase payment rates under the hospital outpatient PPS by 2.1% in CY15. This increase is based on the projected hospital inpatient market basket percentage increase of 2.7% for services paid under the hospital inpatient PPS minus the multifactor productivity adjustment of 0.4% and minus a 0.2% adjustment to the market basket, both of which are required by the Affordable Care Act (ACA).
Highlights of the proposed rule include:
- Comprehensive APCs: Adopted in the CY14 Outpatient PPS final rule but delayed until CY15 for implementation, Comprehensive APCs pay for high cost device dependent services using a single payment for the hospital stay, but unlike the existing device-dependent APCs, these payments will include room and board as well as nursing costs. CMS is proposing several additional Comprehensive APCs and well as consolidating previously proposed Comprehensive APCs, taking the count from 29 to 28 for CY15.
- Packaging: The proposal to package all ancillary services (primarily minor diagnostic tests, sometimes therapeutic services) with status indicator X in last year’s rule was not finalized for CY14. This year CMS proposes to package ancillary services that are currently assigned to APCs with a geometric mean cost of $100 or less. However, CMS will separately pay for these services when they are billed with no other procedures. Although considered ancillary, CMS will pay for preventative services, psychiatry-related services, and drug administration procedures separately regardless of billing with other procedures. CMS is also proposing to package prosthetic supplies, previously not paid for under the Outpatient PPS.
- Off-Campus Provider-Based Departments: CMS proposes to begin collecting data on services furnished in off-campus provider-based departments beginning in 2015 by requiring hospitals and physicians to report a modifier for those services furnished in an off-campus provider-based department on both hospital and physician claims.
- Part B Drugs in the Outpatient Department: CMS is proposing to continue paying average sales price (ASP) + 6 percent for non-pass-through drugs and biologicals that are payable separately under the Outpatient PPS. The packaging threshold for non-pass-through drugs proposed is $90.
- Quality reporting Outpatient: CMS proposes to decrease the number of measures for the Hospital Outpatient Quality Reporting (OQR) program to 25 from 27 for payment year 2017. The proposed changes include removing three chart abstracted measures, adopting one new claims-based measure and changing one chart-abstracted measure (OP-31: Cataracts — Improvement in Patient’s Visual Function within 90 Days Following Cataract Surgery (NQF #1536)) from required to voluntary reporting.
Removes three chart abstracted measures:
- OP-4: OP-4: Aspirin at Arrival
- OP-6: Timing of Prophylaxis Antibiotics
- OP-7: Prophylactic Antibiotic Selection for Surgical Patients
Adopts one claims based measure:
- OP-32: Facility 7-Day Risk-Standardized Hospital Visit Rate after Outpatient Colonoscopy
CMS also is proposing modifications to the Hospital OQR Program validation process and formalization of a review and corrections period.
Quality reporting ASC:
CMS proposes to increase the number of measures for the ASCQR Program to 12 from 11 for payment year 2017. The proposed change adopts one new claims based outcome measure and changes one chart abstracted measure to voluntary.
Adopts one new claims based measure:
- ASC-12: Facility Seven-Day Risk-Standardized Hospital Visit Rate after Outpatient Colonoscopy
Changes one chart abstracted measure to voluntary:
- ASC-11: Cataracts: Improvement in Patient’s Visual Function within 90 Days Following Cataract Surgery
- Additionally proposing to exclude ASC-11 from the CY 2016 measure set
Medicare Physician Fee Schedule
CMS today released the proposed rule for the CY15 Medicare physician fee schedule (PFS) that, absent congressional intervention, will reduce payments to physicians by 20.9 percent in March 31, 2015 as called for under the sustainable growth rate (SGR) formula.
The proposed rule will be published in the Federal Register on July 11, 2014. CMS will accept comments until September 2, 2014.
Among other provisions, CMS proposed the following policies:
Proposed policy and payment changes
- Telehealth Services: Under this proposed rule, annual wellness visits, psychoanalysis, psychotherapy, and prolonged evaluation and management services will be added to the list of services that can be provided to Medicare beneficiaries as a telehealth benefit.
- Revisions to Geographic Practice Cost Indices (GPCIs): CMS proposes to adjust payment rates to account for differences in the cost of operating a medical practice in different areas of the country. All proposed GPCIs include the elimination of the 1.0 work GPCI floor April 1, 2015.
- Open Payments: CMS proposes 4 changes to the open payments program, as follows:
- Delete the definition of “covered device”
- Delete the Continuing Education Exclusion
- Require that the marketed name of the related covered and non-covered drugs, devices, biologicals, or medical supplies is reported, unless the payment is unrelated
- Applicable manufacturers must report stocks, stock options or any other ownership interest as distinct from one another in separate categories
Changes for Calendar Year 2015 Physician Quality Programs and Other Programs in the Medicare Physician Fee Schedule
- Physician Quality Reporting System (PQRS) measures: CMS proposes to add 28 new individual measures and two measures groups to fill existing measure gaps. Additionally, CMS proposes to remove 73 measures from reporting for the PQRS.Under the proposed rule, eligible professionals who see at least one Medicare patient in a face-to-face encounter will be required to report measures from a newly proposed cross-cutting measures set in addition to any other measures that the eligible professional is required to report. These individuals would also be required to report on at least two measures in the newly proposed PQRS cross-cutting measures set.CMS proposes that the number of patients for which group practices report measures under the GPRO web interface will be 248 for all group practices with 25 or more eligible professionals.
- Physician Compare: CMS proposes to make all 2015 PQRS GRPO web interface, registry, and EHR measures for group practices of 2 or more EPs and ACOs available for public reporting on Physician Compare in 2016. Further, these data must meet the minimum sample size of 20 patients and prove to be statistically valid and reliable.Under the proposed rule, CMS will publicly report 20 PQRS individual measures reported in 2013 and collected through a registry, EHR, or claims in 2015. CMS also proposes to make all 2015 PQRS individual measures collected via registry, EHR, or claims available for public reporting on Physician Compare in late 2016.Finally, CMS proposes publicly reporting 2015 Consumer Assessment of Healthcare Providers and Systems (CAHPS) survey data for PQRS for group practices of two or more EPs who report this data, as well as CAHPS for ACOs for those that meet the specified sample size requirements and collect data via a CMS-specified CAHPS vendor in 2016. Also, the 2015 Qualified Clinical Data Registry (QCDR) measure data collected at the individual measure level or aggregated to a higher level of the QCDR’s choosing will be available on Physician Compare.
- Medicare Shared Savings Program (MSSP): CMS proposes to make multiple changes and updates to the current quality measurement requirements in MSSP. Specifically, CMS proposes to revisit the current quality performance standard and make changes to the current quality measures. CMS is seeking comment on future quality performance measures as well.
- Additional Quality Improvement Reward: CMS proposes to revise the quality scoring methodology to recognize and reward year-to-year improvement in scores on individual measures, as opposed to just regarding achievement. In this approach, CMS will provide bonus points to each of the quality domains based on improvement.
- Revisions to Quality Measures Benchmarks: The proposal would modify the benchmark methodology approach to topped out measures by utilizing flat percentages to establish the benchmark when the national FFS data results in the 90th percentile being greater than or equal to 95 percent
- Modifications to the Quality Measures that Make Up the Quality Reporting Standard: CMS proposes to reduce ACO reporting burden by increasing the number of claims-based outcomes measures, and reducing the number of GPRO-reported measures. CMS proposes to increase the number of quality metrics from 33 to 37 (by adding 12 and removing 8), by adding measures focused on all-cause unplanned admissions for patients with multiple chronic conditions, heart failure and diabetes; depression remission; all cause readmissions to a skilled nursing facility; diabetes measures for foot and eye exams; coronary artery disease (CAD) symptom management; CAD beta blocker therapy; CAD antiplatelet therapy; documentation of current medications in the medical record; and a CAHPS survey measure, stewardship of patient resources. In addition, the composite diabetes and coronary artery disease measures would be updated, and ACO #12, 22, 23, 24, 25, 29, 30 and 32 would be retired. Moreover, CMS requests suggestions to implement EHR-based reporting of quality measures.
- Proposed Quality Performance Standard for Measures that Apply to ACOs that Enter a Second or Subsequent Participation Agreement: The proposed rule would require that MSSP participants that move into a second or subsequent participation agreement period would continue to be assessed in pay-for-performance on the quality measures consistent with the third year of the first agreement period.
Proposed changes for the Physician Value-based Payment Modifier in the CY 2015 Medicare Physician Fee Schedule Proposed Rule
- Proposed group size and application of the Value Modifier to non-physician EPs: CMS proposes to apply the Value Modifier to physicians in groups with two or more eligible professionals (EPs) and to physicians who are solo practitioners in CY17.
- Payment adjustments: Under the quality-tiering methodology, CMS also increased the maximum downward adjustment to -4.0 percent for groups of 10 or more EPs classified as low quality/high cost and set the adjustment to -2.0 percent for groups classified as either low quality/average cost or average quality/high cost. CMS also increased the maximum upward adjustment in the CY 2017 payment adjustment period to +4.0x (“x” represents the upward payment adjustment factor) for groups of 10 or more EPs classified as high quality/low cost and set the adjustment to +2.0x for groups classified as either average quality/low cost or high quality/average cost. For groups with two to nine EPs and solo practitioners, the maximum upward adjustment in CY 2017 will be +2.0x if classified as high quality/low cost and for those practitioners that are classified as average quality/low cost or high quality/average cost, the upward adjustment will be +1.0x. Groups of two to nine EPs and solo practitioners will be held harmless from downward adjustments under the quality-tiering methodology for the CY 2017 payment adjustment period.
Groups and solo practitioners that participate in the Shared Savings Program, the Pioneer ACO Model, the CPC Initiative or other similar Innovation Center models or CMS initiatives
- MSSP ACOs: CMS proposes to apply the Value Modifier to physicians and non-physician EPs in groups with two or more EPs and to physicians and non-physician EPs who are solo practitioners that participate in Accountable Care Organizations (ACO) under the Medicare Shared Savings Program (Shared Savings Program) beginning in CY17.Under the proposed rule, the PQRS GPRO web-interface measures will be used to determine the quality of care composite for the ACO MSSP participants in CY17. Additionally, the all cause hospital readmissions measure will be used for inclusion in the quality composite for the Value Modifier for this group.
- Other Innovation Center models: CMS proposes to apply the Value Modifier to physicians and non-physician EPs in groups with two or more EPs and to physicians and non-physician EPs who are solo practitioners that participate in the Pioneer ACO Model, the Comprehensive Primary Care (CPC) Initiative, or other similar Innovation Center models or CMS initiatives during the relevant performance period, beginning in CY17.
- Physician fee schedule proposed rule
- CMS fact sheets
- Proposed changes for the Physician Value-based Payment Modifier in the CY15 Medicare Physician Fee Schedule proposed rule
- Changes for CY15 Physician Quality programs and other programs in the Medicare Physician Fee Schedule
- Proposed policy and payment changes to the Medicare Physician Fee Schedule for CY15