Industry News

CMS Issues Proposed Rule Updating the Physician Fee Schedule.

The Centers for Medicare & Medicaid Services (CMS) recently issued a proposed rule updating the Medicare Physician Fee Schedule (MPFS). Additionally, CMS is releasing a Request for Information regarding solutions to improve transparency, flexibility, program simplification and innovation as part of the national conversation regarding healthcare delivery system improvement.

Selected key provisions of the proposed rule include:

  • Valuation for specific services that generally reflect the expert recommendations from the American Medical Association – Relative Value Scale Update Committee (RUC) for CY 2018;
  • An overall update of +0.31 percent to payments under the PHS. The target for misvalued codes adjustments would be 0.5 percent for 2018.  The proposed 2018 PFS conversion factor is $35.99;
  • A 50% reduction in current PFS payment rates for items and services furnished by certain off-campus hospital outpatient provider-based departments;
  • Addition of new codes to the telehealth services list and elimination of required reporting of the telehealth modifier for professional claims;
  • Malpractice RVUs developed using the most recent data available and alignment of future updates with the geographic practice cost index updates;
  • Adoption of CPT codes for reporting several care management services that currently use Medicare G-codes, for CY 2018;
  • Increased payment for office-based behavioral health services resulting from an improvement in rate setting methodology;
  • Revision of regulations according to new payment requirements in the 21st Century Cures Act, with respect to infusion drugs and biologicals furnished through a covered item of DME;
  • Addition of two new billing codes for new care coordination services and payment for Rural Health Clinics and Federally-Qualified Health Centers;
  • More time for practitioners to focus on and adjust to the Quality Payment Program while they start participating in the Medicare Appropriate Use Criteria (AUC) Program for Advanced Diagnostic Imaging;
  • Additional proposals to implement the Medicare Diabetes Prevention Program (MDPP) expanded model starting in 2018;
  • A reduction of reported measures in the PQRS program policy and clinical reporting requirements under the Medicare Electronic Health Record Incentive Program for eligible professionals;
  • The voluntary use of new modifiers on claims to reflect patient relationship categories required under MACRA;
  • Several modifications to the rules for accountable care organizations (ACOs) participating in the Medicare Shared Savings Program;
  • Changes to the previously-finalized policies for the 2018 Value Modifier under the Quality Payment Program.

In addition, CMS is seeking stakeholder comments regarding:

  • The update of E/M visit code guidelines;
  • Whether emergency department visits are undervalued due to increasing heterogeneity in settings and changes in the patient population;
  • Applicable laboratories and reporting entities’ experience with data collection and reporting periods under the new private payer rate-based Clinical Laboratory Fee Schedule;
  • Payment calculations regarding biosimilar products;
  • Whether the AUC Program should be delayed beyond January 1, 2019.

CMS will accept comments on the proposed rule until September 11, 2017.

The proposed rule is available at: