CMS Proposes Medicare Physician Fee Schedule, OPPS Update, ASC Update, ACO Quality Adjustments for CY 2015 — Key Provisions:


OPPS Update 2.1 Percent

CMS proposes updating the OPPS market basket by 2.1 percent for calendar year 2015. The agency also seeks to continue paying average sales price plus 6 percent for non-pass-through drugs and biological that are payable separately under the OPPS. CMS’s proposed update to Medicare outpatient hospital and community mental health clinic settings would result in an estimated $5.2 billion increase in payments compared to calendar year 2014. The rule also would adjust chronic care management payments and add about 80 codes to the agency’s list of potentially misvalued procedure codes. Click here for the payment changes summary.

Comprehensive APCs Expanded

Adopted in the CY 2014 Outpatient PPS final rule but delayed until CY 2015 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 CY 2015.

CMS Revises the Requirements for Physician Certification of Hospital Inpatient Services

CMS currently requires a physician certification, including an admission order and certain additional elements, for all inpatient admissions. CMS found that for shorter stays and non-outlier stays, the admission order is a sufficient safeguard from both a beneficiary and Trust Fund protection standpoint. Therefore, CMS is proposing that the admission order would continue to be required for all admissions, but the physician certification would only be required for outlier cases and long-stay cases of 20 days or more.

Data Required 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.

Changes to ACO Quality Scoring

The physician fee schedule proposed rule would revise quality scoring methods so that accountable care organizations can get more credit for improved performance on quality measures from one year to the next. The total number of reported quality measures would increase to 37 from 33. But more of them would be calculated directly from claims data and fewer would require separate reporting by the ACOs. New measures will focus on avoidable hospital admissions for patients with multiple chronic conditions, depression remission, all cause readmissions to skilled nursing facilities and “stewardship of patient resources.” It would update existing measures for diabetes and coronary artery disease. Click here for more.

Expanded TeleHealth Services Covered

Annual wellness visits and psychotherapy are among four services CMS is proposing to add to the list of services that can be provided to Medicare beneficiaries via telehealth. Under the proposal, annual wellness visits and psychotherapy, as well as psychoanalysis and “prolonged evaluation and management services” would be covered as Category 1 services. Such services, according to CMS, are defined as “similar to professional consultations, office visits and office psychiatry services” currently covered by the agency.

Physician Speaking Payment Exemption Eliminated

The physician fee schedule would eliminate an exemption for payments made to physicians speaking at continuing education events. The Physician Payment Sunshine Act requires drug and device makers to publicly report payments to providers to shine a light on potential conflicts of interest. But the agency had planned to make an exception for payments to speakers at industry-funded continuing education programs. The rule would also require drug and device makers to report the brand name of any product that is connected to payments made to providers.

Click here for a more detailed CMS summary of the OPPS rule.
Click here for the 687-page proposed OPPS, ASC rule.
Click here for the 609-page proposed Physician Fee Schedule and related rule.

Proposed Home Health Rule Cuts Payments 0.3 Percent

CMS earlier last week proposed a rule that would trim home health payments by about $58 million in 2015 — or 0.3 percent. The cut reflects the second of four years of “rebasing” home health payments as required by the Affordable Care Act. It also makes a number of other adjustments and clarifies when documentation is required of a doctor’s in-person encounter with a patient. CMS spent $18 billion on home health care in 2013 for 3.5 million seniors.

Click here for a summary of the home health rule.
Click here for the 166-page proposed rule.

For all other CMS Fact Sheets related to these rules, click here.