Highlights of Policy and Payment Changes to the Medicare Physician Fee Schedule for 2015

The Centers for Medicare & Medicaid Services (CMS) recently issued its final rule that updates payment policies and rates for services furnished under the Medicare Physician Fee Schedule (PFS) in 2015.

Here are some of the highlights of the policy and payment changes for services furnished under the PFS.

Screening and diagnostic digital mammography. Until now, there have not been separate codes to pay for the higher cost of 3D mammography as compared to 2D mammography. Since 2000, 2D digital mammography has been paid at special payment rates as temporarily provided by a law for digital mammography. To ensure that the higher resources needed for 3D mammography are recognized, CMS is paying for 3D mammography using add-on codes that will be reported in addition to the 2D mammography codes. CMS will revisit payment for 2D and 3D mammography for 2016 when it reviews coding and payment for all mammography services under the misvalued codes initiative.

Primary care and chronic care management. Medicare continues to emphasize primary care by making payment for chronic care management (CCM) services — non-face-to-face services to Medicare beneficiaries who have multiple, significant, chronic conditions (two or more) — beginning in 2015. Chronic care management services include regular development and revision of a plan of care, communication with other treating health professionals, and medication management.

CMS has established a payment rate of $42.60 for CCM that can be billed up to once per month per qualified patient.

Application of beneficiary cost sharing to anesthesia related to screening colonoscopies. The Medicare statute waives the Part B deductible and coinsurance applicable to screening colonoscopy. Increasingly, anesthesia separately provided by an anesthesia professional is becoming the prevalent practice in connection with screening colonoscopies, replacing the previously prevalent practice of moderate sedation provided intravenously by the physician doing the colonoscopy.

Currently, when a single physician furnishes the moderate sedation and the screening colonoscopy, payment for the colonoscopy includes both services and coinsurance is waived for the entire procedure. When anesthesia for a screening colonoscopy is provided separately by an anesthesia professional, Medicare does not waive the deductible and coinsurance associated with the anesthesia. In the CY 2015 final rule, by revising the definition of a "screening colonoscopy," CMS is including separately provided anesthesia as part of the screening service so that the coinsurance and deductible do not apply to anesthesia for a screening colonoscopy, reducing beneficiaries' cost-sharing obligations under Part B.

Potentially misvalued services. Consistent with amendments to the Affordable Care Act, CMS has been engaged in an effort over the past several years to identify and review potentially misvalued codes, and to make adjustments where appropriate. Below are major misvalued code decisions for 2015:

  • Hip and knee replacements: In the CY 2014 PFS final rule, CMS adopted code and valuation changes that reduced payment for hip and knee replacements. The final payments were higher than recommended by the AMA/Specialty Society Relative Value Update Committee (RUC). The agency decided further reductions were not warranted after considering the public comments.
  • Radiation therapy and gastroenterology: Consistent with the final rule policy and in response to public comments, CMS is not adopting code changes for gastroenterology and radiation therapy services until they can go through notice and comment rulemaking to propose values for 2016. As a result of this decision, CMS will not recognize some new CPT codes, and will create G-codes in place of CPT codes to continue current payment rates for CY 2015.
  • Radiation therapy: CMS proposed to refine the way it accounts for the infrastructure costs associated with radiation therapy equipment, specifically to remove the radiation treatment vault as a direct expense when valuing radiation therapy services. The agency decided not to finalize this proposal but will reconsider whether the vault is a direct or indirect cost through rulemaking in a future year.
  • Epidural pain injections: CMS reduced payment for these services in 2014 under the misvalued code initiative. In response to concerns from pain physicians regarding the accuracy of the valuation, CMS proposed to raise the values in 2015 based on their prior resource inputs before adopting further changes after considering RUC recommendations. However, because the inputs for these services included those related to image guidance, CMS proposed to prohibit separate pain management billing for image guidance for CY 2015. CMS finalized the policy as proposed to avoid duplicate payment for image guidance. CMS has asked the RUC to further review this issue and make recommendations on how to value epidural pain injections.
  • Film to digital substitution: CMS finalized its proposal to update the agency's practice expense inputs for X-ray services to reflect that X-rays are currently done digitally rather than with analog film.

Access to telehealth services. CMS is adding the following services to the list of services that can be furnished to Medicare beneficiaries under the telehealth benefit: annual wellness visits, psychoanalysis, psychotherapy, and prolonged evaluation and management services.


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