2015 final rule reflects shift from fee for service

Medicare continues to make policy and payment changes to the Medicare Physician Fee Schedule for 2015. The system continues to become more complex. The stated strategy in one of the Centers for Medicare & Medicaid’s publications is as follows: “The Medicare PFS final rule is one of several rules for calendar year 2015 that reflect a broader Administration-wide strategy to deliver better care at lower cost by finding better ways to deliver care, pay providers, and use information.”

RELATED: Government alliances key to changing pay policies

The strategy may be laudable, but the road is getting bumpier. A possible sustainable growth rate (SGR) cut looms; codes continue to be bundled, resulting in reimbursement decreases; and the penalties for not complying with EMR certifications, Physician Quality Reimbursement System (PQRS) reporting, and value-based modifier qualifications are increasing.

On the bright side, by complying and successfully jumping through the hoops, bonuses are achievable.

Of interest, the final rule confirms the continued shift in practice modality for physicians. The demographics of physicians, as identified by their Tax Identification Number, are as follows: There are 83,500 groups and 210,000 solo practitioners. The groups consist of 815,000 physicians and 315,000 non-physician eligible professionals (EPs). Geographic variation still exists, but the general trend of larger groups and more non-physician providers is obvious.

In this article, we provide you with some facts about the 2015 fee schedule and share some insights on how its changes will impact your practice in the New Year.

SGR cuts?

The snake in the grass continues to be the SGR. Major organizations that represent us on the national level-the AUA, the American Medical Association, and the American College of Surgeons were optimistic that a final solution to the SGR was obtainable last year. It didn't happen. Instead, Congress kicked the can down the road one more time, providing us with a .5% increase for the remainder of 2014 and a 3-month hold on the SGR cut until March 31, 2015. That leaves us with a .5% cut on Jan. 1 and a 21.2% cut starting April 1.

Of course, we are all once again hopeful that Congress will act to at least block the SGR once again. One of the congressmen sponsoring a permanent fix, in his presentation to the AMA in mid-November, was very optimistic that a permanent fix was obtainable during the lame-duck session. The AMA was in cautious agreement. There are reasons to believe that this could happen, but we wouldn't bet the farm on the outcome. However, we do not think, under any circumstance, that Congress will allow the 21.2% decrease in pay to be enacted. (For more on this topic, see “Could GOP majority scuttle SGR reform?”)

Next: Value-based modifier implementation

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Value-based modifier implementation

The Affordable Care Act required that CMS establish a value-based payment modifier (VM) and apply it to specific physicians and groups of physicians starting Jan. 1, 2015 and to all physicians and physician groups by Jan. 1, 2017. The act requires the VM to be budget neutral.

For use of the VM, physicians have been divided into four groups:

• groups of 100 or more EPs

• groups of 10 to 99

• groups of 2 to 9

• solo practitioners.

In addition, CMS has added a fifth group: non-physician EPs.

The implementation of the VM is different for each of the groups.

Groups of 100 or more. The VM will be implemented in calendar year 2015 for groups of 100 or more physicians. The maximum loss for low quality/high cost will be –1%. The maximum gain for high quality/low cost will be 2%. The evaluation will be based on 2013 data, quality, and cost tiers.

In CY 2016, Medicare will use performance data from 2014 and be subject to upward, neutral, or downward adjustments. Maximum loss for a category will be –2% and maximal gain will be +2%. CY 2017 will use CY 2015 performance data and will be subject to the full –4% loss or +4% gain.

Groups of 10 to 99. The VM will be implemented in CY 2016, based on CY 2014 performance data for this group and will be subject to a maximum of –2% loss or +2% gain.

CY 2017 will use CY 2015 performance data and will be subject to the full –4% loss or +4% gain.

Groups of 2 to 9 and solo practitioners. The VM will be implemented in CY 2017 for this group.

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. Those reporting using other methods will be subject to a maximum of +2% gain. Performance data from CY 2015 will be used to determine status. In CY 2018, this group will be subject to a maximum of –2% loss or +2% gain, based on CY2016.

Non-physician EPs. The value modifier will be implemented beginning in CY 2017 to non-physician EPs in groups with two or more EPs and to non-physician EPs who are solo practitioners. For all others the Value Modifier for non-physician EPs will begin in CY 2018 with a maximum of –2% loss or +2% gain. Performance data from CY 2016 will be used to determine status.

Providing you with the maximum gains and losses and the implementation schedule was the easy part. Determining who will be the winners and losers is more complicated. Remember that all VM payments are currently directed to be budget neutral. However, there will be winners and losers. There are numerous ways that data can be reported: claims, registry, etc. In addition, those that are unsuccessful in reporting may still be judged on PQRS data or accountable care organization group practice reporting data.

The majority of physicians will be judged on submitted data using the quality-tiering methodology. This is a complicated calculation using numerous data points and places each physician into a high-, average-, or low-quality group and a high-, average-, or low-cost group. High-quality/low-cost providers may receive the big bonus and low-quality/high-cost will receive the biggest cuts.

Hopefully, all of you reviewed, studied, and implemented changes based on the Quality and Resource Use Reports (QRUR) that were made available to all physicians on Sept. 30, 2014, based on their performance in CY 2013. Another set of QRUR will be provided before the end of the year. We encourage you to read it closely, ask questions if you do not understand, and request changes if you think they are incorrect.

If you would like details and would like to spend a day or two of very boring reading, download the final rule from CMS and proceed to page 924. If you would like a more detailed interpretation of the final rule, go to www.PRSnetwork.com for a more comprehensive explanation of this important topic.

Next - PQRS: Changed again in 2015

PQRS: Changed again in 2015

One of the key parts to participation in the VM program is PQRS. We cannot predict that PQRS will always be a part of the equation, but as long as it remains we will recommend that you play the game. In addition to the VM calculation PQRS, successful participation will afford you a green checkmark on your listing on the Physician Compare website (www.medicare.gov/physiciancompare), indicating successful reporting from the previous year.

PQRS has changed again this year. The number of measures required and the percentages to reach success have not been moved. All reporting mechanisms allowed in 2014 remain an option for 2015. However, Medicare has retired a few urology measures and has blocked some measures from being reported via claims-based reporting, as it continues to push physicians to claims registry, EHR, and clinical reporting tools.

Affecting many urologists, measures 20, 30, and 49 have been retired for 2015. If you were reporting one of all three of these measures, you will need to find additional measures to report in order to avoid penalties in 2017. Two other measures that were targeted for deletion in the proposed rule but were not finalized for deletion and may remain active for next year are measures 23 and 173. Additionally, measures 50, 102, and 104 will be blocked for all but registry reporting. For definitions of specific measures, see www.auacodingtoday.prsnetwork.com and www.cms.gov/PQRS/.

Again, we encourage you to adjust to each of these changes as quickly as possible.

Coding changes

There were only two added codes in the urologic coding section: code 52441 (Cystourethroscopy, with insertion of permanent adjustable transprostatic implant; single implant), and code 52442 (Cystourethroscopy, with insertion of permanent adjustable transprostatic implant; each additional permanent adjustable transprostatic implant [list separately in addition to code for primary procedure]) to address the new prostatic urethral lift device (UroLift). The values are such that in-office implantation is feasible unless the SGR is implemented.

Prostate biopsy codes have changed again. Medicare has decided to eliminate all the G codes for prostate biopsies and revise code G0416 to be reported for all biopsies. The code is further considered misvalued and is targeted for review, signaling a likely drop in value for 2016.

For intensity-modulated radiation therapy (IMRT), new codes were added to CPT, bundling both IMRT and the imaging required for the service. Codes 77385 (IMRT delivery, includes guidance and tracking, when performed; simple), 77386 (IMRT delivery, includes guidance and tracking, when performed; complex), and 77387 (Guidance for localization of target volume for delivery of radiation treatment delivery, includes intrafraction tracking, when performed) were added to the 2015 CPT manual. Codes 77418 (IMRT delivery, single or multiple fields/arcs, via narrow spatially and temporally modulated beams, binary, dynamic MLC, per treatment session) and 0073T (Compensator-based beam modulation treatment delivery of inverse planned treatment using 3 or more high resolution [milled or cast] compensator convergent beam modulated fields, per treatment session) were deleted from CPT.

For 2015 codes 77418 and 0073T will be reported to Medicare under code G6015 (IMRT treatment delivery), and guidance will be allowed to be reported separately. Although this is a short-term win in Medicare, the CPT code changes and Medicare decision not to adopt these codes will have to be monitored in the private sector. Values for G6015 are considered misvalued but have been retained for 2015 at the 2014 levels for 77418. Watch this one closely if you are billing for IMRT.

More to come

The final rule for 2015 continues to modify payment in Medicare to move toward pay for “quality” and away from true fee for service. In this article, we have only scratched the surface and encourage you to stay abreast of both national and local changes in health care.

We expect that Medicare’s influence over the marketplace, coupled with changes dictated by the ACA and the overall focus on health care costs, will continue to drive down fees for many services and drive up the payment for overall quality measures. Adapting to all of these changes on top of the expected transition to ICD-10, EMR, and the myriad other market pressures will not allow the urology office to take a breath.

While it is difficult to project if any changes to legislation will be accomplished under the new legislature, we can, with confidence, say that quality urology services are still needed in the marketplace. A focus on quality care and efficient business practices will win in the long term, but the short term will continue to require change.

The information in this column is designed to be authoritative, and every effort has been made to ensure its accuracy at the time it was written. However, readers are encouraged to check with their individual carrier or private payers for updates and to confirm that this information conforms to their specific rules.

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