An SGR-free final rule: What you need to know

On Oct. 30, Medicare released the final rule for Medicare Part B payment for calendar year 2016. For the first time in 9 years, there will be no last minute adjustment to the conversion factor due to the flawed sustainable growth rate (SGR) formula. As you will recall, the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) was signed into law in April, eliminating the SGR and replacing the flawed formula with a combination of fixed small increases and flat rate updates for the next several years. This year, the final conversion factor was updated to $35.8279, a –0.029% update from last year’s $35.9335. 

Here are the highlights of the 2016 final rule of greatest interest to urologists.

Negative conversion factor

The final conversion factor is negative despite the MACRA-mandated increase of 0.5% because the Achieving a Better Life Experience (ABLE) Act of 2014 included adjustments to the fee schedule to pay for a 1% fee schedule update by reviewing misvalued codes. The analysis of the misvalued codes resulted in a 0.23% difference in the fee schedule. When applying the formulas required by the ABLE Act of 2014, the Centers for Medicare & Medicaid Services (CMS) was required to factor in the additional 0.77% that was not recaptured in the update, resulting in the final –0.029% update to the conversion factor. (The government giveth and the government taketh away.)

Impact from changes in work, practice expense, and malpractice relative value units was calculated by Medicare to be negligible for 2016.

When all is said and done, the projected changes for urology based on past billing patterns for urology as a whole is projected by Medicare to be a 0% impact.

Next: Global data to be collected

Global data to be collected

The 0-, 10- and, 90-day global periods continue unchanged. In the final rule for 2015, Medicare finalized its plan to eliminate the global periods of 000, 010, and 090 for future Medicare payments. Medicare was in the process of developing a transition plan to remove the global periods and adjust values accordingly beginning in 2016. However, MACRA prohibited CMS from implementing this change. MACRA directed CMS to finalize a method of collecting data to analyze the accuracy of global payments by Jan. 1, 2017 and implement changes to global values based on data collected beginning Jan. 1, 2019.

Also see: How ICD-10 is changing how you do Dx coding

MACRA directed the Secretary of Health and Human Services to use rule making to finalize an approach to determine the number and level of visits as well as other services furnished during the global period to improve the accuracy of global payments. Further, MACRA authorized CMS to withhold up to 5% of the CMS payment for services if data required under rule is not provided by the physician. CMS is also required by MACRA to re-evaluate values with a global period every 4 years after the initial implementation in 2019.

Although a method of data collection and analysis is proposed in the final rule, CMS is researching the best way to collect this information. CMS acknowledged that one hurdle that must be overcome is the lack of documented activity for services provided in the global period in present billing protocols. CMS has received some comments and suggestions from interested parties to consider focusing data collection efforts on large groups and the hospital setting. We will keep on eye on CMS proposals to address this requirement for MACRA, as the impact will be felt across urology practices. Bottom line: We need to completely document all services provided during the postoperative period.

Urology codes to be reviewed

Although the list of misvalued codes will not affect payment for 2016, Medicare has listed several common urology codes for analysis of inappropriate valuation.

Codes 51700 (Irrigation of bladder), 51702 (Insert temp bladder catheter), 51720 (Treatment of bladder lesion), 51784 (Anal/urinary muscle study), 51798 (Ultrasound urine capacity measure), 52000 (Cystoscopy), and 55700 (Prostate biopsy) have been tagged as misvalued and will be re-surveyed next year.

Related: Watch out for these 7 common EHR mistakes

In general, codes tagged as misvalued are considered to be valued too high by Medicare. It is important that any urologist who can participate in a survey of these high-volume services provide feedback that is accurate and representative of the full work that is provided for the average urology patient.

Next: Monitor Physician Compare website

Monitor Physician Compare website

You will need to keep an eye on the Physician Compare website (www.medicare.gov/physiciancompare/). Currently, website users can view information about approved Medicare professionals such as name, primary and secondary specialties, practice locations, group affiliations, hospital affiliations that link to the hospital’s profile on Hospital Compare as available, Medicare Assignment status, education, residency, and American Board of Medical Specialties board certification information. Programs you have succeeded or failed to report relative to the Physician Quality Reporting System (PQRS), value modifier status, meaningful use, e-prescribing, and consumer reviews submitted or collected through the Consumer Assessment of Healthcare Providers and Systems (CAHPS) survey can also be viewed.

Read: MACRA’s impact will be felt beyond repealing SGR

In addition, for group practices, users can view group practice names, specialties, practice locations, Medicare assignment status, and affiliated professionals. CMS has implemented a 30-day review process to help you monitor your status and correct errors; it will likely affect your payments. According to the final rule for 2016, you will be notified of the ability to review the information and how to make any necessary changes if there is information on the site that may affect your Physician Compare status. We assume this means that you will be notified of any negative rankings but will not be notified if your status does not include any failures. As these indications are vague, we continue to recommend that you monitor your listing under this website.

In addition to public reporting of general PQRS measure success or failure on the Physician Compare website, PQRS reporting for all provider types will be available for public review for each measure reported regardless of how the measure is reported.

As an additional incentive to participate in PQRS, Medicare continues to use negative payment adjustments 2 years after the reporting year. For PQRS reporting in 2016, all qualified providers are facing a 4% Medicare payment reduction if they fail to qualify for PQRS; this is the sum of 2% for failing to qualify for PRS and 2% for the value-based modifier adjustment.

There are a number of options to participate in PQRS, including claims-based reporting (limited measures are available under this method), EHR, data registry, or quality clinical data registry. The requirements for number of measures and type of measures for either individual reporting or group reporting and CAHPS “ reporting requirements have not changed much for 2016; however, Medicare delayed implementation of the requirement for CAHPS survey vendor for groups between 25-99. For more on CAHPS survey and a list of certified vendors for CAHPS, please go to http://bit.ly/CAHPSinfo. For more information on PQRS updates, go to http://bit.ly/PQRSupdates.

Several new measures have been added to the list of PQRS measurements. Of those new measures, we have identified a few that may be appropriate for consideration in a urology practice (table).

Next: Changes continue trend toward quality-based reimbursement

Conclusion

The changes for 2016 continue the trend for Medicare to move toward a reimbursement policy based less on production and more on “quality.” Does meeting the reporting requirements and measures truly represent quality of care? Most doctors do not think so. Unfortunately, this trend is not expected to ease up over the next few years.

Urology groups will need to continue to adapt to the new regulations, incorporate EHRs, and make use of technology for administrative challenges as we move toward the next generation of Medicare payment. Those who are unwilling or unable to adapt to these new policies will be facing increased financial penalties over the next several years if they choose to remain in the Medicare program. Another option will be to practice urology without participating in Medicare. It appears that most physicians, including urologists, are continuing to move with Medicare or accept the penalties. Participation in Medicare remains the dominant choice, allowing Medicare to conclude that these changes are palatable for the average physician.

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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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