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CMS Finalizes Two Regulations Governing Fees for Treating Medicare Patients

Physician fee schedule and hospital outpatient payment system include items recommended by ACP

As the new year approaches, the Medicare Physician Fee Schedule for 2017 has been finalized, earning a nod of approval from the American College of Physicians. The same holds true for the 2017 final rule for the Hospital Outpatient Prospective Payment System.

On the fee schedule, "the final rule includes several important policies that accurately recognize and support the work of primary care physicians," said Shari Erickson, ACP's vice president for governmental affairs and medical practice. "ACP members should feel encouraged that these updates support high-value primary care and show that the Centers for Medicare and Medicaid Services has been responsive to our recommendations."

The final rule includes new codes that physicians will use in 2017 when seeking reimbursement for treating Medicare patients. According to Erickson, several of these reflect support for ACP's advocacy in favor of primary care, reduced barriers to chronic care management and improved access to behavioral health and prevention services.

These codes include:

  • A G-code to describe the comprehensive assessment and care planning for patients with cognitive impairment, such as dementia. (G0505)
  • Three codes describing an evidence-based psychiatric collaborative care model (CoCM) in which the primary care physician is the billing physician and works with a behavioral health manager and contracting psychiatrist. (G0502, G0503 and G0504)
  • An additional G-code to describe services furnished using other models of behavioral health integration (BHI) in the primary care setting. (G0507)
  • A G-code to account specifically for additional work of the billing clinician in performing a face-to-face assessment of a beneficiary requiring chronic care management (CCM) services and then performing CCM care planning that is not already reflected in the initiating visit. The care planning could be face-to-face or not face-to-face. (G0506)
  • Codes for complex chronic care management services to provide better access and support to patients with chronic illnesses. CMS has not paid for these services in the past. (CPT codes 99487, 99489 and 99490)
"ACP is very appreciative that CMS acknowledged our recommendations and has finalized guidance for billing of the non-face-to-face prolonged services with the CPT guidelines -- allowing for billing of the code a separate day from service," Erickson said. "This will alleviate confusion for when and how to bill these services through both private payers and CMS."

In addition, she said, "the burden reduction associated with billing the Chronic Care Management codes could have a significant impact on the uptake of the codes as well as the promotion of providing these types of important services."

The new fee schedule also includes expansion of the Medicare Diabetes Prevention Program, which allows Medicare beneficiaries to access preventive diabetes services without being subject to copayments. It also gives participating physicians and other clinicians additional payment for providing these preventive services.

As for the final rule on the system covering payment for treating hospital outpatients, Erickson said that "it describes changes to the amounts and factors used to determine the payment rates."

She said the regulation incorporates policies that ACP supported, including:

  • Adding a site-neutral policy on relocation of "excepted" off-campus provider-based departments, which Erickson described as an important step toward equalizing Medicare payments across sites of service and a major factor in reducing unnecessary health care spending.
  • Shortening the reporting period to 90 days for the Electronic Health Records Incentive Program for 2016 and 2017.
  • Removing the Pain Management Dimension of the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey. ACP believes these measures could put pressure on hospital staff to prescribe more pain medication, such as opioids, to achieve a higher HCAHPS score, further contributing to the opioid overdose epidemic.
In the coming months, "ACP staff will work to develop guidance for members on how and when to bill the primary-care-focused codes, as well as discuss any types of overlap with existing codes through practical tool kits and ACP Internist articles," Erickson said. The College intends to publish these resources on its website, on the coding and billing pages and the Physician and Practice Timeline, as soon as they're available.

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