2018 MPFS Proposed Rule Summary

On July 13, 2017, the Centers for Medicare & Medicaid Services (CMS) issued a proposed rule that includes proposals to update payment policies, payment rates, and quality provisions for services furnished under the Medicare Physician Fee Schedule (PFS) on or after January 1, 2018.

Clinical Decision Support/Appropriate Use Criteria

A notable part of the MPFS proposed rule as it relates to radiology is the delay of CDS until January 1, 2019.  The Medicare AUC program is proposed to begin with an educational and operations testing year in 2019, which means physicians would be required to start using AUCs and reporting this information on their claims but will not receive any type of penalty.  During this first year, CMS is proposing to pay claims for advanced diagnostic imaging services regardless of whether they contain information on the required AUC consultation.  This allows both clinicians and the agency to prepare for this new program.

In conjunction with the proposed rule, CMS is posting newly qualified provider-led entities, found here and clinical decision support mechanisms (CDSM), found here. Qualified provider-led entities are permitted to develop AUC, and qualified CDSMs are the tools through which physicians access the AUC.

In order to implement this requirement, CMS is proposing a set of HCPCS level 3 codes.  These G-codes would describe the specific CDSM that was used by the ordering professional and will also contain a code to identify circumstances where there was no AUC consultation through a qualified CDSM.

Conversion Factor and Impact to Radiology

CMS estimates a CY 2018 conversion factor of $35.9903, which reflects the 0.5 percent update specified by the Medicare Access and CHIP Reauthorization Act, a budget neutrality adjustment, and a target recapture amount mandated by the Protecting Access to Medicare Act of 2014.

Overall, this is a slight increase from the current conversion factor of $35.8887.

CMS estimates an overall impact of the MPFS proposed changes to radiology to be a 1 percent decrease, while interventional radiology would see an aggregate decrease of 1 percent and nuclear medicine a 0 percent change if the provisions within the proposed rule are finalized.

Radiation oncology and radiation therapy centers are looking at an overall impact of a 1 percent increase.

Mammography Reimbursement

In the 2017 MPFS final rule, there were 3 new mammography codes (77065, 77066, 77067) created that bundled mammography with CAD, when performed.  While there was some confusion as to whether CMS was going to accept the new set of codes or the existing G-codes in 2017, the proposed rule has clarified that by not including the G-codes in Addendum B.

CMS made a slight increase to the professional component of mammography and maintained the 2016 payment rates for the technical component. CMS did not address the deep cuts to the technical component some feared.

Evaluation and Management Comment Solicitation

There are three key components to selecting the appropriate level when assigning E/M visit codes:

  • History of Present Illness (History)
  • Physical Examination (Exam
  • Medical Decision Making (MDM)

CMS is seeking comment from stakeholders on specific changes they should make to update the guidelines, to reduce the associated burden, and to better align E/M coding and documentation with the current practice of medicine.

CY 2018 Value Modifier/PQRS Payment Adjustment

In order to better align incentives and provide a smoother transition to the new Merit-based Incentive Payment System under the Quality Payment Program, CMS is proposing the following changes to previously-finalized policies for the 2018 Value Modifier:

  • Reducing the automatic downward payment adjustment for not meeting minimum quality reporting requirements from negative four percent to negative two percent (-2.0 percent) for groups of ten or more clinicians; and from negative two percent to negative one percent (-1.0 percent) for physician and non-physician solo practitioners and groups of two to nine clinicians;
  • Holding harmless all physician groups and solo practitioners who met minimum quality reporting requirements from downward payment adjustments for performance under quality-tiering for the last year of the program; and
  • Aligning the maximum upward adjustment amount to 2 times the adjustment factor for all physician groups and solo practitioners.

CMS is also proposing changes to the satisfactory reporting criteria for the PY 2016 of the PQRS program.  While CMS is not proposing to accept changes to what has already been reported or accepting additional data, they are proposing the following for the claims-based submission option:

  • Report at least 6 measures, AND report each measure for at least 50 percent of the EP’s Medicare Part B FFS patients seen during the reporting period to which the measure applies.  If less than 6 measures apply to the EP, the EP must report on each measure that is applicable, AND report each measure for at least 50 percent of the Medicare Part B FFS patients seen during the reporting period to which the measure applies. Measures with a 0% performance rate will not be counted.

Patient Relationship Codes Using Modifiers

The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) requires the development of care episode and patient condition groups, and classification codes for physicians and non-physician practitioners.  To facilitate the attribution of patients and episodes to one or more clinicians, MACRA requires the development of patient relationship categories and codes that define and distinguish the relationship and responsibility of a physician or applicable practitioner with a patient at the time of furnishing a service.

CMS is soliciting comments on the operational list of patient relationship categories published on May 17, 2017 where the category most often pertaining to radiology being “Only as Ordered by Another Clinician”.  MACRA requires that claims submitted for items and services furnished by a physician or applicable practitioner beginning January 1, 2018 should include the applicable codes for the appropriate patient relationship category as well as the MPI of the ordering physician.

Computed Radiology/Digital Radiology

The Consolidated Appropriations Act of 2016 added an amendment for a 7% reduction in payments for the technical component (TC) for x-rays taken using computed radiography technology furnished during CY 2018-2022 and for a 10% payment reduction for the TC of such imaging services furnished during CY 2023 and beyond.  The amendment states this will be communicated for claims paid under the MPFS through the use of a yet-to-be-established modifier.

As always, ADVOCATE will keep you up to date on this and all issues impacting radiology as they become available.

Lauren Sloan, MHA, RD, LD
Director of Regulatory Affairs