CMS release its 2018 proposed Medicare Fee Schedule for physicians, included in the regulation changes are areas pertaining to the Physician Quality Report System (PQRS), payment on code modifiers, E/M documentation guidelines and technology advances such as the use of telehealth services.

July 21, 2017 by the American Academy of Family Physicians (AAFP)

As promised, the AAFP has created a much-abbreviated version of the lengthy proposed 2018 Medicare physician fee schedule that CMS released on July 13 and published in the July 21 Federal Register.(www.gpo.gov)

The AAFP’s four-page executive summary(4 page PDF) provides clarification for busy family physicians on topics of greatest relevance to family medicine.

As is often the case, CMS included recommendations previously offered by the AAFP and made numerous other suggestions that the AAFP deems “favorable steps” because they would “significantly reduce the burden of primary care practices” participating in Medicare.

The AAFP will provide CMS with comprehensive comments and suggestions for improvement by the agency’s Sept. 11 deadline. For now, here’s what family physicians should know about the proposed rule.

Story Highlights

• To assist family physicians, the AAFP has created an executive summary of CMS’ proposed 2018 Medicare physician fee schedule.
• CMS’ proposal includes recommendations previously offered by the AAFP, as well as other suggestions the AAFP deems favorable because they would reduce the burden on physicians who participate in Medicare.
• The summary covers a number of topics, including evaluation and management services, telehealth, and the appropriate use criteria program for advanced diagnostic imaging services.

Hot Topics

In its proposed rule, CMS suggests an overhaul and modernization of evaluation and management (E/M) documentation guidelines and “seeks broad stakeholder feedback” on the issue — welcome news to the AAFP, which has urged action on this front on multiple occasions.

The AAFP summary points out that CMS wants to see E/M guidelines “substantially revised over a multi-year, collaborative effort in order to both reduce clinical burden and improve documentation in a way that would be more effective in clinical workflows and care coordination.”

Furthermore, CMS recognizes that technological advances — in combination with E/M updates — “could improve documentation for patient care while also meeting requirements for billing and population health management,” says the AAFP.

In other favorable news, CMS proposes a delay in implementing the Medicare appropriate use criteria program(www.cms.gov) for advanced diagnostic imaging services until Jan. 1, 2019. “The AAFP has repeatedly expressed concern to CMS due to the disproportional burden this program would place on primary care physicians,” says the summary.

Another promising move is CMS’ proposal to add seven more services to the Medicare telehealth list, including

• psychotherapy for crisis (first 60 minutes and each additional 30 minutes),
• administration of the patient-focused health risk assessment instrument, and
• comprehensive assessment of — and care planning for — patients who require chronic care management services.

In addition, CMS proposes to

• pay rural health centers and federally qualified health centers for regular and complex chronic care management services, general behavioral health integration services, and psychiatric collaborative care model services;
• further implement the Medicare Diabetes Prevention Program expanded model in 2018, and
• reduce payments to new off-campus provider-based hospital departments from 50 percent to 25 percent of the current payment rate — a change the AAFP has called for.

Proposed Changes to CMS Programs

In its executive summary, the AAFP also includes proposed changes to several CMS programs because of their huge impact on family physicians who participate in Medicare.

Regarding the Physician Quality Reporting System (PQRS), CMS proposes retroactively lowering the number of required measures from nine to six to more closely align the PQRS program with the Merit-based Incentive Payment System, one of two payment tracks included in the Quality Payment Program.

Regarding the Medicare Electronic Health Record Incentive Program, CMS suggests changes to the reporting criteria for physicians who report clinical quality measures electronically. CMS also proposes that participants who satisfy the proposed reporting criteria “may qualify for the 2016 incentive payment and may avoid the downward payment adjustment in 2017 and/or 2018.”

Proposed changes to the Medicare Shared Savings Program include modifications to the beneficiary assignment methodology and the inclusion of new chronic care management and behavioral health integration services codes.

CMS Wants Feedback

The AAFP summary points out that CMS is looking for guidance on how to make other improvements in the 2018 proposed fee schedule.

For instance, CMS seeks comments on

• lowering the maximum amount of at-risk payment under its 2018 value modifier program from 4 percent to 1 percent for individual clinicians and groups with fewer than 10 clinicians and to 2 percent for groups of 10 or more clinicians,
• additions to the operational list of patient relationship categories and codes under the Medicare Access and CHIP Reauthorization Act (MACRA), and
• compliance requirements for initial data collection and reporting periods for the clinical laboratory fee schedule.

Final Note

Despite the encouraging progress made in several areas in the 2018 proposal, the AAFP also expresses disappointment that CMS again failed to “achieve the required, minimum net expenditure reduction through identifying misvalued codes.”

This lack of due diligence by CMS in meeting the misvalued code target required by law means that “physicians will not receive the full positive 0.5 percent update in 2018 called for in MACRA.”

The AAFP executive summary also includes a table that shows the proposed physician fee schedule’s estimated impacts on total allowed charges by specialty for calendar year 2018.

Stay tuned for the AAFP’s detailed comment letter to CMS by early September.