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CMS 2018 Proposed Rule Suggests Policy, Payment, and Rate Changes

Written by: Shawn Hewitt on Tuesday, July 25, 2017 Posted in: Outpatient Rehab


On July 13, 2017, CMS released the 2018 proposed rule that suggests updates to Medicare payment and policies for services reimbursed under the Medicare Physician Fee Schedule (PFS). This will impact doctors and rehab clinicians alike. For rehab clinicians working in outpatient settings, the proposed changes would impact services provided in hospital outpatient departments and private practice. These changes will also impact services for skilled nursing facilities, comprehensive outpatient rehabilitation facilities, rehabilitation agencies, and home health providers of Part B services.

Some key areas of interest that will be important for you to read include:

  • Language of new, updated, and deleted CPT codes for 2018
  • Changes to the work relative value unit (RVU) for a series of therapy services/CPT codes
  • Request for information and opportunities to provide feedback

RVUs and Updates to the Work Relative Unit

When most therapists hear relative value units (RVUs), the thought of “units” or “productivity” may come to mind. Payments are based on these relative resources typically used to provide the services. Relative value units (RVUs) are “applied to each service for physician work, practice expense, and malpractice.” These RVUs become payment rates through the mathematical wizardry of a conversion factor. In the proposed rule, the conversion factor that impacts payment for each RVU and CPT code has been increased roughly 0.28% from 2017.

For “therapy services,” CMS looked at the work RVU of roughly 19 current CPT codes. The proposal is to keep the current work RVU for 13 of the 19 CPT codes that were reviewed. CMS is proposing to increase the work RVU of 6 current CPT codes. If interested in looking at the grid in the proposed rule, please direct yourself to page 250 of the proposed rule.

Changes in Valuation for Specific Services

As stated by CMS, “CMS reviews the resource inputs for several hundred codes under the annual process referred to as the potentially misvalued code initiative. Recommendations from the American Medical Association–Relative Value Scale Update Committee (RUC) are critically important to this work. For CY 2018, CMS is proposing the values for individual services that generally reflect the expert recommendations from the RUC without as many refinements as CMS has proposed in recent years.”

Overall Payment Update and Misvalued Code Target

The overall update to payments under the PFS, based on the proposed CY 2018 rates, would be +0.31%. This update reflects the +0.50% update established under the Medicare Access and CHIP Reauthorization Act (MACRA) of 2015, reduced by 0.19% due to the misvalued code target recapture amount, required under the Achieving a Better Life Experience (ABLE) Act of 2014.

In this proposed rule, CMS has proposed misvalued code changes that would achieve 0.31% in net expenditure reductions. If finalized, these changes would not meet the misvalued code target of 0.5% therefore requiring the -0.19 percent overall reduction to payments for PFS services.

Medicare Telehealth Services

There has been much discussion and debate about PT/OT/SLP services for telehealth. There was a request to include a series of “therapy services” to the telehealth options; however, because PT/OT/SLP are not listed as disciplines that can provide and bill Medicare telehealth services, CMS decided not to propose adding all the discussed therapy codes to the options of Medicare telehealth services.

For 2018, CMS is proposing to add several codes to the options of telehealth services, including:

  • HCPCS code G0296 (visit to determine low-dose computed tomography (LDCT) eligibility)
  • CPT code 90785 (Interactive Complexity)
  • CPT codes 96160 and 96161 (Health Risk Assessment)
  • HCPCS code G0506 (Care Planning for Chronic Care Management)
  • CPT codes 90839 and 90840 (Psychotherapy for Crisis)

Care Management Services

For 2018, in an effort to improve payment within traditional fee-for-service Medicare for chronic care management, CMS is proposing to adopt CPT codes for reporting services that are currently reported using Medicare G-codes. Also, CMS is encouraging public comment on ways to further reduce burden on reporting practitioners for chronic care management and similar services, enabling “stronger alignment between CMS requirements and CPT guidance for existing and potential new codes.”

Request for Information

As part of the payment and policy proposal, CMS is including an RFI process to encourage feedback to support its objectives of transparency, flexibility, program simplification, and innovation. “We would like to start a national conversation about improving the healthcare delivery system; how Medicare can contribute to making the delivery system less bureaucratic and complex; and how we can reduce burden for clinicians, providers, and patients in a way that increases quality of care and decreases costs, thereby making the healthcare system more effective, simple, and accessible while maintaining program integrity and preventing fraud.”

This by no means is a complete list of all the proposed changes—just a few that stood out to me. I strongly encourage that you read up on the proposed rule to assess how the suggested changes may impact you. The final rule should be out to us in September.

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