2016 Fee Schedule and HOPD Rules Released

On October 30, 2015 the Centers for Medicare and Medicaid Services (CMS) issued its final 2016 payment policies and payment rates for services furnished under the Medicare Physician Fee Schedule  (PFS) and the Hospital Outpatient Prospective Payment System (OPPS). Payment rates and policies set forth in these rules are effective Jan. 1, 2016. 
ASNC is conducting a detailed analysis of rules. Here are the highlights:


Overall Proposed Rule Impact
There is no change in the estimated combined impact on total allowed charges for cardiology from 2015 to 2016 (0%). The payment impacts reflect averages by specialty based on Medicare utilization. For CY 2016, the PFS conversion factor is estimated to be $35.8279 which reflects a .5% statutory update and a .77% recapture amount because the 1% misvalued target was not met.
Misvalued Codes
CMS has finalized 91codes as potentially misvalued. Consistent with ASNC's comments, CMS is not proposing to review 78452 (heart muscle image spect mult).
Misvalued Codes Target
Last year, Congress set an estimated PFS expenditure target of 1% for CY 2016 that must be met from net reductions in misvalued codes. If the target is not met, fee schedule payments will be reduced to achieve the target. CMS has identified in this final rule payment changes that achieve .23% in net reductions. The effect of not hitting the 1% target is a 0.77 percent reduction to all PFS services, as required by statute.
Appropriate Use Criteria (AUC) Program for Advanced Diagnostic Imaging Services
The “Protecting Access to Medicare Act of 2014” establishes a program requiring adherence to AUC using clinical decision support (CDS) for advanced imaging services. The law specifies Jan. 1, 2017 as the effective date by which professionals who furnish an advanced imaging test must document the ordering professional's consultation of appropriate use criteria to be paid for the service. Because CMS anticipates it will not adopt policies for the program's claims-based reporting requirements until the CY 2017 and 2018 rule making cycles, the Agency states in the final rule that it does not intend to require that ordering professionals meet the AUC requirements by the Jan. 1, 2017 statutory date. This decision constitutes a major victory for ASNC, who called upon CMS to delay the effective date of the program to allow more time for implementation. Key changes include:
Quality Improvement Initiatives
The rule finalizes changes to the Physician Quality Reporting System (PQRS) and the Physician Value-Based Payment Modifier for 2016 reporting and performance assessment. 

  • PQRS – Group practices will be allowed to report quality measures data using a Qualified Clinical Data Registry (QCDR).
  • Value Modifier – For the CY 2018 payment adjustment, the quality-tiering methodology would apply to all groups and solo practitioners who are successful PQRS reporters. All groups and solo physician practitioners would be subject to upward, neutral, or downward adjustments derived under the quality-tiering methodology.
  • Value Modifier – Application of the value modifier will apply to the following non-physican eligible professionals: PAs, NPs, CNSs, CRNAs.


CMS announced that the final rate update for CY2016 for the hospital OPPS will be -.3 percent. This figure is based on the hospital market basket increase of 2.4 percent decreased by .5 percent adjustment for multifactor productivity and a .2 percent required adjustment. 

Restructure of Image Related Procedure Ambulatory Payment Classifications (APCs)
CMS has finalized a restructuring the nuclear medicine APCs citing excessive granularity and grouping by organ or physiologic systems that do not reflect significant differences in resource allocation.
Responding to comments from ASNC, the hospital OPPS panel, and other stakeholders CMS took note of concerns regarding the higher resource cost of PET and inadequacy of reimbursement within the three proposed nuclear medicine APCs and finalized the addition of a new nuclear medicine APC (APC 5594 Nuclear Medicine and Related Services) for PET imaging.
Q9969 Code (Adoption of non – HEU Technetium)
CMS continues to offer an additional $10 add-on payment for radioisotopes produced by non-HEU (highly enriched uranium sources) for CY 2016. CMS does not anticipate that this payment will be available past CY2017.
Comprehensive Observation APCs (C-APC 8011)
CMS finalized the proposal to create C-APC 8011 which will be comprised of the geometric mean costs of all reported OPPS services reported on a claim form during the provision observation services of more than eight hours (not including preventive services and certain inpatient services