Medicare fee schedule proposed rule needs work

Physicians last week submitted comments to the Centers for Medicare and Medicaid Services (CMS) on its proposed rule to revise the Medicare Physician Fee Schedule and Part B. Some of the provisions align with physicians’ previous recommendations while others will require some changes, especially those that mean more costs for patients and undercut the Medicare Access and CHIP Reauthorization Act (MACRA).

The AMA last week submitted a letter to CMS urging changes throughout the proposed rule while also citing areas of agreement that should be finalized. Comments dealth with three of the proposed policies.

CMS proposed a new series of eight G-codes intended to collect data on the pre- and post-operative activities in 10- and 90-day global services. The G-codes are based on place of service, complexity of patient, and completion time. Asking physicians and their staff to use 10-minute increments to document all their non-operating room patient care activities is by itself an incredible burden, and especially so during MACRA implementation—the most significant payment system change in 25 years.

A significant weakness with these G-codes is the inability to match them with the E/M services assumed to be bundled in the current global surgical package.

“Layering on a new regulation that requires reports based on 10-minute increments of service would burden physicians already attempting to comply with existing regulations that require them to spend too much time with record keeping and too little with patients,” said AMA President Andrew W. Gurman, MD.

The AMA and the RUC recommended that the data collection process should not include all services, as many surgical global codes are low volume which would make it difficult to find a meaningful sample, and urged CMS to adopt a data collection method that is limited in scope and uses a representative sample to better understand the necessary post-operative visits.

CMS proposed a new add-on code that would add a $44 fee for services rendered to patients with mobility-related disabilities. This proposal raises program integrity questions, creates unequal coverage for care of disable patients, and increases out of pocket costs for patients with disabilities. Based on the $44 add-on payment for physicians, patients with mobility-related disabilities would have an additional $9 copayment each time special equipment is required during a visit.

CMS intends to fund the new add-on payment by eliminating the physician payment increase that Congress provided for 2017 in the MACRA legislation.

The AMA and the Specialty Society RVS Update Committee (RUC) have offered to work with CMS to develop a more appropriate solution.

There are significant issues with CMS’ proposals to change the ACO quality measures and the risk adjustment model used by CMS for some of these measures.

Physicians also urged CMS to avoid overly prescriptive regulations for ACOs’ use of health information technology and, instead, to recognize that ACOs are best equipped to improve the health of their patients when they are able to utilize health information technology in ways that best and most effectively meet the needs of those patients.

The letter submitted to CMS also detailed several areas where physicians were in agreement with the proposal, including:

• Improved payment accuracy for primary care, care management, and patient-centered services. Specifically, the letter supported a separate payment for non-face-to-face prolonged Evaluation and Management services, separate payments for services furnished using the Psychiatric Collaborative Care Model, the implementation of other codes in the CPT family of Chronic Care Management services, and a separate payment to recognize the work of a physician in assessing and creating a care plan for beneficiaries with cognitive impairment. 
• Expansion of the Diabetes Prevention Program. The letter commended CMS’ proposal to expand coverage of the Medicare Diabetes Prevention Program (DPP) model to Medicare patients at risk of developing type 2 diabetes. This expansion will help at risk seniors and people with disabilities lower their risk factors and prevent their condition from advancing. "CMS has offered a comprehensive approach in the new proposal—and some of it hits and some of it misses,” Dr. Gurman said. “The programmatic changes for prediabetes are exactly right." 
• Addition of new telehealth codes. Physicians expressed their support for the new codes and asked CMS to develop a far more expansive set of strategic proposals that are cohesive and forward-looking in order to expand coverage and access to telehealth services for Medicare beneficiaries.

The comment period for the proposed rule closed on Sept. 6. The AMA and RUC will continue working with CMS to make sure that these recommendations are finalized in a way that is beneficial for both physicians and their patients without adding unnecessary burdens and regulations to patient care processes.

CMS has published a fact sheet that summarizes the proposed rule.