Download cy 2016 medicare physician final rule

CY 2016
MEDICARE PHYSICIAN
FINAL RULE
CRHF ECONOMICS & HEALTH POLICY
DECEMBER 2, 2015
DISCLAIMER
 This presentation is intended only for educational use. Any duplication is prohibited without
written consent of the authors. This information does not replace seeking coding advice from
the payer and/or your coding staff. The ultimate responsibility for correct coding lies with the
provider of services. Please contact your local payer for their interpretation of the appropriate
codes to use for specific procedures.
 Medtronic makes no guarantee that the use of this information will prevent differences of
opinion or disputes with Medicare or other third party payers as to the correct form of billing
or the amount that will be paid to providers of service.
 CPT copyright 2015 American Medical Association. All rights reserved. CPT is a registered
trademark of the American Medical Association. Applicable FARS/DFARS Restrictions Apply
to Government Use. Fee schedules, relative value units, conversion factors and/or related
components are not assigned by the AMA, are not part of CPT, and the AMA is not
recommending their use. The AMA does not directly or indirectly practice medicine or
dispense medical services. The AMA assumes no liability for the data contained or not
contained herein.
 Note: CPT® code descriptions may be abbreviated and not listed in their entirety in all cases in
this presentation. For full descriptions, please refer to your 2016 CPT code book.
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CRHF ECONOMICS & HEALTH POLICY
CONTINUING EDUCATION UNITS

This program has prior approval of the American Academy of
Professional Coders (AAPC) for one continuing education hour. Granting
of this prior approval in no way constitutes endorsement by AAPC of the
program content or the program sponsor.
The AAPC requires attendees to participate in the entire Web-EX
presentation in order to qualify for the CEU certificate.
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CRHF ECONOMICS & HEALTH POLICY
AGENDA
4

Coding Changes for CY 2016

Medicare Coverage Policies

Provider-Based Designation

Medicare National Payment Rates for CRHF Therapies

Common Coding Scenarios

Device Monitoring

Quality Programs

PQRS and the Value-Based Payment Modifier

Appendix

Q &A
CRHF ECONOMICS & HEALTH POLICY
Coding Changes for CY 2016
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CRHF ECONOMICS & HEALTH POLICY
CPT®1 / HCPCS2 CODES FOR CY 2016
Category
III Code2
Description2
Medicare CY 2016 Physician Payment is Contractor Priced3
0387T
Transcatheter insertion or replacement of permanent leadless pacemaker,
ventricular
0388T
Transcatheter removal of permanent leadless pacemaker, ventricular
0389T
Programming device evaluation (in person) with iterative adjustment of the
implantable device to test the function of the device and select optimal
permanent programmed values with analysis, review and report, leadless
pacemaker system
0390T
Peri-procedural device evaluation (in person) and programming of device
system parameters before or after a surgery, procedure or test with analysis,
review and report, leadless pacemaker system
0391T
Interrogation device evaluation (in person) with analysis, review and report,
includes connection, recording and disconnection per patient encounter,
leadless pacemaker system
1 AMA 2016 CPT code book; 2 HCPCS: Healthcare Common Procedure Coding System;
3 Medicare CY 2016
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MPFS Final rule RVU file, link in Appendix.
CRHF ECONOMICS & HEALTH POLICY
PATIENT MANAGEMENT AND COORDINATION OF CARE
Population Health: focus on patient management and coordination of care:
 Transitional Care Management (CPT 99495-99496) effective 1/1/2013
Goal: To increase the quality of patient care and reduce hospital re-admissions.
 Chronic Care Management (CPT 99487-99490) effective 1/1/2015
Goal: Better health and care for individuals, as well as reduced spending.
AND….effective January 1, 2016:
 Prolonged Clinical Staff Services CPT 99415 – 99416
Clinical Staff Services with Physician or Other Qualified Health Care Professional
Supervision
Code effective 1/1/2016 but not covered by Medicare in 2016
 Advanced Care Planning (ACP) CPT 99497, +99498
Code effective January 2015; covered by Medicare in 2016
https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/Transitional-CareManagement-Services-Fact-Sheet-ICN908628.pdf
https://www.cms.gov/Outreach-and-Education/Medicare-Learning-NetworkMLN/MLNProducts/Downloads/ChronicCareManagement.pdf
AMA 2016 CPT code book; 2016 MPFS Final Rule
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CRHF ECONOMICS & HEALTH POLICY
PATIENT MANAGEMENT AND COORDINATION OF CARE
ADVANCE CARE PLANNING (ACP)
 Two CPT Codes for ACP reimbursable by Medicare effective January 1, 2016
 CPT 99497: MPFS National rate $85.99
Advance care planning including the explanation and discussion of advance
directives such as standard forms (with completion of such forms, when
performed), by the physician or other qualified health care professional; first 30
minutes, face-to-face with the patient, family member(s), and/or surrogate
 CPT +99498: MPFS National rate $74.88
Each additional 30 minutes (List separately in addition to code for primary
procedure) (Use 99498 in conjunction with 99497)
 Codes are applicable in two instances:
 When reasonable and medically necessary for the diagnosis or treatment of injury or illness
 As a voluntary, separately payable part of an Annual Wellness Visit (AWV), with modifier -33
Pages 70955-70999 Final rule Federal Register dated November 16, 2015, 42CFR 410.26; AMA 2016 CPT code book
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CRHF ECONOMICS & HEALTH POLICY
Medicare Coverage Policies
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CRHF ECONOMICS & HEALTH POLICY
MEDICARE NCD FOR PACEMAKER IMPLANTS
 August13,2013: Revised NCD in effect for DOS on or after 8/13/2013
 NCD 20.8.3
 July 7, 2014: Implementation – Claims Processing Rules ; Rescinded and Delayed
 July 6, 2015: Implementation – Claims Processing rules
 Change Request CR 9078; MLN Matters® MM9078
 Transmittal 3384 dated October 25, 2015 – Claims Processing rules and CR 9078,
MLN Matters MM9078 article revised on October 26, 2015:
 Due to claims processing issues brought to the attention of CMS, MACs will implement this
NCD at the local level, until CMS is able to revise the claims processing instruction and edits.
See Appendix for links to NCD 20.8.3, Transmittal 3382 and MM9078
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CRHF ECONOMICS & HEALTH POLICY
CARDIAC PACEMAKER EVALUATION SERVICES
NCD §20.8.1 AND 20.8.1.1 OF CMS PUB. 100-03

The decision as to how often any patient's pacemaker should be monitored is
the responsibility of the patient's physician who is best able to take into
account the condition and circumstances of the individual patient.

Transtelephonic monitoring (TTM) Guidelines I and II are for both single and
dual chamber pacemakers. The TTM guidelines are in this NCD.

Pacemaker clinic* service frequency guidelines for routine monitoring are:
 Single chamber: Twice in the first 6 months following implant, then once
every 12 months
 Dual chamber: Twice in the first 6 months following implant, then once
every 6 months

Increased frequency of monitoring must be supported by documented
medical necessity.
* Please note that “Pacemaker clinic” also includes “Physician practice” and “Hospital device monitoring
departments”
Rev. 182, 05-22-15 is available at:
http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/ncd103c1_Part1.pdf
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CRHF ECONOMICS & HEALTH POLICY
Provider-Based Designation
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CRHF ECONOMICS & HEALTH POLICY
PLACE OF SERVICE FOR PROVIDER-BASED PHYSICIANS


A Practice designated as office-based reports POS 11 Office.
Provider-Based: Off-Campus or On-Campus claim submission1:
 New POS 19: Off-Campus Outpatient Hospital
A portion of an off-campus hospital provider based department that provides
diagnostic, therapeutic (both surgical and nonsurgical), and rehabilitation services to
sick or injured persons who do not require hospitalization or institutionalization.
 POS 22 (description change only): On-Campus Outpatient Hospital
A portion of a hospital’s main campus that provides diagnostic, therapeutic (both
surgical and nonsurgical), and rehabilitation services to sick or injured persons who do
not require hospitalization or institutionalization.
 For existing Off-Campus Provider-Based practices (as of November 2, 2015), the
hospital portion of the facility claim is paid separately (under OPPS) and the
physician portion (professional claim) is reimbursed based on the Medicare
Physician Fee Schedule (MPFS).
1 Pub 100-04 Medicare Claims Processing, Transmittal
3315 dated August 6, 2015 and effective on January 1, 2016 is available
at: https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/R3315CP.pdf
Provider Based CMS Transmittal A-03-030 dated 4.18.2003:
https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/downloads/a03030.pdf
CMS Transmittal 143 dated 4.29.2011
https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/downloads/R143BP.pdf
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CRHF ECONOMICS & HEALTH POLICY
PHYSICIAN OWNED PRACTICE AND PROVIDER-BASED
PHYSICIAN PRACTICE EXAMPLES
CPT®
code
CPT Brief Description
CY 2016
Medicare National Payment
Physician owned practice and Place of Service 11 “Office”
93283
Dual lead ICD in person programming
$82.401 Global
Provider-Based Physician practice and
Place of Service 22 “On-Campus Outpatient Hospital – so Modifier PO is not applicable”
93283-26
Dual lead ICD in person programming
$58.401 PC
93283
Dual lead ICD in person programming
(Technical Component)
$33.622 TC
Hospital Outpatient APC*
Total
Provider-Based Payment
$92.02
PC: Professional Component
TC: Technical Component
Global: PC plus TC
* APC: Ambulatory Payment Classification
1 Physician payment rate: http://www.cms.gov/apps/physician-fee-schedule/overview.aspx
2 Hospital payment rate: http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/HospitalOutpatientPPS/index.html
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CRHF ECONOMICS & HEALTH POLICY
Medicare National Payment Rates
for CRHF Therapies
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CRHF ECONOMICS & HEALTH POLICY
CONVERSION FACTOR CY 2016 VERSUS CY 2015
 The Medicare Physician service conversion factor is $35.9335 for July through
December 31, 2015 and $35.8279 for CY 2016.
 The PAMA (Protecting Access to Medicare Act) of 2014 established an annual
target reduction resulting from adjustments to relative values of misvalued codes
for 2017 through 2020. However the Achieving a Better Life Experience (ABLE) of
2014 accelerated the application of the annual target reductions and also set a 1%
target for 2016. The targeted reduction for 2017 and 2018 is set at 0.5%.
 CMS estimated the 2016 misvalued code reduction to be only 0.23%; target
recapture amount is (.23% - 1.00% or -0.77%). The CY 2016 calculation is shown
below:
$35.9335 times 0.5% (update adjustment factor) times -0.02% (budget neutrality
factor) times -0.77% (target recapture) = $35.8279.
Page 71357 of Federal Register dated November 16, 2015.
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CRHF ECONOMICS & HEALTH POLICY
MPFS 2016 NATIONAL PAYMENT CRHF EXAMPLES
Payments do not include the 2% sequestration adjustment
CPT
Brief Description
2016
2015
Change
33206
Insert pacer system; atrial
$479
$481
($2)
33207
Insert pacer system; ventricular
$511
$512
($1)
$554
$554
$0
$1,041
$1,041
$0
$364
$365
($1)
33208
Insert pacer system; atrial and ventricular
Insert cardiac resynchronization therapy system
CRT-P (33208 + 33225)
Remove pacer gen. and replace pacer gen.; single lead
33227 system
33228
Remove pacer and replace pacer gen.; dual lead system
$380
$380
$0
33229
Remove pacer and replace pacer gen.; multiple lead system
$400
$398
$2
33234
Remove pacer lead; single lead system
$516
$517
($1)
33235
Remove pacer leads; dual lead system
$673
$673
$0
PFS Relative Value Files for 2016 and 2015 are available at:
https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched/index.html
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CRHF ECONOMICS & HEALTH POLICY
MPFS 2016 NATIONAL PAYMENT CRHF EXAMPLES
Payments do not include the 2% sequestration adjustment
CPT
Brief Description
33249
Insert ICD system
Insert cardiac resynchronization therapy system
CRT-D (33249 + 33225)
2016
2015
Change
$963
$964
($1)
$1,450
$1,452
($2)
33262
Remove ICD gen. and replace ICD gen.; single lead system
$400
$400
$0
33263
Remove ICD and replace ICD gen.; dual lead system
$416
$416
$0
33264
Remove ICD and replace ICD gen.; multiple lead system
$433
$433
$0
33282
Implant patient-activated cardiac event recorder
$247
$248
($1)
PFS Relative Value Files for 2016 and 2015 are available at:
https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched/index.html
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CRHF ECONOMICS & HEALTH POLICY
COMMON CODING SCENARIOS
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CRHF ECONOMICS & HEALTH POLICY
AV NODE ABLATION WITH PACEMAKER IMPLANT
•
Based on medically necessity, an AV node ablation is performed and then
a single chamber pacemaker with a lead in right ventricle is inserted.
Description
CPT
AV node ablation
Insert SC ventricular pacemaker
Total Estimated Payment
93650
33207
2016 National
Payment
$627
$256**
$883
AV: Atrioventricular
SC: Single Chamber
Modifier -51 (Multiple Procedures) may be required by the payer
** Multiple procedure reduction is applicable
PFS Relative Value Files for 2016 are available at:
https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched/index.html
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CRHF ECONOMICS & HEALTH POLICY
PULMONARY VEIN ISOLATION (PVI) ABLATION
•
A patient with paroxysmal atrial fibrillation undergoes a comprehensive
EPS and PVI. Intracardiac echocardiography is used to assist with
transseptal sheath placement. After the successful PVI, the physician
ensures there are no additional spontaneous or induced arrhythmias.
Description
CPT
PVI ablation
Intracardiac echocardiography
Total Estimated Payment
93656
+93662-26
2016 National
Payment
$1,176
$145
$1,321
Modifier 26: Professional Component
PFS Relative Value Files for 2016 are available at:
https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched/index.html
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CRHF ECONOMICS & HEALTH POLICY
DUAL CHAMBER PACEMAKER UPGRADE TO ICD
•
A patient with previously placed DC pacemaker has VT and requires an
ICD. Defibrillator threshold testing (DFT) is performed.
Description
CPT
Remove PM generator
Insert ICD generator and RV lead
DFT
Total Estimated Payment
33233*
33249
93641-26*
2016 National
Payment
$126**
$963
$169**
$1,258
DC: Dual Chamber
VT: Ventricular Tachycardia
ICD: Implantable Cardioverter Defibrillator
* Modifier -51 (Multiple Procedures) may be required by the payer
Modifier 26: Professional Component
** Multiple procedure reduction is applicable
PFS Relative Value Files for 2016 are available at:
https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched/index.html
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CRHF ECONOMICS & HEALTH POLICY
Upgrade Single Chamber Pacemaker to CRT-P
•
A patient with a previously placed SC pacemaker develops Class III Heart
Failure. The physician also determines the patient would benefit from dual
chamber pacing.
Description
CPT
Upgrade PM SC to DC
Insert left ventricular lead
Total Estimated Payment
33214
+33225
2016 National
Payment
$508
$487
$995
CRT-P: Cardiac Resynchronization Therapy-Pacemaker
SC: Single Chamber
PM: Pacemaker
DC: Dual Chamber
PFS Relative Value Files for 2016 are available at:
https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched/index.html
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CRHF ECONOMICS & HEALTH POLICY
Upgrade Single Chamber Defibrillator to CRT-D
•
A patient with a previously placed SC defibrillator develops Class III Heart
Failure.
Description
CPT
Insert left ventricular lead
Remove/replace ICD generator,
dual lead system
Total Estimated Payment
+33225
33263
2016 National
Payment
$487
$400
$887
CRT-D: Cardiac Resynchronization Therapy-Defibrillator
SC: Single Chamber
ICD: Implantable Cardioverter Defibrillator
PFS Relative Value Files for 2016 are available at:
https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched/index.html
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CRHF ECONOMICS & HEALTH POLICY
DEVICE MONITORING
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CRHF ECONOMICS & HEALTH POLICY
PHYSICIAN NATIONAL PAYMENT AMOUNTS
PACEMAKER/CRT-P CARDIAC DEVICE MONITORING
G: Global
TC: Technical Component
PC: Professional Component
The National Medicare Pacemaker Follow-up
Guidelines released in 1984 are still in effect.
Pacemaker
93286
Interrogation
93279
Single
Lead
G: $50
TC: $17
PC: $33
93280
Dual
Lead
G: $58
TC: $20
PC: $38
Peri-Procedural
in person only
any # of leads
93281
In
Person
Multiple
Lead
G: $69
TC: $23
PC: $46
93288
One code
any # of leads
per encounter
G: $37
TC: $16
PC: $21
G: $28
TC: $13
PC: $15
Remote
93294
Professional
Analysis
any # of leads
Up to 90 days
PC: $34
93296
93293
Technical
Support
any # of leads
Up to 90 days
Transtelephonic
one code
any # of leads
Up to 90 days
TC: $26
CY 2016 Medicare physician payments released on October 30, 2015 at:
http://www.cms.gov/apps/physician-fee-schedule/overview.aspx
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CRHF ECONOMICS & HEALTH POLICY
G: $54
TC: $38
PC: $16
PHYSICIAN NATIONAL PAYMENT AMOUNTS
ICD/CRT-D CARDIAC DEVICE MONITORING
G: Global
TC: Technical Component
PC: Professional Component
ICD
93287
Peri-Procedural
in person only
any # of leads
Interrogation
93282
Single
Lead
G: $63
TC: $20
PC: $43
93283
Dual
Lead
G: $82
TC: $24
PC: $58
93284
Multiple
Lead
G: $91
TC: $27
PC: $64
In
Person
93289
One code
any # of leads
per encounter
G: $66
TC: $20
PC: $46
G: $36
TC: $13
PC: $23
Remote
93295
Professional
Analysis
any # of leads
Up to 90 days
93296
Technical
Support
any # of leads
Up to 90 days
PC: $68
CY 2016 Medicare physician payments released on October 30, 2015 at:
http://www.cms.gov/apps/physician-fee-schedule/overview.aspx
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CRHF ECONOMICS & HEALTH POLICY
TC: $26
PHYSICIAN NATIONAL PAYMENT AMOUNTS
ICM CARDIAC DEVICE MONITORING
G: Global
TC: Technical Component
PC: Professional Component
Implantable Cardiovascular
Monitor (ICM)
In Person
per encounter
Interrogation
Remote
G: $32
TC: $10
PC: $22
93297
93299
Professional
Analysis
any # of leads
Up to 30 days
+
PC: $27
CY 2016 Medicare physician payments released on October 30, 2015 at:
http://www.cms.gov/apps/physician-fee-schedule/overview.aspx
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CRHF ECONOMICS & HEALTH POLICY
Technical
Support
any # of leads
Up to 30 days
Contractor Priced
PHYSICIAN NATIONAL PAYMENT AMOUNTS
ILR CARDIAC DEVICE MONITORING
G: Global
TC: Technical Component
PC: Professional Component
Implantable Loop Recorder
(ILR)
93285
Interrogation
Programming evaluation
per encounter
G: $43
TC: $16
PC: $27
93291
In Person
per encounter
G: $37
TC: $15
PC: $22
Remote
93298
Professional
Analysis
any # of leads
Up to 30 days
93299
+
PC: $27
CY 2016 Medicare physician payments released on October 30, 2015 at:
http://www.cms.gov/apps/physician-fee-schedule/overview.aspx
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CRHF ECONOMICS & HEALTH POLICY
Technical
Support
any # of leads
Up to 30 days
Contractor Priced
MEDICARE GLOBAL SURGICAL PERIOD1




Each surgical CPT code has a surgical period associated with the service
90 days: Major surgical procedures, includes all CRHF implants
10 days: Minor surgical procedures
Some procedures have zero global days
Major surgical procedures and the 90 day global surgical period:
 Bundled: preoperative visits after the decision is made to operate
(includes 1 day before procedure), and 90 days post-implant
 Included: Routine follow-up (e.g., post-op visits), wound checks
Not included in the Global Surgery Period (may be paid separately):
 Initial consultation/evaluation by the surgeon to determine need for major
surgery
 Visits unrelated to the diagnosis for which the surgical procedure is
performed, unless the visits occur due to complication of the surgery.
 Diagnostic tests/procedures, including diagnostic radiological procedures.
 Device monitoring procedures are diagnostic procedures
1
Publication 100-04 Medicare Claims Processing Manual, Chapter 12 Physician/NonPhysician
Practitioners is available at: http://www.cms.gov/Regulations-andGuidance/Guidance/Manuals/Downloads/clm104c12.pdf
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CRHF ECONOMICS & HEALTH POLICY
GLOBAL SURGERY PACKAGE (GSP) & MACRA
 MACRA rules prohibit CMS from implementing planned phase-out of GSP to zero
days in 2017-2018:
 10 day GSP phase-out in CY 2017
 90 day GSP phase-out in 2018
 MACRA requires CMS to develop and implement a process to gather data on
services furnished during a GSP from a representative sample of physicians.
 Can be claims-based data collection
 Can delay up to 5% of payments to selected physicians until data is submitted.
 Process must be performed through rule-making
 Beginning in 2019, CMS will use the data collected and other pertinent data to value
surgical services.
MACRA: Medicare Access and CHIP (Children Health Insurance Program) Reauthorization Act of 2015
https://www.congress.gov/bill/114th-congress/house-bill/2/text
Pages 70915-70916 of Federal Register dated November 16, 2015.
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CRHF ECONOMICS & HEALTH POLICY
DIAGNOSTIC TESTS:
MEDICARE ORDER REQUIREMENTS1,2


Diagnostic tests must be ordered by the physician/practitioner treating the
patient and who uses the results to treat the patient. (Diagnostic tests ordered
by a non-treating physician/practitioner are considered not reasonable and
necessary)
What is an order?
 Communication from the treating physician/practitioner requesting that a
diagnostic test be performed for the Medicare beneficiary
 When a physician/practitioner’s order for a diagnostic test does not require a
signature, the physician/practitioner must clearly document, in the medical records,
his or her intent that the test be performed.

How may an order be delivered?
 An order may be delivered via signed written document, a telephone call, or via email
1 Title 42 Code of Federal Regulations Part 414-Payment for Part B Medical and Other Health Services (Subpart B):
http://www.ecfr.gov/cgi-bin/text-idx?SID=c046900b4d8394fad36b02417227da74&mc=true&node=sp42.3.414.b&rgn=div6
2 Publication 100-04 Medicare Claims Processing Manual, Chapter 23 Fee Schedule Administration and Coding
Requirements, §10.1.2: http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c23.pdf
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CRHF ECONOMICS & HEALTH POLICY
MEDICARE SUPERVISION REQUIREMENTS FOR THE
TECHNICAL COMPONENT OF DIAGNOSTIC TESTS
DIRECT SUPERVISION
Applies to the technical component for all in person cardiac device interrogations.
The physician must be present in the office suite and immediately available to furnish
assistance and direction throughout the performance of the procedure. It does not mean that
the physician must be present in the room when the procedure is performed.
In a hospital (facility) setting, direct supervision means that the physician must be immediately
available to furnish assistance and direction throughout the performance of the procedure.
GENERAL SUPERVISION
Applies to the technical component for all remote interrogation services. The procedure is
furnished under the physician’s overall direction and control, but the physician’s presence is
not required during the performance of the procedure. Under general supervision, the training
of the nonphysician personnel who actually performs the diagnostic procedure and the
maintenance of the necessary equipment and supplies are the continuing responsibility of the
physician.
Medicare Benefit Policy Manual, CMS-Pub. 100-02 Chapter 15, Section 80-Covered Medical and Other Health Services:
http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/bp102c15.pdf
Medicare supervision requirements for specific procedure codes:
http://www.cms.gov/PhysicianFeeSched/PFSRVF/list.asp#TopOfPage
Click on PFS Relative Value Files, then Calendar Year 2016. The most updated file is “RVU16A.”
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CRHF ECONOMICS & HEALTH POLICY
INCIDENT-TO BILLING
CLARIFICATION
 “Incident to” services are defined as those services that are furnished incident to
physician professional services in the physician’s office (whether located in a
separate office suite or within an institution) or in a patient’s home.1
 To qualify as “incident to,” services must be part the patient’s normal course of
treatment, during which a physician personally performed an initial service and remains
actively involved in the course of treatment.
 A supervising Physician/Practitioner must be present in the suite (direct supervision).
 The Physician/Practitioner who bills must be the supervising physician/practitioner
 Services provided by non-physician practitioners (NPPs) must be compliant with
State laws and State supervision requirements.
 Services cannot be provided by individuals who are excluded from Medicare,
Medicaid, or other federal programs.
 Services cannot be provided by an individual who has had Medicare enrollment
revoked.
https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN
/MLNMattersArticles/downloads/se0441.pdf
Pages 71065-71068 of Federal Register dated November 16, 2015.
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CRHF ECONOMICS & HEALTH POLICY
DEVICE MONITORING DIAGNOSIS CODES
ICD-9 VERSUS ICD-10

Routine Device Monitoring
ICD-9-CM Diagnosis Code
ICD-10-CM Diagnosis Code
Pacemaker
V45.01
Z95.0
Cardiac pacemaker in situ
Presence of cardiac pacemaker
Implantable Defibrillator
V45.02
Z95.810
Automatic implantable cardiac
defibrillator in situ
Presence of automatic (implantable)
cardiac defibrillator
Other Cardiac Devices (ILR)
V45.09
Z95.818
Other specified cardiac device
in situ
Presence of other cardiac implants
and grafts
2016 ICD -10-CM and GEMs: https://www.cms.gov/Medicare/Coding/ICD10/2016-ICD-10-CM-and-GEMs.html
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DEVICE MONITORING DIAGNOSIS CODES
ICD-9 VERSUS ICD-10

Device Monitoring for Patients with a Complaint or a Symptom
ICD-9-CM Diagnosis Code
ICD-10-CM Diagnosis Code
Pacemaker
V53.31
Z45.010
Fitting and adjustment of cardiac pacemaker
Encounter for checking and testing of cardiac
pacemaker pulse generator [battery]
Z45.018
Encounter for adjustment and management of other
part of cardiac pacemaker
Implantable Defibrillator
V53.32
Z45.02
Fitting and adjustment of automatic implantable
cardiac defibrillator
Encounter for adjustment and management of
automatic implantable cardiac defibrillator
Implantable Loop Recorder (ILR)
V53.39
Z45.09
Fitting and adjustment of other cardiac device
Encounter for adjustment and management of other
cardiac device
2016 ICD -10-CM and GEMs: https://www.cms.gov/Medicare/Coding/ICD10/2016-ICD-10-CM-and-GEMs.html
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CRHF ECONOMICS & HEALTH POLICY
EXAMPLES OF COMPLAINT/SYMPTOM DIAGNOSIS CODES
ICD-9 VERSUS ICD-10
ICD-9-CM Diagnosis Code
ICD-10-CM Diagnosis Code
427.9: Unspecified cardiac dysrhythmia
I49.9: Cardiac arrhythmia, unspecified
780.2: Syncope and Collapse
R55: Syncope and Collapse
780.4: Dizziness and Giddiness
R42: Dizziness
785.1: Palpitations
R00.2: Palpitations
Remember to review Medicare Local Coverage Determinations (LCDs), or
contact your Medicare Administrative Contractor (MAC), or refer to your private
payer policies
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CRHF ECONOMICS & HEALTH POLICY
Quality Programs
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CRHF ECONOMICS & HEALTH POLICY
PQRS : CARROTS TO STICKS
PHYSICIAN QUALITY REPORTING SYSTEM
Incentives end 2014
based on 2014 PQRS Reporting
payment incentive is calculated on 2014 payments
Penalties begin 2015
2013 PQRS Reporting affects 2015 penalties
2014 PQRS Reporting affects 2016 penalties
2015 PQRS Reporting affects 2017 penalties
2016 PQRS Reporting affects 2018 penalties
https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/PQRS/AnalysisAndPayment.html
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CRHF ECONOMICS & HEALTH POLICY
THE PHYSICIAN QUALITY REPORTING SYSTEM (PQRS)
What is PQRS?
Why is PQRS
Important?
What Does the Future
of PQRS Look Like?
1. The PQRS incentive
•
Established by CMS in 2006, the PQRS provides incentives to eligible
professionals (EP) to encourage reporting of quality measure data1
•
EPs include physicians, practitioners, and therapists who provide services
that are paid under the Medicare Physician Fee Schedule2
•
The goal of the PQRS is to collect meaningful data that can help improve
patient care
•
PQRS is part of broad trend across healthcare to transition
reimbursement systems to reward value rather than volume
•
PQRS gives participating EPs the opportunity to assess the quality of care
they are providing to their patients, helping to ensure that patients get the
right care at the right time
•
As the program shifts from voluntary to mandatory participation, PQRS
EPs are subject to penalties beginning with the 2015 payment year 3
•
CMS continues to refine and update the availability of quality measures and
the reporting requirements through federal rule-making. MACRA rules will
replace the current system after 2018.
payment is supplemented by a payment adjustment beginning in the 2013 reporting year.
professionals (EP) can be found at: http://go.cms.gov/1jlsTBP.
3. To avoid the payment adjustment in 2015 (-1.5%), EPs must have reported to PQRS in 2013. For the 2016 payment adjustment (-2.0%), EPs must satisfactorily
report to PQRS in 2014. For the 2017 payment determination, not only the same payment adjustment (-2.0%) will apply to EPs under PQRS, EPs will be subject
to the Value-Based Payment Modifier which applies a payment modification based on physician performance in 2015, beginning CMS’s transition to a pay-forperformance program.
Sources: CMS Physician Quality Reporting System (PQRS) Overview. http://go.cms.gov/1bv2Oe1; Federal Register. 2015 Revisions to Payment Policies Under
the Physician Fee Schedule. CY 2015. July 2014. http://1.usa.gov/WkG6Cx.
2. A full list of PQRS eligible
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CRHF ECONOMICS & HEALTH POLICY
Medicare professionals who
satisfactorily report clinical data
via PQRS are eligible for an 0.5
percent incentive payment1
PQRS Payment/Penalty Year
PQRS Reporting Year
Incentive/Adjustment Rate
2012
2012
0.5%
2013
2013
0.5%
Payment
year 2015 and
Beyond
Payment
years 20122014
PQRS USES PAYMENT ADJUSTMENTS TO PROMOTE
REPORTING OF CLINICALLY RELEVANT DATA
2014
2014
0.5%
Beginning in 2015,
eligible professionals
who do not fulfill
reporting requirements
will be subject to a
financial penalty
2015
2013
-1.5%
0.5%
0.0%
-0.5%
-1.0%
-1.5%
-2.0%
1. The bonus
payments or adjustments are apply to total estimated Medicare Part B Physician Fee Schedule allowed
charges for covered professional services furnished during that same reporting period
Sources: CMS. Payment Adjustment Information March 2014. http://www.cms.gov/Medicare/Quality-InitiativesPatient-Assessment-Instruments/PQRS/Payment-Adjustment-Information.html
CMS. What’s New For 2014. Published April 2014. http://go.cms.gov/1toSJXH
CMS. 2015 PQRS Payment Adjustment. Published June 2013. http://go.cms.gov/J2eLhk.
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CRHF ECONOMICS & HEALTH POLICY
2016 2017
2014
2015
-2.0%
2018
2016
PQRS &THE VALUE-BASED PAYMENT MODIFIER
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CRHF ECONOMICS & HEALTH POLICY
PENALTIES AND THE VALUE-BASED PAYMENT MODIFIER (VM)
PQRS
PQRS
Objective
Quality
Measures
Reporting
History of
PQRS
VM – Two Programs
•
To use incentive payments and payment penalties to promote reporting of quality
information by eligible professionals (EPs)
•
EPs satisfactorily report data on quality measures for covered services furnished to
Medicare Part B beneficiaries
•
Payment penalties are applied two years following the applicable PQRS reporting year. For
example, a lack of required reporting in 2016 will result in a payment penalty in 2018
•
•
•
•
2006: Medicare Improvements and Extension Acts of 2006 establishes PQRS program
•
2010 Onward: CMS continues program reporting requirements while adding and removing
measures based on CMS’ priorities across therapeutic areas
•
2014-2015: PQRS program moves from a voluntary payment bonus structure for satisfactorily
reporting to a mandatory program to avoid payment penalties
•
2015-2018: CMS will apply a value-based payment modifier (VM) to determine Medicare FFS
physician payments, which is based in part on PQRS quality data reporting
2007: PQRS first implemented, then referred to as Physician Quality Reporting Initiative (PQRI)
2008: PQRS made permanent
2010: The Patient Protection and Affordable Care Act (ACA) of 2010 authorized incentive payments
through 2014 and required negative payment adjustments for not reporting quality data beginning
in 2015 (based on the 2013 reporting year)
Sources: CMS. Electronic Prescribing Incentive Fact Sheet. October 2008. http://go.cms.gov/YYnvgC.
CMS. 2008 Physician Quality Reporting Initiative Specifications Document. http://go.cms.gov/1panFqc.
CMS Physician Quality Reporting System (PQRS) Overview. http://go.cms.gov/1bv2Oe1.
CMS Medicare FFS Physician Value Based Payment Modifier Program Summary. http://goo.gl/UWOSDc Accessed August 19, 2014.
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CRHF ECONOMICS & HEALTH POLICY
VALUE-BASED PAYMENT MODIFIER (VM): 2015-2018
Under the Affordable Care Act CMS is mandated to begin applying a value modifier
under the Medicare Physician Fee Schedule (MPFS).
 The VM provides for a differential payment to a physician or group of physicians
based on the quality of care furnished compared to cost during a performance
period.
 Implementation: PQRS reporting is used for VM
 2015: Physicians in group practices of 100 or more eligible professionals (EPs) who
submit claims to Medicare under a single tax identification number (TIN) will be subject
to the value modifier in 2015, based on their performance in calendar year 2013.
 2016: Physicians in group practices of 10 or more EPs who participate in Fee-For Service
Medicare under a single TIN will be subject to the VM in 2016, based on their
performance in calendar year 2014.
 2017: All physicians who participate in Fee-For-Service Medicare will be affected by the
VM starting in 2017 using performance data from 2015.
 2018: Beginning in 2018, using performance data from 2016, the payment adjustments
will also apply to non-physician EPs who are solo practitioners or are in groups of 2 or
more EPs.
https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeedbackProgram/Downloads
/2016-VM-Fact-Sheet.pdf
https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/
downloads/SE1507.pdf
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CRHF ECONOMICS & HEALTH POLICY
QUALITY TIERING
• CMS will use national benchmark comparisons for the following to
evaluate cost for the quality-tiering election for the VM:
• Total per capita cost
• Per capita cost for beneficiaries with four specific chronic conditions:
1.
2.
3.
4.
Chronic obstructive pulmonary disease (COPD),
Heart failure,
Coronary artery disease (CAD), and
Diabetes.
• Total per capita costs include payments under both Part A and Part B, but do
not include Medicare payments under Part D for drug expenses
PQRS reported quality
information, along with
CMS-calculated
outcomes and cost
measures are analyzed
A quality and a cost
composite score is
calculated for each
practice
Each score is then
classified as ‘high”,
“average”, or “low”
based on the
National mean
score.
CMS then preforms
“quality tiering” analysis to
determine if the Practice
will receive a penalty,
bonus based on
performance.
https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeedbackProgram/Downloads
/2016-VM-Fact-Sheet.pdf
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CRHF ECONOMICS & HEALTH POLICY
2016 VALUE MODIFIER PAYMENT ADJUSTMENTS
https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeedbackProgram/Downloads
/2016-VM-Fact-Sheet.pdf
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CRHF ECONOMICS & HEALTH POLICY
QUALITY & RESOURCE USE REPORT (QRUR)
 The QRUR report summarizes each participant’s (by TIN) performance on quality
measures across six quality domains and on cost measures across two cost
domains.
 Table 3 identifies the domains that are applicable to quality and cost calculations
based on 2014 reporting. These scores will be used for 2016 composite scores.
https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeedbackProgram/2014-QRUR.html
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CRHF ECONOMICS & HEALTH POLICY
CMS PHYSICIAN QUALITY RESOURCES
For complete and updated Physician Quality Reporting information please access:
http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/PQRS/Spotlight.html
https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeedbackProgram/Downloads/2016-VM-FactSheet.pdf
https://www.cms.gov/Outreach-and-Education/Medicare-Learning-NetworkMLN/MLNMattersArticles/downloads/SE1507.pdf
Measures list information:
http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/PQRS/MeasuresCodes.html
2016 Reporting requirements and 2016 and beyond measures list (Pages 71153-71170):
http://www.gpo.gov/fdsys/pkg/FR-2015-11-16/pdf/2015-28005.pdf
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CRHF ECONOMICS & HEALTH POLICY
CARDIAC RHYTHM AND HEART FAILURE (CRHF)
CARDIAC
RHYTHM AND HEART FAILURE (CRHF)
INFORMATION
INFORMATION
CRHF
Visit our website:
www.Medtronic.com/CRDMreimbursement
Economics and Email us:
Health Policy [email protected]
Call our Coding Hotline:
1 (866) 877-4102
To ensure you receive advance notification of webcast
events, it is very easy to register at
www.Medtronic.com/CRDMreimbursement:
Join our E-mail List
Subscribe to receive news and updates.
49
CRHF ECONOMICS & HEALTH POLICY
www.medtronic.com/crdmreimbursement
DOWNLOAD OUR ICD-10 DIAGNOSIS CROSSWALK
50
CRHF ECONOMICS & HEALTH POLICY
APPENDIX
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CRHF ECONOMICS & HEALTH POLICY
APPENDIX – DEVICE MONITORING
CPT®
Code
93279
Description
Programming device evaluation (in person) with iterative adjustment of the implantable
device to test the function of the device and select optimal permanent programmed values
with analysis, review and report by a physician or other qualified health care professional;
single lead pacemaker system
93280
dual lead pacemaker system
93281
multiple lead pacemaker system
93282
Programming device evaluation (in person) with iterative adjustment of the implantable
device to test the function of the device and select optimal permanent programmed values
with analysis, review and report by a physician or other qualified health care professional;
single lead transvenous implantable defibrillator system
93283
dual lead transvenous implantable defibrillator system
93284
multiple lead transvenous implantable defibrillator system
2016 CPT code book
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CRHF ECONOMICS & HEALTH POLICY
APPENDIX – DEVICE MONITORING.. CONTINUED
CPT®
Code
Description
93285
Programming device evaluation (in person) with iterative adjustment of the implantable device
to test the function of the device and select optimal permanent programmed values with
analysis, review and report by a physician or other qualified health care professional;
implantable loop recorder system
93288
Interrogation device evaluation (in person) with analysis, review and report by a physician or
other qualified health care professional, includes connection, recording and disconnection per
patient encounter; single, dual, or multiple lead pacemaker system
93289
single, dual, or multiple lead transvenous implantable defibrillator system, including
analysis of heart rhythm derived data elements
93290
implantable cardiovascular monitor system, including analysis of 1 or more recorded
physiologic cardiovascular data elements from all internal and external sensors
93291
93293
implantable loop recorder system, including heart rhythm derived data analysis
Transtelephonic rhythm strip pacemaker evaluation(s) single, dual, or multiple lead pacemaker
system, includes recording with and without magnet application with analysis, review and
report(s) by a physician or other qualified health care professional, up to 90 days
2016 CPT code book
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CRHF ECONOMICS & HEALTH POLICY
APPENDIX – DEVICE MONITORING.. CONTINUED
CPT®
Code
Description
93296
Interrogation device evaluation(s) (remote), up to 90 days; single, dual, or multiple lead
pacemaker system or implantable defibrillator system, remote data acquisition(s), receipt
of transmissions and technician review, technical support and distribution of results
93299
Interrogation device evaluation(s), (remote) up to 30 days; implantable cardiovascular
monitor system or implantable loop recorder system, remote data acquisition(s), receipt
of transmissions and technician review, technical support and distribution of results
2016 CPT code book
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CRHF ECONOMICS & HEALTH POLICY
APPENDIX: REFERENCES
MPFS CY 2016 Federal Register dated November 16, 2015 is available at:
http://www.gpo.gov/fdsys/pkg/FR-2015-11-16/pdf/2015-28005.pdf
Data files such as “2016 PFS Final Rule Addenda”, “2016 PFS Final Rule List of Medicare
Telemedicine Services” and “2016 PFS Final Rule Multiple Procedure Payment Reduction
Files” are available at:
PhysicianFeeSched/PFS-Federal-Regulation-Notices.html
The 2016 Relative Value file is available by clicking on “PFS Relative Value Files” at:
https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched/PFS-Relative-Value-Files.html
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