Will Medicare Fee Schedule Impact Your Practice?

Effective in 2017, the new Medicare Physician Fee Schedule cites a handful of changes that are likely to affect physician reimbursement in myriad ways. Published on July 15, 2016 by the Centers for Medicare and Medicaid Services (CMS), the impact of this new schedule varies based on specialty, with primary care physicians seeing the most modest of gains in comparison to other specialties who will experience flat or declining payments. In order to fully understand the scope of these new developments, it is vital to outline the details of the proposed fee schedule changes that are in store for physicians in 2017. 

Set to be implemented on January 1, 2017, a handful of new G codes are proposed, relating to global surgical packages, care management, and add-on services, likely to pique the interest of all physicians. 

Global Surgical Packages

An examination of the global surgical packages is addressed, with the government committed to “improve the accuracy of valuation of surgical services.” CMS proposed gathering data about the frequency and input of global surgical services by establishing eight new G codes in 2017 that are intended to measure pre and post-operative care, as well as non-face-to-face services. This potential revaluation would likely have an impact on the 4,200 CPT® codes with a 10- or 90-day global period, and although usage of the codes on claims is stated to be for informational purposes only, CMS is seeking feedback about the potential burden of this approach to data collection and the overall impact of an additional proposal to withhold up to 5% of payments from surgeons who choose not to participate in the research.

Care Management

CMS proposes to introduce a series of new care management codes for primary care, behavioral health, and care coordination services effective in 2017. These additions include code GPPP6 for assessment and care planning of patients with cognitive impairment; GPPP1, GPPP2 and GPPP3 for behavioral health integration services in the Psychiatric Collaborative Care Model used in the primary care setting; and GPPPX for general behavioral health integration provided outside of the model.

Add-on Codes. Also included in the proposed fee schedule are the addition of GDDD1, an add-on code for patients using mobility assistive technology, and GPPP7 for a comprehensive assessment of and care planning by a physician or other qualified healthcare professional for patients requiring chronic care management services. These add-on codes are intended to boost pay when providing these services during a patient’s visit.

With these new changes, however, there are a handful of components that are under scrutiny with CMS, such as the zero-day global services, in addition to a noteworthy change in the conversion factors related to fee schedule adjustments. 

Zero-day Global Services

Commonly billed alongside an evaluation and management (E/M) service code appended with modifier 25, zero-day global services come under scrutiny in 2017. In CMS’ research, the agency reports that 19%, of codes with a 0-day global service were billed more half the time with an E/M code that had been appended with modifier 25. While many of the 83 codes that CMS are under review are for dermatologic services, this list also includes simple pulmonary, otolaryngology, and orthopedic procedures in addition to home dialysis.

Conversion Factors

Adjustments to the fee schedule conversion factor next year will be somewhat of a wash. Counterbalancing a mandated 0.5 percent update to the conversion factor in 2017 are the proposed downward adjustment of 0.07 percent for imaging and a relative value unit (RVU) adjustment of -0.51 percent for budget neutrality. As a result, the 2017 Medicare physician fee schedule conversion factor drops slightly from 35.8043 to 35.7551. Looking at the combined impacts of other proposed adjustments, the specialty of Family Medicine would see a three percent gain, which is the most accorded to any specialty in 2017. Not great news for Interventional Radiology, which would take a seven percent hit, in addition to Pathology and Vascular Surgery who also face fee schedule setbacks of a negative two percent each overall.

Fortunately, CMS has introduced new components in the fee schedule related to proposed reimbursement that are mostly seen as a positive change. 

Diabetes Self-Management Training

The government is proposing an expansion of opportunities to be paid for diabetes self-management training (DSMT), G0108 and G0109. CMS introduced an entirely new initiative - the Medicare Diabetes Prevention Program (MDPP); the proposed reimbursement method for the program focuses on paying physicians for patients who experience weight loss.

Prolonged Care

Prolonged care codes 99358 and 99359 for extended non-face-to-face E/M services before or after an in-person office visit have existed for a number of years but have never been reimbursed by Medicare. In 2017, CMS will begin paying for the codes when the services are rendered to Medicare patients.


CMS is expanding covered telehealth services in 2017 by proposing to pay for end-stage renal disease (ESRD)-related services, advanced care planning and critical care consultations. The latter group of services, the critical care consultations via telehealth, would be paid through new codes, GTTT1 and GTTT2. The agency also announced plans to create a new place of service (POS) code to clarify reporting of the location of a telehealth service.

Within the changes outlined in the proposed fee schedule, CMS has focused on the relaxation of specific procedures and requirements for the implementation of certain codes, specifically with Chronic Care Management.  

To address the issue of what the agency sees as the underutilization of chronic care management (CCM) code, 99490, which can be reported once per month when providing 20 or more minutes of non-face-to-face care to a patient, CMS proposes to ease requirements in the use of this code. These include the removal of the requirement that physicians must have 24/7 electronic access to the patient’s care plan when furnishing CCM after hours, in addition to a relaxation in requirements with initiating visits, formatting and sharing care plans and clinical summaries, and obtaining patient consent. 

The government also intends to cover the codes, 99487 and 99489, for complex CCM. These two new CCM codes, as well as GPPP1, GPPP2, GPPP3, and GPPPX, will require only general supervision by the physician or advanced practice provider when providing these complex and, often, time-consuming services. The proposal also proposes to lift the burden of direct supervision, replacing it with general supervision for the use of these codes in rural health clinics (RHCs) and federally qualified health centers (FQHCs).

With these changes, there are also adjustments in regards to the data reporting and informal review processes, seen as welcomed modifications. 

Data Reporting

Accountable care organization (ACO) participants have traditionally not been required to submit data for the Physician Quality Reporting System (PQRS). While that can sound favorable to physicians, it has proven disastrous if and when the ACO is poorly managed. In response to these challenges, CMS has proposed to allow eligible professionals (EPs) billing under the tax identification number (TIN) of an ACO an option to report separately as individual EPs or as group practices for PQRS. ACO participants also would have the option of reporting quality data outside of the ACO to meet PQRS requirements in 2017 and 2018. The intention is to exempt these groups from the group reporting registration process for the current calendar year, since the deadline was June 30, 2016.

Informal Review

The informal review for penalties for failure to successfully report to PQRS will be eased for affected physicians - and the review process for the Value-based Payment Modifier (VBPM) will also be restructured. Seen as a welcomed move, CMS proposes to revise the informal review policies, creating a protocol for how VBPM quality and cost composites would be affected for the 2017 and 2018 payment years should unexpected issues arise, such as an error by CMS in its calculations or a mistake by a vendor or other third party.

While most of the changes would not become effective until January 1st, 2017, CMS is currently seeking feedback on its recommendations in advance of issuing a final rule set for late October.

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