The proposed Outpatient Prospective Payment System rule seeks to make more episode-based payments, while the proposed physician payment rule contains changes to the Medicare Electronic Health Record Incentive program.
The Centers for Medicare & Medicaid Services late Monday took several steps to make the way it pays for outpatient and physician services in 2014 more like the way it pays for inpatient care, with episode-based rates, and more "packages" of services.
The agency is striving to streamline payments in ways that "will remove incentives hospitals may have to provide medically unnecessary services or expend additional, unnecessary resources to achieve a higher level of visit payments."
In its 718-page proposed Outpatient Prospective Payment System rule, CMS projects a 1.8% increase for CY 2014, affecting payments for about 4,000 hospitals and their outpatient and emergency departments, inpatient rehabilitation and inpatient psychiatric facilities, long-term acute care hospitals, children's hospitals and hospitals specializing in care for cancer patients.
In a separate proposed rule, governing policies and payments to the Medicare Physician Fee Schedule, or Part B, for 2014, the agency wants to expand payment criteria from care that requires a face-to-face visit to care that involves "managing select Medicare patients' care needs beginning in 2015."
The proposed physician payment rule also changes quality reporting initiatives, the Medicare Electronic Health Record Incentive program, and the Physician Compare tool on Medicare.gov.
Outpatient rule
Seven categories of items and services would be "packaged" or included in payment for a primary service:
1. Drugs, biological, and radiopharmaceuticals that function as supplies when used in a diagnostic test or procedure;
2. Drugs and biologicals that function as supplies or devices when used in a surgical procedure;
3. Certain clinical diagnostic laboratory tests
4. Procedures described by add-on codes;
5. Ancillary services, such as a chest x-ray, that are assigned status indicator "X";
6. Diagnostic tests on the bypass list, and
7. device removal procedures.
CMS also is proposing to create 29 comprehensive ambulatory payment classifications, or APCs, to replace 29 existing device-dependent APCs, such as those that involve imaging services.
To further the agency's goals of using larger payment bundles to incent hospitals to provide care more efficiently, discourage upcoding, and set accurate payments, CMS wants to streamline five levels of outpatient visit codes into one single "Healthcare Common Procedure Coding System" or HCPCS code.
There would be one such HCPCS code "for each unique type of outpatient hospital visit (24 hour and non-24 hour).
"By collapsing the current five levels of codes to one level, CMS believes this proposal will remove incentives hospitals may have to provide medically unnecessary services or expend additional, unnecessary resources to achieve a higher level of visit payments under the OPPS, will reduce administrative burden and be easily adopted by hospitals, and will allow a large universe of claims to be utilized for rate setting."
For ambulatory surgical centers, the proposed payment update would be .9% for 2014.
CMS proposes to package ancillary or adjunct services for payment, and would reduce by 2% payments to ambulatory surgical centers that fail to meet quality reporting program requirements.
Significant changes are proposed for the outpatient quality reporting program, to affect payments in 2016, but with data collection starting Jan. 1, 2014. These new measures include:
- Influenza vaccination coverage among healthcare personnel
- Complications within 30 days following cataract surgery that require additional surgical procedures
- An appropriate follow-up interval for normal colonoscopy in average-risk patients
- A colonoscopy interval for patients with a history of adenomatous polyps to avoid inappropriate use.
- Whether a cataract surgery patient's visual function improved within 90 days.
The proposed rule also contains more information that affects the agency's value-based purchasing program, defined under the Hospital Inpatient Prospective Payment Rule, for FY 2016. Specifically, the rule proposes to set baseline and performance periods for hospital rates of catheter-associated urinary tract infections, central line-associated bloodstream infections, and surgical site infections.
CMS proposes to change eligibility criteria for Quality Improvement Organizations, as well as the contracting process for those groups.
Proposed physician fee schedule rule
In this 652-page proposed rule governing the 2014 Physician Fee Schedule, CMS proposes to pay separately for complex chronic care management services starting in 2015.
"Specifically, we proposed to pay for non-face-to-face complex chronic care management services for Medicare beneficiaries who have multiple, significant, chronic conditions (two or more)." Rather than paying based on face-to-face visits, CMS would use "G-codes" to pay for revision of care plans, communication with other treating professionals, and medication management over 90-day periods.
These code payments would require that beneficiaries have an annual wellness visit, that a single practitioner furnish these services, and that the beneficiary consent to this arrangement over a one-year period.
The agency proposes to modify telehealth rules so that certain regions classified as "health professional shortage areas or HPSAs are able to benefit.
Significant changes are proposed to the GPCI, or geographic practice cost indices that pay physicians in some regions more than in others based on regional differences in costs, such as malpractice insurance policies.
The proposed rule includes provisions to adjust about 200 "misvalued" service codes "where Medicare pays more for services furnished in an office than in an outpatient hospital department or ambulatory surgical center."
The agency's proposal would establish service caps of two per beneficiary for physical therapy and speech language pathology, and another two per beneficiary for occupational therapy services, when a critical access hospital provides those services starting Jan. 1, 2014.
Comments are due until Sept. 6, 2013. The final rule is expected on or about Nov. 1.