1 The Other Final FY 2015 & Proposed CY 2015 Medicare PPS Updates Larry Goldberg Larry Goldberg...

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The Other Final FY 2015 & Proposed CY 2015

Medicare PPS UpdatesLarry Goldberg

Larry Goldberg Consulting

September 11, 2014

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Comments

The updates on MB are varied CMS has always taken a year delay to update the area wage

index from IPPS values to the other PPS programs Why isn’t CMS adopting the new OMB area delineations

for all providers• Yes, some will be better remaining under old• Make sure you go to provider specific wage files

Be careful understanding amounts of increases

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Agenda

FY 2015 Final PPS Updates IPF SNF IRF Hospice

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Agenda

CY 2015 Proposed PPS Updates OPPS ESRD Physician Home Health

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Inpatient Psychiatric Facilities

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Published in Aug 6st Federal Register Copy at:

http://www.gpo.gov/fdsys/pkg/FR-2014-08-06/pdf/2014-18329.pdf

Tables are part of the rule Effective 10/1/14

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Market Basket increase is 2.9 percent Reduced by a 0.5 percent multifactor productivity (MFP)

adjustment Reduced by a 0.3 percentage point reduction by the

ACA Net increase is 2.1 percent CMS estimates increase of $120 million

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Update Net MB of 2.1 percent AWI budget neutrality factor = 1.0002 FY 2015 Federal per diem base rate of $728.31

• [FY 2014 rate $713.19 x 1.021 x 1.0002 = $728.31] FY 2015 ECT per diem base rate = $313.55

• [FY 2014 rate $307.04 X 1.021 x 1.0002 = $313.55] Labor Share = 0.69294

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Area Wage Index Will use FY 2014 factors NOT adopting new OMB delineations till FY 2016

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Patient-Level Adjustments: No changes Adjustment for MS-DRG Assignment that group to one

of 17 MS-IPF-DRGs Payment for Comorbid Conditions Patient Age Adjustments Variable Per Diem Adjustments

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Facility-Level Adjustments: No changes For the wage index – 1.0020 IPFs located in rural areas – 17 percent Teaching IPFs = 0.5150 Cost of living adjustments for IPFs located in Alaska and

Hawaii IPFs with a qualifying emergency department (ED)

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Outlier Payments FY 2014 $10,245 FY 2015 $ 8,755 (Again) Failing to pay the 2.0 percent outlier pool

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Quality 8 previously adopted

• Hours of Physical Restraint Use*• Hours of Seclusion Use*• Patients Discharged on Multiple Antipsychotic Medications*• Patients Discharged on Multiple• Alcohol Use Screening**• Follow-Up After Hospitalization for Mental Illness**• Post-Discharge Continuing Care Plan Created*• Post-Discharge Continuing Care Plan Transmitted to Next

Level of Care Provider

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Quality 2 new for FY 2016

• Patient Experience of Care – requires attestation as to whether the facility conducts some type of patient experience survey.

• Use of an Electronic Health Record – requires attestation as to which one out of a group of statements best characterizes the facility’s EHR use.

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Quality (continued) 4 New for FY 2017

• -Two Tobacco Use Measures-Screening & Cessation Intervention – assesses if patients 18 and older have been a) questioned about tobacco use and b) for those patients identified as tobacco users, offered and provided tobacco cessation intervention treatment and medications

• One Influenza Immunization Measure – assesses the percentage of inpatients that are screened and vaccinated for influenza during the October through March period

• One Healthcare Worker Immunization Measure – assesses the percentage of healthcare personnel who receive influenza vaccination during the October through March period

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Skilled Nursing

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Skilled Nursing

Published in Aug 5th Federal Register Tables on CMS website Copy at:


Tables at: http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/SNFPPS/index.html

Effective 10/1/14

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SNF PPS Update

Market Basket Increase = 2.5 percent No MB correction adjustment –

FY 2013 actual 2.2 vs 2.5 (-0.3 percent) Comment – only PPS with MB data correction

Further reduced by MFP = -0.5 percent Net Update is 2.0 percent Labor Share increases to 69.180 CMS estimates total payments to increase $750 million

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SNF PPS Update

AWI Budget neutrality factor 1.0009

Will use new OMB area – “delineations (because they) accurately reflect the local economies and wage levels of the areas in which hospitals are currently located, we proposed to implement the new OMB delineations as described in the February 28, 2013 OMB Bulletin No. 13-01, for the SNF PPS wage index beginning in FY 2015” [Read this quote]

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SNF PPS Update

Will be based on a 50/50 percent blend for one year 50 percent of the FY 2015 wage index based on the

proposed new OMB delineations, and 50 percent of their FY 2015 wage index based on the

OMB delineations used in FY 2014

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SNF PPS Update

Change of Therapy (COT) assessment policy update CMS is revising the current COT Other Medicare

Required Assessment (OMRA) policy to permit providers to use the COT OMRA to reclassify a resident into a therapy RUG from a non-therapy RUG, but only in certain limited circumstances.

ICD-10-CM Delayed [Acknowledging] Congress changed the effective date to services furnished

on or after October 1, 2015, the AIDS add-on will apply to beneficiaries with an ICD-10-CM diagnosis code of B20

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SNF PPS Update

Civil Money Penalties CMS clarifies that states may use federal CMP funds only

after obtaining prior approval from CMS, and may not use these funds if CMS has disapproved their intended use, or use these funds for purposes other than to support activities that benefit residents as specified in statute

CMS also requires that States provide more public transparency on the projects that have been funded by CMP funds

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Inpatient Rehabilitation Facilities

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Published in 8/6/13 Federal Register Tables on CMS website Copy at:. http://www.gpo.gov/fdsys/pkg/FR-2014-08-

06/pdf/2014-18447.pdf Tables at: http://www.cms.hhs.gov/Medicare/Medicare-

Fee-for-Service-Payment/InpatientRehabFacPPS/ Effective 10/1/14

http://www.ofr.gov/OFRUpload/OFRData/2013-18956_PI.pdf

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Market Basket Increase – 2.9 percent Further reduced by MPF = -0.5 percent Further reduced by ACA = -0.2 percent Net Update is 2.2 percent Labor Share increases to 69.294

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Will NOT use new OMB area delineations Using FY 2014 pre-floor, pre-reclassified hospital wage

index data to derive the applicable IRF PPS wage index for FY 2015

Comment How can CMS cite the need for more up-to-date

wage info for SNFs, but ignore for IRFs??? Says it will consider for FY 2016

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Change in Outlier payments Threshold will be $8,848 Current is $9,272 Obviously paying less

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CMS estimates payments to increase $180 million, “or 2.4 percent relative to payments FY 2014” Increase is due to increase in outlier payments For FY 2014 CMS says its paying only 2.8 percent of

the required 3.0 percent amount Claim of increasing monies is absurd – FY 2014

outlier monies are gone!

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Facility-level adjustment updates CMS is freezing, as proposed, all facility-level

adjustment factors for FY 2015 and subsequent years at FY 2014 levels

CMS says it is continuing to monitor the most current IRF data available and evaluate the effects of the FY 2014 changes it made.

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“60-percent rule” presumptive methodology code list updates To qualify for IRF PPS - 60 percent of patients

require intensive inpatient rehabilitation services for one or more of 13 conditions specified in regulation

In the FY 2014 IRF PPS final rule CMS revised the list of ICD-9-CM diagnosis codes that are compared with a patient’s comorbidities in determining an IRF’s presumptive compliance with the 60 percent rule

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“60-percent rule” (continued) CMS is finalizing additional revisions to the

comorbidity, Impairment Group Code, and Etiologic Diagnosis portions of the presumptive compliance methodology to be consistent with the changes implemented in the FY 2014 final rule

The changes finalized in this rule will be for compliance review periods beginning on or after October 1, 2015

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Additional ICD-9-CM Codes to be removed from Presumptive Compliance

ICD-9-CMCode

Diagnosis

V49.65 Below elbow amputation statusV49.66 Above elbow amputation statusV49.67 Shoulder amputation status

V49.73 Foot amputation status

V49.74 Ankle amputation status

V49.75 Below knee amputation status

V49.76 Above knee amputation status

V49.77 Hip amputation status

V52.0 Fitting and adjustment of artificial arm (complete) (partial)

V52.1 Fitting and adjustment of artificial leg (complete) (partial)

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Changes to the Impairment Group Codes That Meet Presumptive Compliance Criteria An “impairment group code” is not an ICD diagnosis

code, but part of a separate unique set of codes specifically developed for the IRF PPS for assigning the primary reason for admission to an IRF

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Removal of Impairment Group Codes (IGCs) for Unilateral Upper Extremity Amputations and Arthritis From Appendix B: Impairment Group Codes That Meet Presumptive Compliance Criteria CMS is removing the following codes:

• Impairment Group Codes That Meet Presumptive Compliance Criteria:

• IGC 0005.1—Unilateral Upper Limb Above the Elbow (AE),• IGC 0005.2—Unilateral Upper Limb Below the Elbow (BE),• IGC 0006.1—Rheumatoid Arthritis, and• IGC 0006.9—Other Arthritis.

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Data Collection of the Amount and Mode (Individual, Group, and Co-Treatment) of Therapy Provided in IRFs According to Occupational, Speech, and Physical Therapy Disciplines Adding a new Therapy Information Section to the IRF-PAI (Patient

Assessment Instrument) to record the amount and mode of therapy (that is, Individual, Concurrent, Group, and Co-Treatment) patients receive in each therapy discipline

Requiring IRFs to record the total number of therapy minutes received by mode and discipline only for weeks one and two of the IRF stay

Will also require “Concurrent Therapy” to be reported as a separate category from “Group Therapy.” This requirement will become effective for IRF discharges occurring on or after October 1, 2015

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Data Collection of the Amount and Mode (Individual, Group, and Co-Treatment) of Therapy Provided in IRFs According to Occupational, Speech, and Physical Therapy Disciplines (continued)

Will use the definition of Group Therapy as one therapist working with 2 to 6 patients who are all performing the same or similar activities solely for the purposes of this data collection effort

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Revision to the IRF-PAI to Add Data Item for Arthritis Conditions Will implement a “Yes”/“No” indicator to the IRF-PAI form

in which providers can indicate that the prior treatment and severity requirements have been met for patients with arthritis conditions

Effective FY 2016

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ICD-10-CM Conversion CMS is finalizing conversion of ICD-9-CM to ICD-10-CM

codes for the IRF PPS in this final rule Will not/ can not implement until FY 2015

• Protecting Access to Medicare Act of 2014 (PAMA)

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Quality New Measure Proposals

• Finalizing two proposed quality measures for the IRF QRP:

– NHSN Facility-Wide Inpatient Hospital-Onset Methicillin-Resistant Staphylococcus aureus (MRSA) Bacteremia Outcome Measure (NQF #1716), and

– NHSN Facility-Wide Inpatient Hospital-Onset Clostridium difficile Infection (CDI) Outcome Measure (NQF #1717)

– IRFs will be required to begin reporting these quality measures via the Center for Disease Control and Prevention’s (CDC) National Healthcare Safety Network (NHSN) beginning with admissions and discharges occurring on or after January 1, 2015

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New Policy Proposals Reconsideration Process. Will require that IRF providers follow

specific procedures when submitting a request for CMS’ reconsideration of an initial IRF QRP provider compliance determination

Data Completion Thresholds and Data Validation. Will require randomly selected IRF providers to meet a 75% data accuracy threshold for certain required IRF-PAI quality indicator data items. We are additionally finalizing our proposed Data Completion thresholds, which require IRF providers to meet a data completion threshold of 95% for mandatory IRF-PAI quality indicator items, as well as a threshold of 100% for data submitted through the CDC’s NHSN (i.e., data covering each month of the applicable reporting

period)

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Hospice

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Hospice

Published in Aug 22 Federal Register Copy at:


Tables at: http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/Hospice/index.html

Effective 10/1/14

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Hospice

Market Basket = 2.9 percent Reduced by MPF = 0.5 Percent Reduced by ACA = 0.3 percent Net increase 2.1 percent Labor portions

Routine Home Care 68.71 percent Continuous Home Care 68.71 percent General Inpatient Care 64.01 percent Respite Care 54.13 percent

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Hospice

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Hospice

No quality reduction is 2.0 percent Sixth year of 7 year BNAF adjustment

FY 2015 BNAF is 0.9313 percent Hospice aggregate cap amount for the 2014 cap year will be

$26,725.79 Requires filing 5 months after cap year

Adopts CAHPS® Hospice Survey for the FY 2017 Payment Determination

Timeframes for Filing the Notice of Election (NOE) and Notice of Termination/Revocation 5 calendar days

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CY 2015 Proposed PPS

OPPS & ASC MPFS ESRD Home Health

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Proposed CY 2015 OPPS & ASC

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Proposed CY 2015 OPPS

Posted 7/3/14 Published in 7/14/14 Federal Register Comments were due by 9/2/14 Effective 1/1/15 Copy at:


Has good executive summary

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The Addenda relating to the OPPS are available at: http://www.cms.gov/Medicare/Medicare-Fee-for-Service-

Payment/HospitalOutpatientPPS/index.html The Addenda relating to the ASC payment system are

available at: http://www.cms.gov/Medicare/Medicare-Fee-for-Service-

Payment/ASCPayment/index.html

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Updates Disregard proposed update of 2.7 percent less 0.4

MPF and 0.2 ACA (net = 2.1) Will follow final IPPS increase 2.0 percent less for no quality

Proposed Conversion factor at $74.146 Would maintain rural SCH and EACH 7.1 percent rural

adjustment Would maintain (11) cancer hospital adjustment

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Labor Share would continue at 60 percent Frontier State hospitals will receive a wage index of

1.0000 Part B drugs would be payable at ASP+6 percent,

unless packaged Packing threshold would increase to $100

Exceptions for:• Preventive services• Psychiatry-related services• Drug administration services

• APC weights and rates in Addendum A & B

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Outliers would be 1.75 times the APC payment amount and exceeds the APC payment rate plus a $3,100 fixed-dollar threshold [increasing – current $2,900]

Outliers for CMHC would be 3.40 times the payment rate for APC 0173, calculated as 50 percent of the amount by which the cost exceeds 3.40 times the APC 0173 payment rate

CMS estimates that it paid 0.1 percent above the CY 2012 outlier target of 1.0 percent of total aggregated OPPS payments

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Partial Hospitalization Program

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Off-Campus Provider-Based Departments New data collection by CMS Providers will have to report a separate modifier

• For all off-campus provider-based departments• Applies to both hospital and physician claims

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Composite APC Criteria-Based Costs Proposing to continue composite policies for extended

assessment and management services, LDR prostate brachytherapy, cardiac electrophysiologic evaluation and ablation services, mental health services, and multiple imaging service

Proposing to continue to pay for all multiple imaging procedures within an imaging family performed on the same date of service using the multiple imaging composite APC payment methodology

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Composite APC Criteria-Based Costs (continued) Proposing to replace composite APC 8000 with proposed

[comprehensive] C-APC 0086

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Comprehensive APCs Defined as classification for the provision of a primary

service and all adjunctive services and supplies provided to support the delivery of the primary service

The policy for comprehensive APCs that was finalized in the CY 2014 OPPS/ASC final rule to be effective 1/1/2015

Proposing a total of 28 comprehensive APCs for CY 2015

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Comprehensive APCs (continued) Consolidates and restructures current 39 device

dependent APCs into 26 from current 29 Proposing 2 new comprehensive APCs

• C-APC 0067 for single-session cranial stereotactic radiosurgery (SRS) and

• C-APC 0351 for intraocular telescope implantation. In addition

• Would reassign CPT codes 77424 and 77425 that describe intraoperative radiation therapy treatment (IORT) to C-APC 0648 (Level IV Breast and Skin Surgery)

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Proposed Reconfiguration & Restructuring of Comprehensive APCs Includes:

• Endovascular clinical family (renamed Vascular Procedures, VASCX)

• Automatic Implantable Cardiac Defibrillators, Pacemakers, and Related Devices (AICDP)

• Delete the clinical family for Event Monitoring • Two levels instead of three levels for Urogenital Procedures• Rename the arthroplasty family of APCs to Orthopedic

Surgery • Three levels of electrophysiologic procedures

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Proposed Reconfiguration & Restructuring of Comprehensive APCs Includes: (continued)

• Three new clinical families: Gastrointestinal Procedures (GIXXX) for gastrointestinal stents, Tube/Catheter Changes (CATHX) for insertion of various catheters, and Radiation Oncology (RADTX)

• Proposing to delete APC 8000 for CY 2015

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Proposed OPPS Ambulatory Payment Classification (APC) Group Policies

Addresses codes adopted during April, July and October

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Proposed OPPS APC-Specific Polices Includes:

Ophthalmic Procedures and Services Female Reproductive Procedures (APCs 0188, 0189, 0192, 0193,

and 0202) Image-Guided Breast Biopsy Procedures (APC 0005) Image-Guided Abscess Drainage Procedures (APCs 0005 and

0007) Cystourethroscopy and Other Genitourinary Procedures (APCs

0160, 0161, 0162, and 0163)

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Proposed OPPS APC-Specific Polices (continued) Includes:

Wound Treatments and Services (APCs 0015 and 0327) Endoscopic Retrograde Cholangiopancreatography (ERCP) with

Stent (APC 0384) Radiation Therapy (APCs 0066, 0067, 0412, 0446, 0648, and 0667)

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Contains numerous additions and deletions of CPT and HCPCS codes

Contains adjustments to OPPS payment for full or partial credit devices

Identifies 9 drug and biologicals that will lose pass through status December 31, 2014

Identifies 22 drugs and biologicals that will continue pass through status

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Quality (OQR) Proposing to remove 3 measures

• Aspirin at arrival (OP-4)• Timing of prophylaxis antibiotics (OP-6))• Prophylactic antibiotic selection for surgery (OP-7)

Adding one for CY 2017 payment• Hospital visit rate after O/P colonoscopy (OP-32)

One measure goes to voluntary from mandatory• Improved vision 90 days after cataract surgery

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Proposed CY 2015 ASC

Update For CY 2015, the CPI-U update is projected to be 1.7

percent The MFP adjustment is projected to be -0.5 percent Resulting in an MFP-adjusted CPI-U update of 1.2

percent for CY 2015

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Update Will adopt OMB’s revised area delineations Proposing that if ASC wage index for FY 2015 is lower

than 2014, would apply a 50/50 percent blend of two year indexes

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Quality ASCs not fulfilling quality would incur 2.0 percent

payment reduction Would add one outcome measure (Facility Seven-Day

Risk-Standardized Hospital Visit Rate after Outpatient Colonoscopy) and the transition of one outcome measure (Cataracts -- Improvement in Patient’s Visual Function within 90 Days Following Cataract Surgery (NQF #1536)) to voluntary reporting for both the Hospital OQR and ASCQR Program

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Proposed CY 2015 MPFS

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Posted 7/3/14 Published in 7/11/14 Federal Register Copy at:


Tables at: http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched/PFSFederal-Regulation-Notices.html

Comments were due by 9/2/14 Effective 1/1/15

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Does NOT reflect SGR reduction under current law Update would be Zero from 1/1/15 to 3/31/15

Per statute Could be minus 20.9 percent after then

Congress will need to intervene --Again

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GCPIs 1.5 work GPCI continues in Alaska 1.0 work GPCI elsewhere, sunsets 4/1/15 1.0 expense GPCI continues in Frontier states

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Primary care and complex chronic care management Proposes a payment rate of $41.92 for a CCM code that can be

billed no more frequently than once per month per qualified patient Propose to allow greater flexibility in the supervision of clinical staff

providing CCM services Is not proposing to establish separate standards that practitioners

and practices furnishing this service would have to meet Proposing one additional requirement – standards for electronic

health records – and seeks comment on whether additional standards are needed

Payment for CCM is only one part of a multi-faceted CMS initiative to improve Medicare beneficiaries’ access to primary care

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Misvalued Codes Adding about 80 codes Includes

• Epidural Injection and Fluoroscopic Guidance − CPT Codes 62310, 62311, 62318, 62319, 77001, 77002 and 77003

• Neurostimulator Implantation − CPT codes 64553 and 64555• Mammography − CPT codes 77055, 77056, and 77057, and

HCPCS codes G0202, G0204, and G0206• Abdominal Aortic Aneurysm Ultrasound Screening − G0389• Prostate Biopsy Codes – HCPCS codes G0416, G0417, G0418,

and G0419

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Global surgery Moving all 10- and 90-day codes to 0 days Effective 1/1/17

Changing process to allow more public input

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Telehealth – adding CPT codes 90845 (Psychoanalysis); 90846 (family psychotherapy (without

the patient present); and 90847 (family psychotherapy (conjoint psychotherapy) (with patient present)

CPT codes 99354 (prolonged service in the office or other outpatient setting requiring direct patient contact beyond the usual service; first hour (list separately in addition to code for office or other outpatient evaluation and management service); and, 99355 (prolonged service in the office or other outpatient setting requiring direct patient contact beyond the usual service; each additional 30 minutes (list separately in addition to code for prolonged service)

HCPCS codes G0438 (annual wellness visit; includes a personalized prevention plan of service (pps), initial visit; and, G0439 (annual wellness visit, includes a personalized prevention plan of service, subsequent visit)

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Contains extensive discussion and measures for the Physician Quality Reporting System (PQRS)

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Proposed CY 2015 ESRD

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Posted 7/2/14 Published in 7/11/14 Federal Register Copy at: http://www.gpo.gov/fdsys/pkg/FR-2014-07-

11/pdf/2014-15840.pdf Tables at:

http://www.cms.gov/ESRDPayment/PAY/list.asp Comments were due by 9/2/14 Effective 1/1/15 Also addresses some DME issues

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Update Zero per statute (Protecting Access to Medicare Act)

(would have been 2.7 percent) BN adjustment = 1.001306 Proposed base rate is $239.33 Proposing to rebase the market basket Revising labor share to 50.673 from 41.737

Phase-in over 2 years 50/50 in CY 2015

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Outliers Fixed-dollar amounts

• $56.30 for peds (up from $54.01)• $85.24 for adults (down from $98.67)

Medicare Allowable Payments (MAP) amounts• $40.05 for peds (up from $37.29)• $52.61 for adults (up from $51.97)

CMS acknowledges it did NOT pay out the 1.0 percent outlier pool

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Wage Index Would use new CBSAs delineations One-year transition:

• 50/50 old/new in 2015• 100% new in 2016

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ICD-9 continues until 10/1/15 Clarify eligibility for Low Volume Patient Adjustment No payment under PPS for oral-only drugs until 1/1/24 (per

statute)

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Quality Proposed changes for PY 2017

• QIP measure set will contain 8 clinical measures and 3 reporting measures

• Involve anemia management, dialysis adequacy and hospital readmissions among others

Proposed changes for PY 2018• 11 clinical measures and 5 reporting measures• Tweaking the scoring

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DME Will use data from comp bidding in adjusting fee

schedule amounts• Where comp bidding won’t be used• Set a national ceiling at 110% of regional averages• Set floor at 90% of regional average• Use national ceiling in rural areas

Phase-in of bundled monthly amounts• For certain items• In lieu of capped rental price

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Proposed CY 2015 ESRD.)

DME (continued) Will allow a hearing aid to be considered a prosthetic device in

certain limited circumstances• Thus, would be covered

Update rules re special training• For custom fitting services• By provider not certified as orthotists

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Proposed CY 2015 Home Health

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CY 2014 Proposed Home Health

Published in July 3rd Federal Register Copy at:


Tables at: http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/HomeHealthPPS/Home-Health-Prospective-Payment-System-Regulations-and-Notices.html

Comments were due by 9/2 Effective 1/1/2014

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Update Market Basket = 2.6 percent Reduced by MFP 0.4 percent Net = 2.2 percent ($427 million) Rebasing MB (-$485 million) Net Loss

Labor remains at 78.535

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Wage Index Move to new CBSAs One-year transition

• 50/50 old/new for 2015• 100% new for 2016

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CY 2014 Proposed CY 2015 Home Health

Update – Proposed 60 day national episode payment amount

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Outliers No changes being proposed Will do so in final

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Quality Minimum OASIS submission threshold

• 70% for 7/1/15 to 6/30/16• Increases to 90% over next two periods

First reports will affect payment in CY 2017

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Questions

1 The Other Final FY 2015 & Proposed CY 2015 Medicare PPS Updates Larry Goldberg Larry Goldberg...

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