Final rule: Good news, bad news for urologists

Robert A. Dowling, MDOn Nov. 2, 2016 the Centers for Medicare & Medicaid Services (CMS) released its final rule on the 2017 Medicare Physician Fee Schedule (bit.ly/2017finalrule). The final rule is the annual update to policies that determine payment for most Part B professional services, including relative value calculations.

Also by Dr. Dowling - MACRA: How changes in final rule affect urology

In this article, I outline what urologists should know about major provisions in the final rule and how it may impact their bottom line.

Negative pay adjustments for urology

The first thing to know about the PFS final rule is that it is, in the words of the authors, “economically significant.” Changes to relative value units (RVUs) and other factors that would change total expenditures by more than an established threshold ($20 million for 2017) must be offset by adjustments to preserve budget neutrality. That threshold was crossed in 2017, and there are adjustments to the fee schedule that create winners and losers among certain codes and certain specialties.

Urology is one of the losers: The combined impact of changes to the work RVUs, practice expense RVUs, and malpractice RVUs is estimated at –2% of total allowed charges compared to CY2016 PFS. Family practice, internal medicine, and general practice are among the winners (+1% each). No specialty has more than a 2% swing except independent laboratory (–5%).

Second, there are a handful of common CPT codes used by urologists that received attention this year as potentially misvalued (read: overvalued or in need of reduction). After the significant input of organizations like the AUA and others following the publication of the proposed rule, the results published in the final rule include an increase in some potentially misvalued codes including laparoscopic radical prostatectomy (55866), which saw a 25% increase in work RVUs compared to 2016. Needle biopsy of the prostate (55700) saw a 3.1% decrease in work RVUs, while the work RVU for cystoscopy (52000) was decreased 31% from 2016.

The final impact on allowed charges will depend upon a number of factors, including changes in the conversion factor, the relative contribution of the work RVU to the total RVUs, and geographic location. The impact on allowed charges for diagnostic cystoscopy is certain to be significant in most office practices and is estimated to be –19% (bit.ly/AUAfinalruleanalysis).

Third, CMS significantly modified changes to implementing the collection of data (required under MACRA) on postoperative services for procedures with a 10- or 90-day global period that it had originally proposed earlier this year. In the proposed rule, all practices would have been required to begin using new G codes in the postoperative period designed to collect data on the frequency and intensity of those services. This onerous requirement was modified and finalized as follows: The requirement to report postoperative services will only be implemented in nine states (FL, KY, LA, NV, NJ, ND, OH, OR, RI), only for groups of 10 or more providers, and only after July 1, 2017. Furthermore, the reporting will only require the use of an existing code 99024 instead of the new and more complex G codes.

Read: Medicare Part D data reveal prescriber patterns

The collection of data is required under MACRA, and the responses to extensive comments in the final rule indicate that CMS may well expand this data collection in the future as it reviews global surgery packages. For now, the data collection will be much more limited in scope than originally proposed and use a code already familiar to most surgeons-99024. Urologists may consider a more disciplined use of this code starting now, as it may aid in analysis of your claims data for your own purposes.

Next: Appropriate use criteria finalized

Appropriate use criteria finalized

Last, CMS finalized several provisions regarding the implementation of appropriate use criteria for advanced diagnostic imaging services. This set of requirements was authorized in statute by the Protecting Access to Medicare Act of 2014 (bit.ly/ProtectingAccess) and directs the establishment of appropriate use criteria (AUC) for applicable diagnostic imaging tests, the identification of clinical decision support mechanisms (CDSM) to consult those AUC, a requirement that ordering professionals consult AUC through CDSM and report that on a claim, and the identification of outliers (providers who do not consult/report AUC when they should). Urologists should know that the final PFS rules in 2016 and 2017 have established the foundation for this requirement with certain definitions of AUC and CDSM, and CMS will publish a list of qualified CDSMs on July 1, 2017.

Also see - Open Payments: How urology measures up

If the current timeline holds, all professionals would be required to consult and report this activity on a claim starting Jan. 1, 2018 and could anticipate that outlier activity would be published the following year. CMS has identified several priority clinical areas to focus on (coronary artery disease, suspected pulmonary embolism, headache, hip pain, low back pain, shoulder pain, lung cancer, neck pain), but clarifies that these requirements apply even outside those areas to all professionals who order relevant imaging studies. As urologists frequently order advanced imaging studies, they should expect to begin meeting these requirements in 2018.

Bottom line: The PFS for CY 2017 is another piece of the complicated puzzle that determines how physicians charge and get reimbursed under Medicare. For 2017, it is a mix of good and bad news for urologists with a projected 2% loss in total allowed charges, relief from cuts that were proposed to be even worse, significant reduction in proposed data collection requirements, and further clarification on new requirements for ordering advanced imaging studies. As you examine your path forward in the post-MACRA world, remember there are other levers that affect how you will be reimbursed and measured.

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