MACRA

TOA members are encouraged to turn to TOA’s e-mail newsletters for more information regarding MACRA.  TOA will also cover MACRA at TOA’s May 6, 2017 annual conference in Dallas.

Click here to view TOA’s October 31, 2016 webinar on MACRA implementation.

Click here to claim CME for participating in the webinar.

Cheat sheet for TOA Members coming soon.

Webinar Objectives:

  • Overview of the final rule and the elements that will be important for TOA practices to know for January 1, 2017.
  • In-depth analysis of each MIPS category and the requirements for the successful reporting requirements in a quick and easy manner.
  • Review of options available for reporting on Quality and Advancing Care Information measures, including how to effectively utilize the “Pick Your Pace” allowance.
A Look at Medicare’s Competitive Bidding Program for DME

TOA recently sat down with Ross DeRogatis of Matrix Orthopedics to look at Medicare’s Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) Competitive Bidding program, which will affect back and knee braces.

Ross is the President/Owner of Matrix Orthopedics, an exclusive Donjoy distributor.  He has been in the DME space for over 10 years and currently has a team of 24 servicing accounts throughout the state of Texas (with the exception of the Houston and El Paso markets).

TOA: What is the current status of Medicare’s DMEPOS competitive bidding program?

Ross DeRogatis:  The Centers for Medicare & Medicaid Services (CMS) contracted with Palmetto GBA to operate as the competitive bidding implementation contractor (CBIC) to administer the Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) Competitive Bidding Program. Palmetto GBA is responsible for conducting certain functions including performing bid evaluations, selecting qualified suppliers, setting payments for all competitive bidding areas, and supporting CMS education efforts. Palmetto GBA also assists CMS and its contractors in monitoring the program’s effectiveness, access and quality.

In 2003, Congress originally authorized CMS to implement a competitive bidding program (CBP) for DMEPOS. Multiple rounds of bidding have been conducted for many different DMEPOS categories over the past decade.

On November 3, 2018, CMS requested feedback on a proposal to include certain off-the-shelf (OTS) knee and back orthotics/braces in the next round of competitive bidding (known as Round 2021, since contracts will become effective on January 1, 2021).

In early 2019, CMS announced that OTS knee and back braces would be included in the 2021 round.

OTS orthotics are defined as products that require minimal self-adjustment, and do not require expertise in trimming, bending, molding, assembling, or customizing to fit to the individual.

TOA: What are the next steps for the industry when it comes to the competitive bidding program?

Ross DeRogatis: DMEPOS suppliers will compete to become Medicare contract suppliers by submitting one bid for the “lead” item within a product category (e.g., knee orthotics/braces) for each competitive bidding area (CBA). There are 130 CBAs included in the 2021 round. Winning bidders must be able to provide the lead item in a product category, as well as all other products included in that category. This can be accomplished through various approaches.

CMS will evaluate bids based on the supplier’s eligibility to provide the identified products within a CBA, its financial stability, and the bid price offered. Contracts will be awarded to suppliers who offer the best price and meet applicable quality and financial standards.

DJO also has been working closely with industry associations and thought leaders to protect access to high quality products needed by our patients and advocated for the exclusion of certain codes of the identified products/HCPCS codes from the CMS competitive bidding process and changes to the correct coding guidance with respect to custom fitted codes.

DMACs issued a revised Correct Coding Guidance in March 2019:
https://cgsmedicare.com/jb/pubs/news/2019/03/cope11845.html
https://cgsmedicare.com/jc/pubs/news/2019/07/cope13077.html

More information is available at these links:

Official CMS website
Industry educational sites like DME CBP Education
Timeline

Medicare’s CY 2020 OPPS/ASC Payment Proposal

The Centers for Medicare and Medicaid Services (CMS) released its proposed payment policy for the Medicare hospital outpatient prospective payment system (OPPS) and ambulatory surgical center (ASC) payment system for calendar year (CY) 2020 on July 29, 2019.

Keep in mind that the American Association of Orthopaedic Surgeons (AAOS) is currently digging through the proposed rule, and AAOS will provide an extensive analysis and comment letter in the near future.

TOA members have been provided an extensive analysis of this proposal. TOA members can either check their e-mail or log into TOA’s website to view the full proposal.

Stakeholder comments are due on September 27, 2019, and you may want to consider making comments on some of these proposals.

Click here to reference the full rule.

Key Concepts
TOA encourages you to read through TOA’s entire summary. In addition, watch for AAOS’s extensive summary.

Some of the key concepts include (these are all proposals):

    • Add TKA to the ASC-payable list. CMS would like comments on what is appropriate for TKA in the ASC setting.
    • Remove THA from the inpatient-only (IPO) list. (This would not necessarily relate in a payable service for ASCs.)
    • Remove additional spine services from the IPO list. (Again, this does not necessarily mean that they would be ASC-payable services in 2020.)
    • Additional guidance related to hospital pricing disclosure. This proposal would have major implications for hospitals. Some of the “shoppable services” would include orthopaedic-related services.
    • Prior authorization for certain non-musculoskeletal services in an attempt to move these services away from the hospital setting. The idea of prior authorization for Medicare services is a controversial topic that Congress addressed (and backed away from) several years ago.
    • Continued payment update parity for ASCs. (Although a less favorable weight scalar of .8452 for ASCs is seen as a negative.)
    • Comments solicited for TracPatch and AUGMENT Bone Graft.
Medicare’s CY 2020 Physician Fee Schedule Proposal

The Centers for Medicare and Medicaid Services (CMS) released its proposal for the calendar year (CY) 2020 Physician Fee Schedule (PFS) on July 29, 2019.

The American Association of Orthopaedic Surgeons (AAOS) will provide a lengthy summary of the proposal and a response in the near future. In the meantime, TOA has provided a summary for its members. TOA members will receive a lengthy summary in the TOA member e-mail.

Click here to view CMS’s proposal:

Some of the key concepts include:

    • Another approach to the future of E/M services.
    • A lengthy discussion on the future of 10- and 90-day global surgery codes and a look at three new studies related to the topic.
    • A potential overhaul of MIPS through the proposed MIPS Value Pathways.

TOA members can turn to their e-mail newsletter or TOA’s website to view the full proposal.

TOA Comments on Medicare’s Back and Knee Brace Proposal

The Texas Orthopaedic Association (TOA) submitted feedback on December 17, 2018 that expresses concern regarding the Centers for Medicare and Medicaid Services (CMS) proposal to add back and knee braces to Medicare’s new round of competitive bidding.

TOA expressed concern that this could limit the number of physicians who would be able to provide these braces, and this could compromise the coordinated care model.

TOA members can find the response on TOA’s website.

Medicare Unveils Price Procedure Lookup Tool for ASCs and HOPDs

The Centers for Medicare and Medicaid Services (CMS) introduced the Price Procedure Lookup tool, which allows consumers to compare the prices of ambulatory surgery centers (ASCs) and hospital outpatient departments (HOPDs), on November 27.

The tool was created in January 2017 by the 21st Century Cures Act.

Click here to learn more from CMS.

TOA Update: Medicare Finalizes 2019 Physician Fee Schedule & ASC/HOPD Rules

The Centers for Medicare and Medicaid Services (CMS) released the final calendar year (CY) 2019 Physician Fee Schedule (PFS) rule on November 1, and CMS modified the controversial E/M proposal. CMS also released the hospital outpatient department (OPPS) and ambulatory surgery center (ASC) final payment policy rule for CY 2019 on November 2.

Click here to view AAOS’s summary of the potentially mis-valued THA/TKA codes.  Click here to view AAOS’s summary of the final Physician Fee Schedule rule.  Click here to view AAOS’s summary of the final ASC/HOPD rule.

In addition, TOA’s coding course on Friday, February 1, 2019 in Houston will cover many of the new coding changes. (Click here for details.)

CMS introduced the concept of eliminating the current E/M system this summer with a proposal that would have resulted in only two levels: level one and a new level to replace the current levels two through five. CMS indicated that this was an attempt to reduce paperwork. In addition, CMS pointed out that several specialties, including orthopaedics, would have witnessed an overall increase. However, certain sub-specialties that rely on the more complex codes would have witnessed a hit.

The initial proposal received tremendous pushback from stakeholders.

CMS’s final rule this week will result in three levels for E/M beginning in 2021:

  • Keep level one
  • Keep level five
  • “Collapse” the current levels two through four and create a new level to replace those three.

CMS estimated that if the 2021 E/M policy went into effect in 2019, orthopaedic surgery would witness an aggregate 1 percent increase, hand surgery would witness a 3 percent increase, and podiatry would witness a 10 percent aggregate increase. Meanwhile, anesthesiology as an aggregate would witness a 2 percent decrease and neurosurgery would witness a 1 percent decrease.

Keep in mind that since this has not been scheduled until 2021, extensive changes could be made between now and then.

Axios Vitals summarized it in the following graphic:

Other Physician Fee Schedule and MIPS Issues

AAOS will have an extensive analysis of the rule in the near future.

TOA members should turn to their November 3, 2018 e-mail update for the full background on this issue.

CY 2019 Payment Policy for ASCs and HOPDs: A Big Day for ASCs

CMS finalized its CY 2019 payment policy rule for ASCs and hospital outpatient departments on November 2, 2018, and, as mentioned over the past few months, it was a monumental proposal for ASCs. ASCA, the Ambulatory Surgery Center Association, had been pushing many of these issues for many years.

The greatest victory for ASCs was CMS’s decision to finalize the proposal to align the annual payment update factor for ASCs and HOPDs. In the past, HOPDs received the higher annual market basket update (ASCs received an annual update that was tied to the lower inflation rate). As a result, the gulf between ASC and HOPD payments widened each year. While ASCs will continue to be paid less than HOPD services, that gulf is unlikely to grow every year due to the alignment.

In regards to new ASC services for Medicare in 2019, a dozen cardiac catheterization procedures and five additional procedures performed during cardiac catheterization procedures were added for the CY 2019 final rule.

Musculoskeletal services did not feature a large debate in the 2019 proposal. Last summer featured a debate over adding THA/TKA to ASCs for the 2018 Medicare payment proposal, and CMS eventually backed away from adding them to ASCs. However, CMS is likely to take a look at THA, TKA, shoulders, and some other services for ASCs in future proposals.

Several other musculoskeletal-related issues were confirmed in the CY 2019 final rule, including a lower device intensive procedure threshold and payment for non-opioid pain management therapy (Exparel).

Upcoming ASC vs. HOPD Price Comparison Website

CMS also used this rule as an opportunity to remind stakeholders that the 21st Century Cures Act, which was signed into law by then-President Obama in early 2017, directed HHS to create a website that allows patients to analyze the costs associated with ASCs and HOPDs:

For example, to provide for easier comparisons between hospital outpatient departments and ASCs, as previously discussed in the CY 2018 OPPS/ASC final rule with comment period (82 FR 59389), we stated in the CY 2019 OPPS/ASC proposed rule that we also will make available a website that provides comparison information between the OPPS and ASC payment and copayment rates, as required under section 4011 of the 21st Century Cures Act (Pub. L. 114-255). Making this information available can help beneficiaries and their physicians determine the cost and appropriateness of receiving care at different sites-of-service. Although resources such as this website will help beneficiaries and physicians select a site-of-service, we do not believe this information alone is enough to control unnecessary volume increases.

New Site Neutral Payments for Checks ups (Clinic Visits)

TOA has been talking about the concept of site neutral payments in its newsletters since 2012, so our hope is that every reader understands the concept, which has been embraced by both Democrats and Republicans in Congress and CMS. To summarize, if a service can be paid in two different types of settings, and one setting is being paid at a higher rate, then Medicare will pay for that service at the same rate in any type of facility.

CMS pointed out several stakeholder comments in the final rule’s commentary:

For certain cardiology, orthopedic, and gastroenterology services, employed physicians were seven times more likely to perform services in a HOPD setting than independent physicians, resulting in additional costs of $2.7 billion to Medicare and $411 million in patient copayments over a 3-year period. (Avalere, PAI: Physician Practice Acquisition Study: National and Regional Employment Changes, October 2016.)

This other comment by CMS will help you to understand CMS’s interest in the site neutral payment concept:

In the CY 2015 OPPS/ASC proposed rule (79 FR 41013), we stated that we continued to seek a better understanding of how the growing trend toward hospital acquisition of physicians’ offices and subsequent treatment of those locations as off-campus provider-based departments (PBDs) of hospitals affects payments under the PFS and the OPPS, as well as beneficiary cost-sharing obligations. We noted that MedPAC continued to question the appropriateness of increased Medicare payment and beneficiary cost-sharing when physicians’ offices become hospital outpatient departments and that MedPAC recommended that Medicare pay selected hospital outpatient at PFS rates (MedPAC March 2012 and June 2015 Reports to Congress).

CMS finalized its proposal to extend site neutral payments to clinic visits that are part of hospital outpatient departments for “check ups,” and these represent the most common service billed under the outpatient prospective payment system (OPPS). Per CMS:

Method to Control for Unnecessary Increases in Utilization of Outpatient Services
CMS is exercising its authority to utilize a method to control unnecessary increases in the volume of covered hospital outpatient department services by applying a Physician Fee Schedule (PFS)-equivalent payment rate for the clinic visit service when provided at an off-campus provider-based department (PBD) that is paid under the OPPS. The clinic visit is the most common service billed under the OPPS. Currently, Medicare and beneficiaries often pay more for the same type of clinic visit in the hospital outpatient setting than in the physician office setting.

This policy would result in lower copayments for beneficiaries and savings for the Medicare program in an estimated amount of $380 million for 2019, the first year of a two year phase-in we are utilizing to implement this policy. For an individual Medicare beneficiary, current Medicare payment for the clinic visit furnished in an excepted off-campus PBD is approximately $116 with $23 being the average beneficiary copayment. The policy to adjust this payment to the PFS equivalent rate would reduce the OPPS payment rate for the clinic visit to $81 with a beneficiary copayment of $16 (based on a two year phase-in), thus saving beneficiaries an average of $7 each time they visit an off-campus department in CY 2019.

No Action on New Clinical Families of Services for Site Neutral – Page 658

Congress passed a budget bill that was signed into law on November 2, 2015 that created a site neutral payment policy for certain services at off-campus, hospital-based provider-based department (PBD). Any PBD acquired after the effective date would no longer be paid the higher OPPS fee for certain services.

However, Congress did not make it clear whether a grandfathered PBD could begin offering a new service after November 2, 2015 and be paid the higher OPPS rate for that new service. CMS has indicated its belief that it has the statutory authority to limit new service additions at higher rates if they were not provided in a grandfathered PBD prior to November 2, 2015. However, CMS has received considerable pushback from hospital stakeholders and has declined to move forward at this time: “In response to public comments, we did not finalize our proposal to limit the expansion of excepted services at excepted off-campus PBDs.” (Page 661.)

CMS made the following comment in this rule:

However, while we continue to believe that section 1833(t)(21)(B)(ii) of the Act excepted off-campus PBDs as they existed at the time that Pub. L. 114-74 was enacted, and provides the authority to define excepted off-campus PBDs, including those items and services furnished and billed by such a PBD that may be paid under the OPPS, we are concerned that the implementation of this payment policy may pose operational challenges and administrative burden for both CMS and hospitals. After consideration of the public comments we received, we are not finalizing this policy as detailed below.

CMS commented in the rule:

In the CY 2015 OPPS/ASC proposed rule (79 FR 41013), we stated that we continued to seek a better understanding of how the growing trend toward hospital acquisition of physicians’ offices and subsequent treatment of those locations as off-campus provider-based departments (PBDs) of hospitals affects payments under the PFS and the OPPS, as well as beneficiary cost-sharing obligations. We noted that MedPAC continued to question the appropriateness of increased Medicare payment and beneficiary cost-sharing when physicians’ offices become hospital outpatient departments and that MedPAC recommended that Medicare pay selected hospital outpatient

CMS has CMS proposed to add additional clinical families of services to the excepted (grandfathered) HOPDs that were in place before November 2, 2015 and continue to get paid at the higher OPPS rate for certain services. However, CMS ultimately chose to not do so in this final rule:

In response to public comments, we did not finalize our proposal to limit the expansion of excepted services at excepted off-campus PBDs. (Page 661.)

Further Background on the HOPD/ASC Rule for CY 2019.

Stay tuned for AAOS’s upcoming summary. In addition, TOA’s coding course on Friday, February 1, 2019 in Houston will cover many of the changes – click here for details.

Medicare Extends Site Neutral Policy in 2019 HOPD/ASC Payment Proposal; ASC Victories

A discussion related to approving hip and knee replacement surgeries for Medicare payment in ASCs dominated last year’s hospital outpatient department (HOPD) and ambulatory surgery center (ASC) payment proposal for Medicare. (Ultimately, CMS simply removed TKA from the inpatient only list.) The 2019 proposal, which was released on July 25, 2018, only addressed the anesthesia portion of TKA.

A new site neutral payment proposal that focuses on standard office visits (HCPCS code G0463) and potential new victories for ambulatory surgery centers (ASCs) have made the biggest headlines in the 2019 proposal. Under the 2019 proposal, the Ambulatory Surgery Center Association (ASCA) achieved most of its advocacy goals.

TOA members have been provided a lengthy proposal of the summary, which includes:

  • New site neutral payment provisions for clinic visits.
  • Removal of three pain communication questions, which will help with the opioid crisis.
  • A separate payment for Exparel in the ASC setting to address non-opioid pain management drugs.
  • The removal of the anesthesia-related code for TKA from the IPO list.
  • A lower device intensive procedure threshold proposal.
  • Progress on ASC payments and the market basket update.
Medicare’s 2019 Physician Fee Schedule and Quality Payment Program Proposal Released

The Centers for Medicare and Medicaid Services (CMS) released the calendar year 2019 payment rule for the Medicare Physician Fee Schedule (PFS) and Quality Payment Program for MACRA on July 13, 2018. Comments are due on September 10, 2018.

TOA’s members are invited to review TOA’s analysis of the proposal, which can be found in the e-mail newsletter or by visiting the website.

The following proposals relate to orthopaedics in the proposal:

  • Patient-reported outcomes for MIPS.
  • Checking the state’s prescription monitoring drug program (PDMP) database for MIPS.
  • Adding physical therapy to MIPS.
  • CMS believes that it will save the average physician 51 hours a year due to the new E/M proposal.
  • A small payment for “virtual visits” prior to an office visit.
  • Global data collection and its future. Hint: 90-day payments are big in orthopaedics.
  • Physician employment: Hospitals remain unhappy.