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.
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.

TOA Urges Lawmakers to Contact Congress on BPCI Advanced/CJR Conflict

BPCI Advanced – Medicare’s new physician-led bundled payment program that was announced in January 2018 – will not allow orthopaedic surgeons located in Texas’ five Comprehensive Center for Joint Replacement (CJR) to lead their own bundles for lower extremity joint replacements in the new BPCI Advanced program.

Due to the upcoming March 12, 2018 application deadline, TOA is encouraging TOA members in these CJR markets to contact their Members of Congress to contact the Centers for Medicare and Medicaid Services to allow orthopaedic surgeons to lead their own BPCI Advanced bundles in CJR markets.

The physician groups that have been participating in the existing BPCI Model 2 have demonstrated significant savings for Medicare. A study conducted by the largest BPCI physician group practice (PGP) convener of 15 private practice orthopaedic groups across the nation found that they saved Medicare $3,214 (15 percent) per LEJR episode in 2015 (compared to the 2009-2012 historic baseline data).

TOA has told Congress that patients and orthopaedic surgeons practicing in the CJR markets should not be penalized based on their geographic location.

Click here to view the sample letter.

Click here to view the CJR hospitals around the country.


IPAB and Physical Therapy Included in Congress’ Medicare Extender Package

The U.S. House and U.S. Senate approved a funding resolution on February 9 that includes several Medicare provisions that affect musculoskeletal care:

Physician-owned Hospitals:  No Relief. An effort by Texas lawmakers to allow physician-owned hospitals located in areas affected by the recent hurricane to expand by 50 percent was not included in the bill. However, Congressman Brian Babin of Texas is circulating a request for CMS to provide relief.

IPAB Elimination.  The Independent Payment Advisory Board (IPAB), which was created by the Affordable Care Act to address rising Medicare costs, was eliminated.

Physical Therapy’s Cap. Medicare’s existing “hard” physical therapy cap has been repealed (effective December 31, 2017).  However, it comes at a cost, and Congress relied on several offsets to help pay for it:

Explanation of the “New Cap” for Outpatient Medicare Part B

The threshold for targeted medical review will be lowered from $3,700 to $3,000 through 2027. However, not all claims that go over $3,000 will be subject to medical review. Instead, only a sample of the claims that meet certain criteria, such as high claims denial percentage or certain billing patterns, will be subject to the review.

The $3,000 per beneficiary applies to combined physical therapy and speech language pathology services – or $3,000 in occupational therapy claims alone.

Therapy claims for outpatient Medicare Part B that go over $2,010 (adjusted annually) will require the KX modifier for medical necessity.

Congress gave HHS the regulatory authority to address the manual medical review.

Physical Therapy Assistants Payment Reductions

The legislation will reduce payments to physical and occupational therapy services provided by a therapy assistant to 85 percent.  The payment reduction is scheduled to begin in January 2022 for outpatient therapy services.

The text of the therapy cap provision can be found on page 19. (Click here to view the bill’s language.)

Orthotist and Prosthetist Notes. Orthotist and prosthetist notes are now part of the medical record for purposes of Medicare medical necessity and claims audits.

Per the legislation:

13 Section 1834(h) of the Social Security Act (42 U.S.C. 1395m(h)) is amended by adding at the end the following new paragraph:”
(5) DOCUMENTATION CREATED BY ORTHOTISTS AND PROSTHETISTS. – For purposes of determining the reasonableness and medical necessity of orthotics and prosthetics, documentation created by an orthotist or prosthetist shall be considered part of the individual’s medical record to support documentation created by eligible professionals described in section 1848(k)(3)(B).”.

Stark Modernization. Commentary on the Stark laws begins on page 136 (click here). It exempts holdover lease arrangements and personal service arrangements from the definition of a prohibited compensation arrangement.

Meaningful Use. The bill contains parts of the Health Information Technology for Economic and Clinical Health Act by removing a mandate that meaningful use standards must evolve to be more stringent over time.

MIPS. The bill prohibits CMS from scoring an eligible clinician on improvement in the second, third, fourth, and fifth years (for which MIPS applies to payments).

Both the House and Senate bills block CMS from ever raising cost cutting to more than 30 percent of a physician’s scores.

Physician Fee Schedule. The updated will be reduced from 0.5 percent to 0.25 percent in 2019.

Medicare Announces New Bundled Payments

The Centers for Medicare and Medicaid Services (CMS) announced on January 9, 2018 that it is creating the voluntary Bundled Payments for Care Improvement Advanced (BPCI Advanced) demonstration that requires participants to take on financial risk. In addition, the program, which includes outpatient and inpatient episodes of care, would count as an Advanced APM for MACRA (Medicare’s physician payment program) for a 5 percent provider bonus.

Unfortunately, the proposal could have a harmful effect on markets that are affected by the Comprehensive Center for Joint Replacement (CJR) mandate. Those markets may not be able to participate in BPCI Advanced. Click here for full information.

TOA’s April 13-14, 2018 Annual Conference in Fort Worth will include a panel discussion on Medicare’s new bundled payment program.

Medicare-certified acute care hospitals and physician group practices (PGPs) may participate as either Convener Participants or Non-Convener Participants. The application ends on March 12, 2018. The next application period will not occur until January 1, 2020.

Some of the new program’s highlights include:

  • It will include a single payment and risk track. The original BPCI included four models.
  • The program begins on October 1, 2018 and runs through 2023, and it will include all participants to take on downside financial risk. Applications must be submitted by March 12, 2018.
  • For those who miss the initial application, a second application opportunity will open in 2020.
  • BPCI Advanced relies on a retrospective approach. CMS will provide a preliminary target price in advance of the first performance period of each model year prior to calculating a final target price retrospectively based on patient case-mix. The “CMS Discount” will subtract 3 percent from the benchmark that is based on historical fee-for-service spending.
  • As a result of BPCI Advanced not being a shared-savings initiative, participants can participate in this model and accountable care organizations (ACOs).
  • The episodes will last 90 days.
  • BPCI Advanced will qualify as an Advanced APM under MACRA beginning on October 1, 2018, which is the performance period’s effective date. On January 1, 2019, BPCI Advanced participation will result in a 5 percent APM incentive payment and the Qualifying APM Participant (QP) determination.

The CMS Innovation Center will hold a Q&A Open Forum on Tuesday, January 30, 2018 from 11 a.m. – 12 p.m. CST. This event is open to those who are interested in learning more about the model and how to apply. Please register in advance here.

Click here to learn more about the model.

Thirty-two types of clinical episodes will be included. Three outpatient episodes have been added to the inpatient episodes in the earlier BPCI model. Most of the episodes are found in the original BPCI model. However, an episode related to liver disorders is new.

For a list of the 29 Inpatient Clinical Episodes, please see below:

  • Disorders of the liver excluding malignancy, cirrhosis, alcoholic hepatitis *
    *(New episode added to BPCI Advanced)
  • Acute myocardial infarction
  • Back & neck except spinal fusion
  • Cardiac arrhythmia
  • Cardiac defibrillator
  • Cardiac valve
  • Cellulitis
  • Cervical spinal fusion
  • COPD, bronchitis, asthma
  • Combined anterior posterior spinal fusion
  • Congestive heart failure
  • Coronary artery bypass graft
  • Double joint replacement of the lower extremity
  • Fractures of the femur and hip or pelvis
  • Gastrointestinal hemorrhage
  • Gastrointestinal obstruction
  • Hip & femur procedures except major joint
  • Lower extremity/humerus procedure except hip, foot, femur
  • Major bowel procedure
  • Major joint replacement of the lower extremity
  • Major joint replacement of the upper extremity
  • Pacemaker
  • Percutaneous coronary intervention
  • Renal failure
  • Sepsis
  • Simple pneumonia and respiratory infections
  • Spinal fusion (non-cervical)
  • Stroke
  • Urinary tract infection

For a list of the 3 Outpatient Clinical Episodes, please see below:

  • Percutaneous Coronary Intervention (PCI)
  • Cardiac Defibrillator
  • Back & Neck except Spinal Fusion

Key Dates
March 12, 2018 – Application portal closes.

May 2018 – CMS distributes target prices.

June 2018 – CMS offers participant agreements.

August 2018 – Signed participant agreements are due.

October 1, 2018 – Model goes live.

March 31, 2019 – First date for Advanced Alternative Payment Model (APM) qualified participant determination.

January 1, 2020 – Next application period.

December 31, 2023 – End of the first cycle.