Summary Medicare Physician Fee Schedule Payments

On Oct. 30, 2015, the Centers for Medicare & Medicaid Services (CMS) issued a that updates payment policies, payment rates, and quality provisions for services furnished under the Medicare Physician Fee Schedule (PFS) on or after Jan. 1, 2016. This year, CMS finalized a number of new policies, including several that are a result of recently enacted legislation. In addition, the rule includes discussions regarding:

  • “Potentially Misvalued PFS Codes
  • Telehealth Services
  • Advance Care Planning Services
  • Establishing Values for New, Revised, and Misvalued Codes
  • Target for Relative Value Adjustments for Misvalued Services
  • Phase-in of Significant RVU Reductions
  • ‘Incident to’ policy
  • Portable X-ray Transportation Fee
  • Updating the Ambulance Fee Schedule regulations
  • Changes in Geographic Area Delineations for Ambulance Payment
  • Chronic Care Management Services for RHCs and FQHCs
  • HCPCS Coding for RHCs
  • Payment to Grandfathered Tribal FQHCs that were Provider-Based Clinics on or before April 7, 2000
  • Payment for Biosimilars under Medicare Part B
  • Physician Compare Website
  • Physician Quality Reporting System
  • Medicare Shared Savings Program
  • Electronic Health Record (EHR) Incentive Program
  • Value-Based Payment Modifier and the Physician Feedback Program”1

“This is the first PFS final rule since the repeal of the Sustainable Growth Rate (SGR) formula by the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA).”2 The calendar year 2016 PFS final rule is one of several final rules reflecting a broader Administration-wide strategy to create a healthcare system that results in better care, smarter spending, and healthier people.

A provided by CMS, discusses the changes to payment policies and payment rates for services furnished under the PFS and other programs.

Summary CMS Outpatient Prospective Payment System and Ambulatory Surgery Center Payments

On Oct. 30, 2015, CMS released the Calendar Year (CY) 2016 Hospital Outpatient Prospective Payment System (OPPS) and Ambulatory Surgical Center (ASC) Payment System policy changes, quality provisions, and payment rates final rule with comment period (OPPS/ASC final rule) [CMS-1633-FC]. The updates Medicare payment policies and rates for hospital outpatient departments (HOPDs), ASCs, and partial hospitalization services provided by community mental health centers (CMHCs), and refinements to programs that encourage high-quality care in these outpatient settings. OPPS payment amounts vary according to the Ambulatory Payment Classification (APC) group to which a service or procedure is assigned. The final rule also includes important changes to the Two Midnight Rule effective beginning in CY 2016. See the related for detailed information.

CMS continues to look for ways to improve their methodologies for estimating the costs associated with providing services, including the methodology for packaging services. This will continue in future years. They have finalized the proposed rule without making changes to the packaged revenue codes relating to anesthesia which include Anesthesia General Classification, Incident to Radiology, Incident to other DX Services, or Other Anesthesia.3 Anesthesia providers billing separately for their services would not be impacted.

View complete web2pro Summary of the (PDF, 271 KB)

1 Medicare Program; (PDF, 17 MB); Final Rule. Nov. 16, 2015. 42 CFR Part 405, 410, 411, et al. Pages 70888–70889 
2 CMS. . Oct. 30, 2015. 
3  (PDF, 2 MB) pages 70318–70321

Author - Female

About the author

Lynn Cook is Compliance Program Director with Anesthesia and Pain Management of web2pro Business Performance Services.