This review of the CMS Final Rule will provide the various sections that were listed in the ruling that may affect or be of interest to the specialty of Radiology. It will not include a comprehensive review of all components of the proposed rule. This document is for “informational use only” and it is not intended to provide legal advice or counseling on the various rulings from CMS. If the reader has concerns or questions they should consult with their compliance and/or legal counsel for advice.

The Centers for Medicare & Medicaid Services (CMS) published in the Federal Register their annual Physician Fee Schedule, Medicare Program; Revisions to Payment Policies under the Physician Fee Schedule and Other Revisions to Part B for CY 2016. Known as the Physician Fee Schedule (PFS) Final Rule it proposes updates to payment policies and payment rates on or after Jan. 1, 2016 (CY 2016). The Final Rule finalizes many of the changes in medical practice and relative value units proposed in the CY 2016 Proposed Rule. CMS accepted comments on the Final Rule until 5:00 p.m. Dec. 29, 2015. Additionally, CMS has posted a Fact Sheet related to policy and payment changes and quality reporting programs.

(PDF, 18 MB).


CY 2016 Physician Fee Schedule (PFS) Final Rule - Payment Rates

Congressional Action
Recently, Congress passed and the President signed into law significant changes to the Social Security Act. Among the changes were the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), changes to the Protecting Access to Medicare Act of 2014 (PAMA) and Achieving a Better Life Experience Act of 2014 (ABLE).

provided the much anticipated repeal of the Sustainable Growth Rate (SGR) formula. Replacing the SGR under MACRA will be an annual update of 0.5% through 2019.1 For years 2020 through 2025, no update will be applied and physicians will have the ability to add to their revenue through the Merit-based Incentive Payment System (MIPS).2 Under MIPS, physicians and non-physician practitioners (NPPs) will receive annual incentive based payment increases or decreases based on their performance in a prior period. MIPS will attempt to bring together three incentive programs that are already in existence, the Physician Quality Reporting System (PQRS), the Value-Based Modifier (VBM), and Meaningful Use. After 2018, PQRS will be phased out and replaced by MIPS. A physician’s composite score will come from four categories: quality, resource use, meaningful use, and clinical practice improvement activities. The CY2015 Final Rule had called for the transitioning of 10 and 90-day global periods to 0 days. MACRA prohibits that transition and instructs the Secretary to gather information using the rule making process and requesting input from physicians.

PAMA established targeted reductions in the Physician Feed Schedule (PFS) resulting from adjustments of misvalued codes. The target was originally set at 0.5% per year of estimated expenditures for CY 2017 through 2020.3 A provision of ABLE accelerated the application of the target to CYs 2016 -2018 with a 1.0% target for 2016 and 0.5% each for CYs 2017 and 2018.4

 (PDF, 209 KB).

1 42 US Code. § 1395w-4(d)(18).
2 Revisions to Payment Policies under the Physician Fees Schedule and other Revisions to Part B Final Rule for CY Fed. Reg. 220, (November 16, 2015) (to be codified at 42 CFR Parts 405, 410, 411, 414, 425, 495 et al.). 2016, 80. Page 70891.
3 Ibid.
4 Ibid.

Merit-based Incentive Payment System (MIPS) Final Rule
Author - Male

About the author

Nicholas Parish of Compliance – Radiology, web2pro Business Performance Services.