Reimbursement

2017 Medicare Payment for Physicians

July 11, 2016

 

The Centers for Medicare & Medicaid Services is proposing new payment rates and policies for the physician fee schedule that would encourage care coordination, prevention, and greater use of telehealth services. The proposal would apply to reimbursement for physicians treating Medicare patients during calendar year 2017:

 

  • Care Coordination: CMS proposed changes in payment and coding to reward primary care services, care coordination, chronic care management, and the time physicians spend with their patients listening and advising about their care, including patients with multiple chronic conditions. In mental and behavioral health, CMS proposed payment for specific services furnished via a collaborative team approach.

 

  • Telehealth: Several services would be added to the list of those eligible to be furnished via telehealth, including:
    • End-stage renal disease related services for dialysis;
    • Advance care planning services;
    • Critical care consultations furnished via telehealth using new Medicare G codes.

 

  • Mammography: CMS proposed to implement new coding for mammography services to reflect use of current technology, including a transition from film to digital imaging. The proposal also would eliminate separate coding for computer aided detection services. The technical component for mammography services would not be changed.

 

  • Prevention: CMS proposed expanding the Diabetes Prevention Program in Medicare starting in January, 2018. The program, which has previously been tested by CMS, is a structured lifestyle intervention of dietary coaching and physical activity intended to prevent the onset of diabetes in those who are pre-diabetic.

 

  • Appropriate Use: The proposal further implements a 2014 law requiring physicians to consult appropriate use criteria when ordering advanced diagnostic imaging services. It includes a proposed list of priority clinical areas for use of such criteria: chest pain, abdominal pain, headache, low back pain, suspected stroke, altered mental status, lung cancer, cervical or neck pain. 
    • CMS said that it would not require clinicians to begin consulting appropriate use criteria and appending this information to Medicare claims forms before January 1, 2018.
    • CMS also proposed requirements for clinical decision support mechanisms—the electronic tools through which clinicians consult appropriate use criteria.

 

  • Payment Rate: The proposal includes an update of 0.5% as required by the Medicare Access and CHIP Reauthorization Act (MACRA) which last year eliminated the long-time Sustainable Growth Rate (SGR) formula.

 

  • Additional Changes: Other changes proposed by CMS include updating the quality measures set used by accountable care organizations and requiring providers who contract with Medicare Advantage plans to be screened and enrolled in Medicare.

 

Comments on the proposal are due September 6, 2016

 

View CMS fact sheet.