News & Insights

Medicare Fee Schedule Changes

February 07, 2017

By Natalie Cohen, MBA, MHA, LAMMICO Practice Management Specialist


Medicare Fee Schedule Changes

The new CMS fee schedule was finalized and released on Tuesday, November 15, 2016. In addition to the adjustment to the conversion factor and publication of allowable amounts, CMS included some significant additions and changes to the Part B program.  Below is a summary of some of those changes.

  • Providers who are continuing to use film instead of digital imaging will see a 20% decrease in their reimbursement (on the technical component) for all imaging services using film. Providers will be asked to self-report those services by affixing an “–XX” modifier onto the CPT code.
  • Services performed during a global period will be studied by CMS. Practices with over 10 providers will have to report on global period services for 275 high frequency CPT codes beginning in June 2017. They will report these services using CPT code 99024.
  • Medicare Diabetes Prevention Program (MDPP) will be expanded and its reimbursement modified, however, the new program will not go into effect until 2018.  
  • One of the biggest changes to the fee schedule is the changes involving Chronic Care Management (CCM). CCM (CPT 99490) has been part of the fee schedule for years but has not been frequently used. It is a service that can be billed monthly for patients with 2 or more chronic conditions expected to last at least 12 months or if the conditions put the patient at significant risk of death, functional decline or acute exacerbation. CMS has reduced the requirements for CCM services, as well as increased reimbursement. To access the CCM section of the 2017 fee schedule changes, please click here.
  • CMS has revised the rules to allow auxiliary clinical staff to furnish these CCM and Transitional Care Management Services (TCM) under general rather than direct supervision in Rural Health clinics and Federally Qualified Health Centers.
  • CMS created a code for separate payment for assessing and creating a Behavioral Health care plan for beneficiaries with a cognitive impairment (e.g., dementia).
  • Moderate sedation has been unbundled from select services.
  • Prolonged Services have historically been paid only when direct face-to-face contact has occurred. Non face-to-face prolonged services were reportable but not reimbursed. Beginning in 2017, providers can be reimbursed for the additional time they spend rendering services for the patient even if they are not in direct face-to-face contact. These services must be billed with an E & M code.
  • CMS has added some additional services that can be reimbursed when performed via Telehealth. They are listed below. In addition, CMS has created a new place of service code to further identify telehealth services. The new place of service code is 19.
    • ESRD (End Stage Renal Disease)
    • ACP (Advanced Care Planning)
    • Consult for Critical Care
  • Effective November 15, 2018, Medicare Advantage plans will require physicians to be enrolled in Medicare in order to provide services and contract with Medicare Advantage plans.  CMS is also prohibiting Medicare Advantage organizations from paying providers that are excluded by the Department of Health and Human Services Office of Inspector General or revoked from the Medicare program.

Sources:

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