Cardiovascular Rounds

3 ways CV outpatient payments could change in 2019

by Megan Tooley and Emily Snow

As usual, this summer brought new CMS proposals for outpatient and physician payments, which if finalized would go into effect for the 2019 calendar year. While this year's proposed updates were not as monumental as some in recent years, there are still some significant changes that will impact cardiovascular service lines.

Here are our three major takeaways from this year's proposals—and how CV leaders should prepare.

1. Even more CV services may be impacted by site-neutral payments

Until 2017, hospital outpatient departments (HOPD) received higher Medicare reimbursement for the same services provided at off-campus facilities paid under the physician fee schedule. This incentivized many hospitals to acquire independent sites to capture higher payments rates. In 2017, CMS implemented a site-neutral payment provision to reduce the payment discrepancies between services performed at HOPDs and provider-based sites (e.g., physician offices and freestanding clinics). The policy mandates that new off-campus HOPDs receive reimbursement at a site-specific Medicare Physician Fee Schedule (MPFS)—currently 40% of the hospital rate.

CMS updated this rule in the 2019 Medicare Physician Fee Schedule (MPFS) and Quality Payment Program (QPP) proposals. First and foremost, the proposal upheld the adjusted 40% rate for impacted services and sites. More notably, the proposed rule contains two polices that could significantly expand services paid at the site-neutral rate.

  1. CMS proposed to pay the site-neutral rate for any new groups of services not offered at a site between November 1, 2014, and November 1, 2015. This means that a site that did not previously fit the three criteria for the site-neutral rate may be subject to the 40% site-specific MPFS payment for all services that fall into the new clinical family. Specifically relevant to CV services, there is a single vascular, endovascular and cardiovascular clinical family, including services like transcatheter biopsies, and a minor imaging clinical family, including services like echocardiograms.

  2. Last year, CMS found that one code accounted for more than 50% of all codes billed at off-campus HOPDs. The code, G0463 (hospital outpatient clinic visit for assessment and management of a patient), is currently reimbursed at $116 under the Hospital Outpatient Prospective Payment System (HOPPS). To further equalize payments, CMS proposed to make this service non-exempt from site-neutral payments at all sites. In other words, previously exempted HOPDs will receive 40% of the HOPPS rate ($46) for clinic visits. Based on Advisory Board analysis, a significant percentage of cardiovascular claims for this code are provided at exempt off-campus sites. This means, if finalized, cardiovascular programs will see significant payment reduction for these clinic visits.

2. CMS considers expanding CV services eligible for reimbursement in ambulatory surgery centers (ASCs)

Historically, CMS has not reimbursed for catheterization services performed in ASCs or freestanding facilities. However, in the 2019 Hospital Outpatient Prospective Payment and Ambulatory Surgical Center Payment Systems proposed rule, CMS has proposed to add 12 diagnostic cardiac catheterization procedures (CPT codes 93451-93462) to the ASC covered surgical procedures list for the first time on the grounds that they require short recovery time.

If finalized, this would expand provider opportunities to perform diagnostic cath services for Medicare patients in ASCs instead of limiting coverage to patients with commercial insurance. It is important to note that state and certificate of need (CON) laws will continue to present additional barriers for performing diagnostic catheterization in ASCs in select states. The 2019 proposed ASC payment rate for all 12 diagnostic cath codes is $1,381.45, which is almost a 50% reduction compared to the 2019 proposed hospital outpatient reimbursement rate of $2,829.89 for the same codes.

3. Cardiovascular physicians could be held accountable for clinical decision support (CDS) adherence

In the Protecting Access to Medicare Act (PAMA) of 2014, Congress included a mandate for ordering providers to consult Medicare Appropriate Use Criteria (AUC) via electronic imaging clinical decision support (CDS) when ordering outpatient advanced imaging exams for Medicare patients. Beginning January 1, 2020, cardiovascular providers ordering advanced imaging must consult AUC, and furnishing providers—most commonly radiologists and imaging programs—must document this consultation on professional and technical claims submitted to Medicare. The first year is deemed an "education and testing" period, meaning claims will be paid regardless of documentation, but beginning January 1, 2021, Medicare will deny claims that do not include necessary information.

In July, CMS released updates to the CDS mandate in the Medicare Physician Fee Schedule (MPFS) and Quality Payment Program (QPP) proposals for calendar year 2019, one of which is notable for cardiovascular leaders. The proposed rule gave clinical staff "working under the direction of the ordering professional" the ability to consult CDS. If finalized, cardiovascular physicians may have their non-physician staff consult CDS on their behalf. However, their NPI number will still be recorded on the imaging claim and providers will be held accountable for incorrect consultation.

A very important note for CV ordering providers is that CMS plans to identify up to 5% of ordering providers in eight clinical priority areas, of which coronary artery disease is one, as outliers and will require them to obtain preauthorization when ordering advanced imaging.

There are two ways CV leaders can prepare for this rule. First, begin working with health system leaders and imaging directors to understand how your organization is preparing for the 2020 start date. CV programs may need to integrate CDS consultation into existing workflow or electronic medical records. Second, start educating ordering physicians about the ways CDS can improve clinical quality to ensure proper adoption upon roll out. We recommend highlighting the ways CDS helps providers stay updated on changing guidelines, decreases inappropriate exams and reducing unnecessary variation.

Click here for a detailed update on the CDS mandate

Learn more about outpatient payment changes and ambulatory strategy at the 2018-19 Cardiovascular Roundtable National Meeting

The Cardiovascular Roundtable is actively researching these proposed changes, their impact on cardiovascular programs and how CV leaders are responding. Register for our National Meeting to receive this information first hand.

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