CMS Releases CY 2015 MPFS Proposed Rule

by King & Spalding

On July 3, 2014, CMS released a Proposed Rule regarding payment policies under the Medicare Physician Fee Schedule (MPFS) for services furnished on or after January 1, 2015. Unless Congress intervenes, CMS estimates that the sustainable growth rate (SGR) formula will result in a 20.9 percent reduction in MPFS payment rates for CY 2015. Among other notable changes, CMS proposes a new process for establishing MPFS rates that will require that future changes go through notice and comment rulemaking process. The proposed process would require that changes to MPFS rates—except for new services never before valued under the MPFS—are only effective after CMS has responded to public comment. Comments on the Proposed Rule must be received no later than 5:00 p.m. on Tuesday, September 2, 2014.

Last year, CMS finalized a separate payment to begin in 2015 for managing, outside of a face-to-face visit, the healthcare of Medicare beneficiaries with two or more chronic conditions. The Proposed Rule offers details regarding implementation of the new chronic care management (CCM) policy, including proposed payment rates. Among other things, CMS is proposing a payment rate of $41.92 for the CCM code, which can be billed no more than once per month per qualified patient. CMS also seeks to provide greater flexibility in the supervision of clinical staff who provide CCM care. In this regard, CMS proposes to remove restrictions that services provided by clinical staff under general (rather than direct) supervision may be counted only if they are provided outside the practice's normal business hours. Thus, under the Proposed Rule, time spent by clinical staff providing aspects of CCM services could be counted toward the CCM time requirement irrespective of the time at which the services were performed, provided that the staff are under the general supervision of the practitioner and all "incident to" requirements set forth at 42 C.F.R. § 410.26 are met. CMS also proposes removing the requirement that clinical staff be directly employed by the practitioner or practitioner's practice in order for the time they spend in furnishing care to count toward the CCM time requirement.

In addition, the Proposed Rule seeks to change some of the quality reporting initiatives related to MPFS payments including the Physician Quality Reporting System, Medicare Shared Savings Program, and Medicare Electronic Health Record Incentive Program, as well as changes to the Physician Compare tool.

The Proposed Rule continues the implementation of the physician value-based payment modifier, established by the Affordable Care Act, that impacts payments to physicians and other eligible professionals, based on the cost and quality of care they provide to beneficiaries enrolled in the Medicare fee-for-service program.

As under the CY 2015 OPPS/ASC Proposed Rule, CMS also proposes in this CY 2015 MPFS Proposed Rule to begin collecting data on services furnished in off-campus provider-based departments beginning in 2015.

CMS is also proposing changes to reporting requirements under the "Open Payments (Sunshine Act)" program. CMS is proposing four changes:

  • Deleting the definition of "covered device";
  • Deleting the Continuing Education Exclusion;
  • Requiring the reporting of the marketed name of the related covered and non-covered drugs, devices, biologicals, or medical supplies when the payment or other transfer of value is related to a particular covered item; and
  • Requiring applicable manufacturers to report stocks, stock options or any other ownership interest as distinct categories.

Finally, among other things, the Proposed Rule seeks to update global surgery codes, add approximately 80 codes to CMS's list of potentially misvalued codes including codes that account for a high level of Medicare expenditures, propose new malpractice relative value units (RVUs), expand telehealth benefits to include annual wellness visits, psychoanalysis, psychotherapy, and prolonged evaluation and management services, and define screening colonoscopy to include anesthesia.

The Proposed Rule is scheduled to be published in the Federal Register on July 11, 2014. To view the Proposed Rule, click here. The CMS Fact Sheet on the CY 2015 MPFS Proposed Rule is available here.

Reporters, Katy G. Lucas, Atlanta, + 1 404 572 2822, and Lauren S. Gennett, Atlanta, + 1 404 572 3592,


DISCLAIMER: Because of the generality of this update, the information provided herein may not be applicable in all situations and should not be acted upon without specific legal advice based on particular situations.

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