CY 2016 Revisions to Payment Policies under the Physician Fee Schedule and
Other Revisions to Medicare Part B (CMS-1631-P)
Summary of Identified Key Provisions in the Proposed Rule
Deadline for Comment Submission: September 8, 2015 at 5pm
(Section references refer to the preamble of the proposed rule.)
Section II. Provisions of the Proposed Rule for PFS
SUBSECTION E. IMPROVING PAYMENT ACCURACY FOR PRIMARY CARE AND CARE MANAGEMENT
SERVICES

Seeking comments on ways to recognize the different resources involved in
delivering broad-based ongoing treatment, beyond evaluation and management
services

Seeking comments on establishing a separate payment for collaborative care,
specifically on the parameters and resources involved in collaboration between
specialist and primary care practitioner
o
Includes looking at technology supports for collaborative care
o
Includes consideration of a potential CMMI model with a waiver of beneficiary
financial liability for interprofessional consultation as part of collaborative care
SUBSECTION I. VALUATION OF SPECIFIC CODES
6. C. Advance Care Planning

Proposing to assign the status of “A” (Active code), to two advance planning codes.
(“A” (active code) means these codes are separately payable under the PFS. There
will be RVUs for codes with this status.” The presence of an “A” indicator does not
mean that Medicare has made a national coverage determination regarding the
service. Contractors remain responsible for local coverage decisions in the absence of
a national Medicare policy.):
o
CPT code 99497: Advance care planning including the explanation and
discussion of advance directives such as standard forms (with completion of such
forms, when performed), by the physician or other qualified health professional;
first 30 minutes, face-to-face with the patient, family member(s) and/or
surrogate;
o
CPT code 99498 (add-on code): Advance care planning including the explanation
and discussion of advance directives such as standard forms (with completion of
such forms, when performed), by the physician or other qualified health
professional; each additional 30 minutes (List separately in addition to code for
primary procedure).
o
Seeking comment on the proposal, including whether payment is needed and
what type of incentives this proposal creates. And, whether payment for advance
care planning is appropriate in other circumstances such as an optional element,
at the beneficiary's discretion, of the annual wellness visit.
**CMS administrators have stressed they welcomed recommendations for
implementation of payment for advanced care planning**
Section III. Other Provisions of the Proposed Regulations
SUBSECTION C. CHRONIC CARE MANAGEMENT SERVICES FOR RURAL HEALTH CLINICS AND
FEDERALLY QUALIFIED HEALTH CENTERS (§ 405.2462 PAYMENT FOR RHC AND FQHC
SERVICES AND § 405.2464 PAYMENT RATE.)

New proposals on payment, beneficiary eligibility, and scope of services included in
chronic care management
SUBSECTION H. PHYSICIAN COMPARE WEBSITE

Includes plans to consult and test language with consumers to ensure that Physician
Compare is as consumer friendly and consumer focused as possible

Seeking comment on potential measures that would benefit from future public
reporting on physician compare

Seeking comment on adding Medicare Advantage physicians to the website

Seeking comment on proposed new benchmark for quality measures. CMS wants the
proposed benchmark to allow consumers to more easily evaluate the information
published by providing a point of comparison between groups and between
individuals.

Seeking comment on measure stratification by race and ethnicity and gender, as
well as the inclusion of other measures of health equity
SUBSECTION I. PHYSICIAN PAYMENT, EFFICIENCY, AND QUALITY IMPROVEMENTS—
PHYSICIAN QUALITY REPORTING SYSTEM (§ 414.90 PHYSICIAN QUALITY REPORTING SYSTEM
(PQRS).)
7. Request for Input on the Provisions Included in the Medicare Access and CHIP
Reauthorization Act of 2015 (MACRA)

MIPS: seeking comment on what activities could be classified as clinical practice
improvement activities according to the current definition. The current definition of
clinical practice improvement must include the following sub-categories:
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
o
Expanded practice access
o
Population management
o
Care coordination
o
Beneficiary engagement
o
Patient safety and practice assessment
o
Participation in alternative payment model
Planning to issue a forthcoming RFI on alternative payment models. In advance of
the RFI, CMS is seeking comment on approaches to implementing any of the APM
topics listed below, including in provisions not enumerated above, and any other
related concerns.
o
The criteria for assessing physician-focused payment models;
o
the criteria and process for the submission of physician-focused payment models
eligible APMS,
o
qualifying APM participants;
o
the Medicare payment threshold option and the combination all-payer and
Medicare payment threshold option for qualifying and partial-qualifying APM
participants;
o
the time period to use to calculate eligibility for qualifying and partial-qualifying
APM participants, eligible APM entities, quality measures and EHR use
requirements; and
o
the definition of nominal financial risk for eligible APM entities.
SUBSECTION K. POTENTIAL EXPANSION OF THE COMPREHENSIVE PRIMARY CARE INITIATIVE

Seeking comment on the potential expansion of the program and the following
elements:
o
Practice readiness: practices currently are asked to reorganize their work flows
to accomplish the five comprehensive primary care functions. CMS is interested
in understanding the proportion of primary care practices ready for these
transformation expectations and whether readiness varies systematically for
differently structured practices (for example, small primary care practices, multispecialty practices, and employed primary care practices within integrated
health systems).
o
Practice standards and reporting
o
Practice grouping
o
Interaction with state primary care transformation initiatives: Various states
are leading their own efforts to transform primary care practices. Although these
efforts may have processes and goals that are similar to those in the CPC
initiative, requirements and outcomes can differ in important ways. CMS is
interested in whether a potential expansion of the CPC initiative could and
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should exist in parallel in a state with a separate state-led primary care
transformation effort, especially if Medicare is participating in that effort.
o
Learning activities: CMS is interested in what support practices would require to
provide the five comprehensive primary care CPC functions in a potential
expansion of the CPC initiative, and the readiness of the private sector to
respond to the need for this support. Also interested in the willingness and
ability of existing state and regional primary care or patient centered medical
home learning collaboratives to support practices in an a potential expansion of
the CPC initiative.
o
Payer and self-insured employer readiness
o
Medicaid: CMS is interested in whether state Medicaid agencies would be willing
to participate in a potential expanded CPC initiative for their fee-for-service
enrollees. Also interested in whether Medicaid managed care plans would be
willing to participate in a potential expanded CPC initiative.
o
Quality reporting: CMS is interested in comment on practice readiness to report
eCQMs, and payer interest in using practice site level data rather than their own
enrollees' information for performance based payments, including shared
savings, in a potential expansion of the CPC initiative.
o
Interaction with CCM fee
o
Provision of data feedback to practices
SUBSECTION L. MEDICARE SHARED SAVINGS PROGRAM (§ 425.20 TO § 425.504)

Proposing to add a new quality measure to be reported to CMS – the measure is
specific to cardiovascular disease and CMS seeks comment on implementation of the
measure

Seeking comment on how the HIT measure might evolve in the future to ensure we
are incentivizing and rewarding providers for continuing to adopt and use more
advanced health IT functionality.

Seeking comment on the proposal to exclude services furnished in SNFs from the
definition of primary care services will complement our goal to assign beneficiaries
(§ 425.20 Definitions.)
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