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December 2017
CMS Updates: Diagnostics Reimbursement Cuts, Medicare Physician Fee Schedule, QPP & ID

Cuts to ID Diagnostic Reimbursement Set to Take Effect

The Centers for Medicare and Medicaid Services (CMS) has released its final rate determinations for Medicare reimbursement for diagnostic tests. Most infectious diseases (ID) diagnostic tests will get a ten percent reduction in 2018, with a possibility of additional ten percent reductions over the next two years (for a total 30% reduction by 2020). The rates are scheduled to take effect on January 1, 2018. IDSA and other physician organizations remain concerned that the myriad issues with CMS’ approach to data collection led to inappropriate new reimbursement rates for many tests, which will subsequently reduce patient access to testing.

IDSA continues to work with the American Medical Association (AMA) and other laboratorian- and clinician-focused organizations to educate Congress on the likely negative impacts of decreased reimbursement on patient care, public health and diagnostics innovation. To help support our advocacy efforts, take our quick online survey or email to share how your patients/research/institutions will be effected by the Clinical Laboratory Fee Schedule (CLFS) payment system. Specific examples of how decreased reimbursement may harm your patients will help us advocate for more appropriate reimbursement.

The agency also reported that it is working on an application that labs can use to classify their tests as advanced laboratory diagnostic tests, which are priced every year, or clinical diagnostic lab tests, which are priced every three years. The public has until January 17, 2018 to request reconsideration of gapfill (used when no comparable test is available) or crosswalk (used when a new test is clinically or technologically similar to existing tests) payments for new or substantially revised test codes. The public may then comment on these reconsideration requests at the next CMS Annual Laboratory Public Meeting in August.

CMS Releases the Final Rule for the 2018 Medicare Physician Fee Schedule

CMS recently released the Medicare Physician Fee Schedule Final Rule for 2018. Of note, the agency responded to comments on how the it should proceed with possible revisions of the evaluation and management (E/M) guidelines.

The current E/M guidelines were developed over 20 years ago and in that time the complexity of patients’ illnesses and comorbidities, as well as the practice of medicine has changed considerably. In our comments (PDF) to the agency, IDSA requested that CMS focus not only on revising the guidelines pertaining to the patient history and physician exam, but to take a more holistic approach to the revision of all components of an E/M visit including medical decision making, history, and the physical exam. CMS continues to defer on conducting an extensive research project that would revise and revalue the entire E/M code set. IDSA will continue to press the agency to conduct this research.

CMS finalized patient relationship modifiers that physicians will use to indicate the type of relationship a physician has with a patient during a specific episode of care. The modifiers are not mandatory at present, but it is expected that the use of the modifiers will become mandatory in the coming years. As of January 1, 2018, physicians may voluntarily report the modifiers as means to become familiar with their use. IDSA noted in our comments to CMS that we consider the modifiers another layer of administrative burden while adding nothing to the improvement of patient care. The modifiers are as follows:

Patient Relationship Modifiers
X1 Continuous/broad service
X2 Continuous/focused services
X3 Episodic/broad services
X4 Episodic/focused services
X5 Only as ordered by another clinician

Quality Performance Improvement: Implications for the ID Clinician

2018 Quality Payment Program Final Rule Comments

CMS has released the final rule with comment period for the 2018 Quality Payment Program (QPP). The 2018 QPP final rule establishes the requirements clinicians must meet to receive Medicare reimbursements. IDSA continues to advocate on behalf of the IDSA membership regarding issues that may impact the satisfactory participation of ID physicians in the QPP. In brief, IDSA has submitted the following comments to CMS regarding the 2018 QPP final rule.

Cross-cutting Measures: Historically, CMS physician quality payment incentive programs have required clinicians to report on quality measures that are broadly applicable to all clinicians regardless of the clinician’s specialty, also known as “cross-cutting measures.” For example, a patient screened for high blood pressure with a documented recommended follow-up care plan is a designated cross-cutting measure. In the 2018 QPP final rule, CMS has not finalized the policy of requiring clinicians to report cross-cutting measures. IDSA provided comments stating our belief that this requirement would be overly burdensome and promotes overutilization as it does not leverage the expertise of a specialist when treating a patient.

Topped Out Measures: CMS defines a quality measure as “topped out” if the measure’s performance rate is consistently high such that meaningful performance improvement cannot be distinguished amongst clinicians. With this definition of topped out, two of the five quality measures most reported by ID physicians in previous CMS physician quality payment incentive programs will be phased out over a four-year period. IDSA has expressed serious concern with this as the options of clinically relevant quality measures to appropriately measure the performance of an ID physician is nearly nonexistent and this prospective removal of the two measures would detrimentally effect ID physician reporting.

Infectious Diseases Measure Set: CMS has made available specialty measure sets that should be used as a guide for clinicians to choose measures applicable to their specialty. In the 2018 QPP final rule, CMS has finalized the Infectious Disease Specialty Measure Set in Table B. 29. IDSA has stated our strong reservations regarding the clinical relevancy of many of the measures outlined in this set. Furthermore, IDSA urged CMS to revise the measure set to include four measures that better align with the practice and reporting patterns of an ID physician.

Please visit IDSA’s Access and Reimbursement for ID Services page for past comment letters.

List of Measures under Consideration for Medicare Programs (MUC)

Annually, CMS is mandated to release a list of quality measures for consideration, known as the MUC List, for adoption through rulemaking for Medicare quality payment incentive programs such as the Merit-based Incentive Payment System (MIPS), which is one of two possible clinician participation tracks for the Quality Payment Program (QPP), and the Hospital Inpatient Quality Reporting Program. IDSA has provided comments to the MUC List for 2017 (PDF), specifically regarding a proposed quality measure related to shingles vaccination, MUC17-310 Zoster (Shingles) Vaccination. We stated our full support of the evidence and rationale for this measure to be adopted into Medicare quality programs but had concerns regarding the Medicare coverage for the shingles vaccine. Medicare does not reimburse physicians for administering the shingles vaccination. Additionally, the measure is unclear whether a physician would be required to vaccinate a patient who has no documentation for being vaccinated for shingles. For more information regarding the MUC List and the rulemaking process for measure selection for Medicare quality payment programs, please visit CMS’ Pre-rulemaking page.

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