Wednesday, November 25, 2015

CMS Updates 2016 Medicare Part B Physician Fee Schedule File – Therapy File Posted on AHCA Website

Dan Ciolek

On November 16, 2015, the Centers for Medicare and Medicaid Services (CMS) published the CY 2016 Medicare Physician Fee Schedule (PFS) Final Rule (CMS-1631-FC) in the Federal Register. This is the first PFS final rule since the passage of the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) which repealed the Sustainable Growth Rate formula. The MACRA allowed the zero percent update that would have ended on March 31, 2015, to continue through June 30, 2015, allowed for a one-half percent (0.5%) update from July 1, 2015, to December 31, 2015, and allows for a one-half percent (0.5%) update for CY 2016. The MACRA also extends the physician work geographic practice cost index (GPCI) floor of 1.0, and the therapy cap exceptions process, through December 2017.

You may note that the 2016 conversion factor of $35.83 is slightly lower that the 2015 conversion factor of $35.93. This is due to the application of a required -0.02 percent Budget Neutrality Adjustment and a -0.77 percent Target Recapture Amount adjustment related to the misvalued procedure code policy.

The final rule continues the multiple procedure payment reduction (MPPR) policy for “always therapy” services. The MPPR policy required, effective April 1, 2013, a 50 percent reduction to be applied to the practice expense component of payment for the second and subsequent “always therapy” service(s) that are furnished to a single patient by a single provider on one date of service (including services furnished in different sessions or in different therapy disciplines). The MPPR worksheet lists those “always therapy” services subject to the MPPR policy and the reduced fee payment amounts.

Supporting documentation and downloads for Regulation #CMS-1631-FC may be found here. An overview of the Physician Fee Schedule Payment Policies may be found at and an overview of skilled nursing facility consolidated billing and annual updates can be found at

Thanks again to the efforts of Tony Marshall, President and CEO of the Georgia Health Care Association; AHCA is able to offer members the 2016 therapy fees for each CPT/HCPCS Code in each geographic area are provided in this Excel file. The file contains the following information:

1. The 2016 Medicare Part B Fee Schedule (Part B Fees) for Outpatient Rehabilitation for each Carrier and Locality

2. The 2016 Medicare Part B MPPR Fee Schedule for "Always Therapy Services (50% MPPR Factor) for each Carrier and Locality

3. The 2016 Relative Value Units (RVUs) for each Outpatient Rehabilitation Therapy Code

4. The 2016 Geographic Practice Cost Indices (GPCI) by Medicare Carrier and Locality

The Part B Fee Schedule amounts are calculated as follows:

((A1 x B1) + (A2 x B2) + (A3 x B3)) x Conversion Factor (Part B Fees), and

((A1 x B1) + ((A2 x B2) x (1-MPPR Factor) + (A3 x B3)) x Conversion Factor (MPPR Part B Fees), where:

A1 = Physician Work RVU
A2 = Non-Facility Practice Expense RVU
A3 = Malpractice RVU
B1 = Work GPCI
B2 = Practice Expense GPCI
B3 = Malpractice GPCI

Conversion Factor = $35.8279

MPPR Factor = 50%

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