Tuesday, November 28, 2017

CMS Updates 2018 Medicare Part B Physician Fee Schedule File - Therapy File Posted on AHCA Website

Dan Ciolek

Thanks again to the efforts of Tony Marshall, President and CEO of the Georgia Health Care Association; AHCA is able to offer members the 2018 therapy fees for each CPT/HCPCS Code in each geographic area on our website under the “Medicare Part B Fee Schedules” heading. Please note that the fees effective January 1, 2018 are calculated based upon the Revisions to Payment Policies Under the Physician Fee Schedule (MPFS) and Other Revisions to Part B for Calendar Year (CY) 2018 Final Rule (CMS-1676-F) published in the Federal Register on November 15, 2017.

Background 
On November 15, 2017, the Centers for Medicare and Medicaid Services (CMS) published the CY 2018 Medicare Physician Fee Schedule (PFS) Final Rule (CMS-1676-F) in the Federal Register.  This final rule reflects the requirements of the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) which repealed the Sustainable Growth Rate formula. Further, the MACRA allowed for a one-half percent (0.5%) update from July 1, 2015, to December 31, 2015, a one-half percent (0.5%) update for CY 2016, and allows a one-half percent (0.5%) update for CY 2017. The MACRA provision extending the physician work geographic practice cost index (GPCI) floor of 1.0 through December 2017 ends for CY 2018. Additionally, as required by the ACA, the 1.5 work GPCI floor for Alaska and the 1.0 practice expense GPCI floor for frontier states are permanent, and therefore, applicable in CY 2018.

You may note that after all required adjustments, the conversion factor has increased from $35.8887 for CY 2017 to $35.9996 for CY 2017. However, Table 50 in the Final Rule titled CY 2018 PFS ESTIMATED IMPACT ON TOTAL ALLOWED CHARGES BY SPECIALTY indicates that, due to relative changes in the weights of various PFS procedure codes, the value of Part B physical and occupational therapy code payments in aggregate will decrease 2% in 2018.  AHCA anticipates that the impact will be less on SNF providers as most of the codes experiencing negative adjustments are not commonly used in SNF, while more commonly used codes such as neuromuscular reeducation (97112) and gait training (97116) saw increased values.     

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.

Further, the final rule updates the Medicare Part B therapy CPT code list for CY 2018 by modifying the descriptors for two CPT codes (97760 and 97761), adding one new “always therapy” code (97763) and one new “sometimes therapy” code (G0515), and deleting one code (97762). Please see Transmittal 3924/Change Request 10303 and Centers for Medicare and Medicaid Services (CMS) MLN Matters article MM10303 for complete information on the 2018 Annual Update to the Therapy Code List.

While not impacting fee schedule pricing, the final rule also announced that the Medicare Part B outpatient therapy cap amounts are updated  (Transmittal 3918/Change Request 10341 and MLN Matters MM10341)  and are $2,010 for occupational therapy and $2,010 for physical therapy and speech-language pathology services combined for CY 2018. The MACRA provision extending the therapy cap exceptions process expires December 31, 2017; therefore, this final rule notes the caps will be enforced without exception at the new $2,010 threshold in CY 2018 unless Congress takes action before then.

Finally, supporting documentation and downloads for Regulation #CMS-1676-F may be found here. An overview of the Physician Fee Schedule Payment Policies may be found here and an overview of skilled nursing facility consolidated billing and annual updates may be found here.

The AHCA 2018 Medicare Part B therapy fee schedule file includes five tabs containing the following information:

  1. The 2018 Medicare Part B Fee Schedule for Outpatient Rehabilitation for each Carrier and Locality (Part B Fees)
  2. The 2018 Medicare Part B MPPR Fee Schedule for "Always Therapy Services (50% MPPR Factor) for each Carrier and Locality (MPPR Fees)
  3. The 2018 Relative Value Units for each Outpatient Rehabilitation Therapy Code (RVUs)
  4. The 2018 Geographic Practice Cost Indices by Medicare Carrier and Locality (GPCI)
  5. The 2018 Counties Included in 2018 Localities (GPCI Counties) (Same as 2017)


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 = $35.9996

        MPPR Factor = 50%

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