AACVPR Health Policy & Reimbursement Update
December 1, 2015
Final 2016 Medicare Regulations and Payment Rates for Hospitals and Physicians
CMS (Centers for Medicare & Medicaid Services) has published final regulations for the Hospital Outpatient Prospective Payment System (HOPPS) and Physician Fee Schedule (PFS) rules for 2016. These regulations were published in the Federal Register on November 13, 2015 and November 16, 2015, respectively. The effective date for both of these regulations is January 1, 2016.
Hospital Outpatient Prospective Payment System (HOPPS)-Final 2016 Regulation
These rates are national averages and will vary based on geographic location due to adjustments related to labor costs. The payment rate below includes the co-payment amount. This means that Medicare reimburses a percentage (roughly 80%) of the listed payment rate and the co-payment amount is included in that payment rate.
It is important to also note that the co-payment amounts listed here are for Medicare Fee-For-Service (FFS) beneficiaries. Alternative Medicare coverage plans, called Medicare Advantage Plans, are allowed a degree of leeway in setting co-payment amounts for services under that program. The December Health Policy & Reimbursement Update will discuss the issue of excessive CR and PR co-payments within the Medicare Advantage Program.
Reimbursement – Pulmonary Rehabilitation in a Hospital Setting
The most significant change is the payment amount identified for G0237. Note that all procedure codes have been assigned new APCs (Ambulatory Payment Classification). Here are the relevant codes related to pulmonary rehabilitation services.
|Procedure Code||APC||Payment Rate||Co-pay|
While the change in payment rates is certainly important, program directors also should know of the change in the APCs. Program directors should know there is not only relatively wide variation with codes lumped into an APC family, but CMS tries to structure its APCs with a level of clinical coherence in terms of resources utilized.
Program directors should also note that all of the above codes carry a status indicator of Q1, signaling that the code is recognized as a packaged code. This status indicator has no direct impact on processing claims other than to signal that certain other codes related to the bundled package of services are not separately billable. Other than new APCs, billing and coding for pulmonary rehabilitation and respiratory care services remain unchanged from 2015 to 2016.
Reimbursement – Cardiac Rehabilitation (CR) in a Hospital Setting & Intensive Cardiac Rehabilitation (ICR)
|Procedure Code||APC||Payment Rate||Co-pay|
|93797 (CR without ECG)||5771||$103.92||$20.79|
|93798 (CR with ECG)||5771||$103.92||$20.79|
|G0422 (ICR with exer)||5771||$103.92||$20.79|
|G0423 (ICR without exer)||5771||$103.92||$20.79|
In July, 2015 the proposed 2016 rate for ICR had been calculated to be significantly higher than what appears here. More recent CMS analysis of hospital claims data revealed that the geometric mean costs of ICR are more consistent with 2015 rates and with the geometric mean cost of CR, so CMS changed the final payment rate for ICR in 2016 to again be equivalent to CR.
Physician Fee Schedule (PFS) – 2016 Final Regulation
Reimbursement for Cardiac and Pulmonary Rehabilitation in a Physician Setting
Payment for cardiac and pulmonary rehabilitation services in the physician setting is calculated using a different formula than that used for hospitals. In recent years, the reimbursement rate has been significantly lower than reimbursement in the hospital outpatient setting and that remains the case for 2016. (Intensive cardiac rehabilitation is reimbursed the same amount for both physician office and hospital outpatient settings, as seen in the chart above).
CPT 93798 $ 25.43
CPT 93797 $ 16.48
Pulmonary Rehabilitation & Respiratory Care (Therapy) Services
“Cardiac Rehabilitation Patient Referral from Outpatient Setting” Performance Measure
The National Quality Strategy (NQS) is led by the Agency for Healthcare Research and Quality on behalf of the U.S. Department of Health and Human Services (HHS). CMS is finalizing its proposal to place the “Cardiac Rehabilitation Patient Referral from Outpatient Setting” performance measure under the new NQS domain of Communication and Care Coordination. This is one of six priority domains that NQS is focusing on to improve health care quality.
Moving this measure under this NQS priority domain most appropriately reflects the function of this measure. As CR practitioners already recognize, the role of cardiac rehabilitation as a valuable part of care coordination with the patient/family and with the physician-health care team improves the effectiveness of chronic disease management. The care coordination integral to cardiac rehabilitation services spans the continuum from hospitalization or initial diagnosis to long-term secondary prevention interventions and outcomes, providing an individualized focus on self-management behavior changes. Closing an acknowledged care gap through improved communication and the accountability that occurs via cardiac rehabilitation coordination is achieved in harmonization with its companion measure, “Cardiac Rehabilitation Patient Referral from Inpatient Setting.”
This performance measure is available for physicians to use when they see patients in the office, as part of the PQRS Program. You may consider making offices that refer patients to your cardiac rehab program aware of this measure. Physicians in the office setting who see eligible patients for this Class I indication in clinical guidelines should be routinely asking the question, “Have you been referred to a cardiac rehabilitation program?”
References a Denial Checklist for Pulmonary Rehab Services:
Education Topics for Pulmonary Rehab patients to fulfill CSM Requirement: