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What you should know about the PFS Final Rule

What you should know about the PFS Final Rule


Along with the release of the QPP Final Rule early this month, the PFS Final Rule was also released.  The biggest surprise was the announcement of reduced penalties/incentives related to the Value-Based Payment Modifier Program.

Payment Reductions Reduced

Payment reductions for physicians who were slated to be penalized via the Value-based Payment Modifier program (which included all physicians, except those who had opted out of Medicare) were reduced from 4% and 2% to 2% and 1%, respectively.  This included the physicians who had been classified as “high cost” or “low quality” providers, who are now “held harmless” from this penalty for 2018.  The VBPM program was related to PQRS (Physician Quality Reporting System), which has been converted into the ‘Quality’ category of MIPS.

Not only did the PFS Final Rule reduce the penalties, but the negative information (high cost / low quality) will not be reported publicly on the Physician Compare website.  However, any physicians who were deemed to be high-quality/low-cost will only receive half of the incentive increase that CMS had originally proposed for the program.

Increase in 2018 Reimbursements

The PFS Rule includes what MACRA promised providers – a 0.50% increase in reimbursement for 2018, although some of that was lost on CMS’ attempt to recapture misvalued services and to offset spending for new services.  The PFS conversion for 2018 is $35.99, only ten cents more than 2017.

Telehealth & Mobile Health

Telehealth and Mobile Health will be receiving major boosts. The following codes are now being reimbursed:
  • G0296 (Visit to determine low-dose computed tomography eligibility);
  • 90785 (Interactive Complexity);
  • 96160 and 96161 (Health Risk Assessment);
  • G0506 (Care Planning for Chronic Care Management); and
  • 90839 and 90840 (Psychotherapy for Crisis)
CMS has also pledged to pay separately for CPT 99091; previously bundled, this code, which incorporates “remote patient monitoring,†is now valued at 1.1 work RVUs . CMS’ requirements for it being reimbursed are:
  1. Patient must be informed in writing
  2. The consent is documented in the patient’s record
  3. A face-to-face service must be provided to the patient within the previous year when remote monitoring is initiated
  4. The service can only be billed once in a 30-day period.
That covers most of the major highlights of the PFS Final Rule for 2018, but these are significant changes in terms of coverage toward telemedicine, which aligns with the aims of the 21st Century Cures Act.
The PFS Final Rule may also be an early predictor of how CMS will deal with MIPS incentives and penalties for 2017 if they are out of line with expectations and predictions.