Good and Bad Medicare Reimbursement Changes in 2016

December 3, 2015

A recently released final rule from CMS on reimbursements changes in 2016 includes good and bad news for physicians.

Through the recently released CMS final rule detailing the $133 million in decreased reimbursements for Outpatient Prospective Payment System (OPPS) and Ambulatory Surgical Center (ASC) Payment System, physicians can get compensated for end-of-life counseling.

However, let’s begin with the bad news first. The final rule, which becomes effective Jan. 1, 2016, touches on a lot of significant items in addition to the decreased payments for the OPPS and ASC systems, including changes to the midnight rule, transitioning payments for hospitals that lost their Medicare-dependent small rural hospital status, and finalization of select “Medicare regulations governing provider administrative appeals and judicial review relating to appropriate claims in provider cost reports.” (CMS-1633-FC/1607-F2). The two-midnight rule requires a two night stay in order to be reimbursed under Medicare Part A. CMS made an exception and detail it on a fact sheet, “an inpatient admission may be payable under Medicare Part A on a case-by-case basis based on the judgment of the admitting physician. The documentation in the medical record must support that an inpatient admission is necessary, and is subject to medical review.” Hence, underscoring the importance of detailed documentation and the use of the appropriate ICD-10 codes.

Now, the good news. CMS has given Medicare Audit Contractors (MACs) the authority to review and process the advance-care planning (ACP) claims. “There are two current procedural terminology (CPT) billing codes for ACP. CPT code 99497 covers a discussion of advance directives with the patient, a family member, or surrogate for up to 30 minutes. An additional 30 minutes of discussion takes the add-on code of 99498. Medicare will pay roughly $86 for 99497 and $75 for 99498 when the counseling occurs in a physician's office, according to the AMA.”

In sum, physicians need to be vigilant about reimbursement changes across a lot of fronts. Now is a good time to re-evaluate the potential impact of the various changes.