CMS Proposes Payment for Advance Care Planning and Changes to ACO Attribution

July 10, 2015
Policy Snapshot

Earlier this week, the Centers for Medicare & Medicaid Services (CMS) issued its annual physician fee schedule proposed rule. The rule proposes updates to payment policies, payment rates, and quality provisions for services furnished under the Medicare Physician Fee Schedule (PFS) on or after January 1, 2016.

Advance Care Planning

Among the various proposals, CMS proposes to pay for the already established Advance Care Planning CPT codes. The proposal, applauded by AMDA, would establish separate payment and a payment rate for two advance care planning services provided to Medicare beneficiaries by physicians and other practitioners. In making its decision, CMS cited a letter from 66 provider and consumer groups, including AMDA, AARP, and the American Medical Association, wrote to Secretary Burwell in support of Advance Care Planning because it “leads to better care, higher patient and family satisfaction, fewer unwanted hospitalizations, and lower rates of caregiver distress, depression and lost productivity.” In a press release AMDA president Naushira Pandya, MD, CMD, expressed her support for the “vital advance care planning services” further stating that “post-acute and long-term care practitioners provide quality and thoughtful care and family members and friends of very ill patients will receive greater peace of mind that the care their loved ones receive is based on adequate medical information, collaborative goal setting, as well as respect for personal wishes and values in order to maximize comfort and quality of life.” AMDA members played an integral role responding to requests for input during the development phase of these codes.

SNF POS 31 and ACO Attribution

CMS also responded to AMDA’s concerns around attribution of skilled nursing facility (SNF) (POS 31) patients to the Medicare Shared Savings Accountable Care Organizations (ACO). In the rule, CMS states that they received comments arguing that “ACOs are often inappropriately assigned patients who have had long SNF stays but would not otherwise be aligned to the ACO and with whom the ACO has no clinical contact after their SNF stay.” AMDA raised similar concerns in its letters and meetings with CMS officials. CMS further states that, “Although the same CPT visit codes are used to describe these services in SNFs (POS31) and NFs (POS32), the patient population is arguably quite different.” CMS opines that the difference in the populations is that “Patients in SNFs (POS 31) are shorter stay patients who are receiving continued acute medical care and rehabilitative services. While their care may be coordinated during their time in the SNF, they are then transitioned back in the community. Patients in a SNF (POS 31) require more frequent practitioner visits often from 1 to 3 times a week. In contrast, patients in NFs (POS 32) are almost always permanent residents and generally receive their primary care services in the facility for the duration of their life. Patients in the NF (POS 32) are usually seen every 30 to 60 days unless medical necessity dictates otherwise.”

Based on this distinction, CMS proposed to amend the definition of primary care services at §425.20, for purposes of the Shared Savings Program, to exclude services billed under CPT codes 99304 through 99318 when the claim includes the POS 31 modifier.

AMDA has previously argued that the exclusion of SNF POS 31 would result in a more appropriate and equitable ACO attribution scheme and will comment on this proposal.

Other proposals in the rule include updates to the Physician Quality Reporting System (PQRS), Medicare Electronic Health Record (EHR) Incentive Program, as well as changes to the Physician Compare tool on the website. Finally, the rule continues the phased-in implementation of the physician value-based payment modifier (Value Modifier), created by the Affordable Care Act, that would affect payments to physicians and physician groups, as well as other eligible professionals, based on the quality and cost of care they furnish to beneficiaries enrolled in the traditional Medicare fee-for-service program.

Please look for updates on all of these provisions in future editions of AMDA’s Health Policy Advisor.

CMS invites comments on the rule by September 8, 2015.

Helpful Links:

To read the entire rule put on display,  click here.

To read the CMS Fact Sheet on the rule, click here.

To read CMS Press Release on the rule, click here.

To read AMDA’s press release on Advance Care Planning Services, click here