Summary. CY 2014 Medicare Physician Fee Schedule (MPFS) Final Rule

Summary CY 214 Medicare Physician Fee Schedule (MPFS) Final Rule On November 27, 213, the Centers for Medicare & Medicaid Services () released the 214 final rule. The final rule contains payment and programmatic changes for services furnished under the Medicare Physician Fee Schedule (MPFS) on or after January 1, 214 unless noted otherwise. The final rule has been published in the December 1, 213 Federal Register. will accept public comments on the final rule until January 27, 214. The Federal Register version of the final rule is available: http://www.gpo.gov/fdsys/search/pagedetails.action?granuleid=213-28696&packageid=fr-213-12- 1&acCode=FR The CY 214 MPFS RVU and data input files can be found at: http://www.cms.gov/medicare/medicare-fee-for-service-payment/physicianfeesched/pfs-federal- Regulation-Notices-Items/-16-FC.html?DLPage=1&DLSort=3&DLSortDir=descending Executive Summary In its CY 214 MPFS final rule, : Did not expand the Multiple Procedure Payment Reduction (MPPR) policy Implements the 9 percent utilization rate assumption for CT and MRI services Finalizes plans to use interest rates from the Small Business Administration Adjusts the work, practice expense, and malpractice relative values based on new Medicare Economic Index (MEI) information Revises clinical staff time and supply for select interventional radiology and radiation oncology services Defers action on: Capping non-facility practice expense relative values ( PERVUs) based on rates under the Hospital Outpatient Prospective Payment System (HOPPS) or for Ambulatory Surgical Centers (ASCs) Collecting information on provider-based entities Establishes CY 214 interim work and practice expense values for new or revised codes in response to recommendations from the AMA s RVS Update Committee. Notably, decreased the and clinical staff time for certain CT and MRI codes. Decreased the for code 76942 (Ultrasound guidance for needle placement)

RBMA s Summary - 214 MPFS Final Rule 2 Impact Selected Impacts for Radiology Specialties from Table 93: CY 214 PFS Final Rule with Comment Period Estimated Impact Table: Impacts of Work, Practice Expense, and Malpractice RVUs, and the MEI Adjustment* (A) Specialty 2-INTERVENTIONAL RADIOLOGY (B) Allowed Charges (Millions) (C) Impact of Work and MP RVU (D) Impact of PE RVU Changes (E) Impact of Adjusting the RVUs to Match the Revised MEI Weights (F) Combined Impact $221-1% % -1% -2% 25-NUCLEAR MEDICINE $51 % % % % 37-RADIATION ONCOLOGY $1,788 % 3% -2% 1% 38-RADIOLOGY $4,655 % -2% % -2% 47-DIAGNOSTIC TESTING $79 % -6% -5% -11% FACILITIES 57-RADIATION THERAPY $63 % 5% -6% -1% CENTERS *Table 93 shows only the payment impact on PFS services. These impacts use a constant conversion factor and thus do not include the effects of the January 214 conversion factor change required under current law. Table 93 in its entirety appears in the Appendix. Column A (Specialty): The Medicare specialty code as reflected in our physician/supplier enrollment files Column B (Allowed Charges): The aggregate estimated PFS allowed charges for the specialty based on CY 212 utilization and CY 213 rates. Column C (Impact of Work and Malpractice (MP) RVU Changes): This column shows the estimated CY 214 impact on total allowed charges of the changes in the work and malpractice RVUs, including the impact of changes due to new, revised, and misvalued codes. Column D (Impact of PE RVU Changes): This column shows the estimated CY 214 impact on total allowed charges of the changes in the PE RVUs, including the impact of changes due to new, revised, and misvalued codes, the statutory change to the utilization rate from 75 percent to 9 percent for expensive diagnostic imaging, the implementation of the ultrasound recommendation to replace expensive ultrasound rooms with less expense portable ultrasound units, and other miscellaneous and minor provisions. Column E (Impact of Adjusting the RVUs to Match the Revised MEI Weights): This column shows the estimated CY 214 combined impact on total allowed charges of the changes in the RVUs and conversion factor adjustment resulting from adjusting the RVUs to match the revised MEI weights. Column F (Cumulative Impact): This column shows the estimated CY 214 combined impact on total allowed charges of all the changes in the previous columns.

RBMA s Summary - 214 MPFS Final Rule 3 Conversion Factor (Federal Register page 74397) The calendar year (CY) 213 conversion factor (CF) is $34.23. For 214, the conversion factor based on the sustainable growth rate (SGR) formula mandated by law is $27.26, representing a -2.1 percent decrease. This reflects a smaller decrease than was projected in the proposed rule. The smaller reduction is due in part to a 4.72 percent adjustment to the conversion factor to offset the decrease in Medicare physician payments that would otherwise have occurred due to the CY 214 rescaling of the RVUs so that the proportions of total payments for the work, PE, and malpractice RVUs match the proportions in the final revised Medicare Economic Index (MEI) for CY 214. The overall 214 reduction in physician fee schedule payments required under the SGR methodology is unchanged by this rescaling. Utilization Rate (Federal Register page 74238) currently uses an utilization rate of 75 percent for so-called expensive diagnostic imaging, which is priced at over $1 million (CT and MRI). The America Taxpayer Relief Act of 212 (ATRA) requires that for fee schedules for CY 214 and subsequent years, the Secretary shall use a 9 percent utilization assumption. The agency noted that several commenters objected to the statutorily-mandated change in utilization rate assumptions, but none provided evidence that has authority to use a different utilization assumption for these services. The RBMA was among the stakeholders that provided comments objecting to this change stating that a 9 percent usage assumption for CT, MRI or any other imaging modality for that matter is arbitrary and inconsistent with standard practice in freestanding (non-hospital) imaging center. Therefore, has finalized its proposal to apply the 9 percent utilization rate assumption in CY 214 to all of the services to which the 75 percent utilization rate assumption applies in CY 213. (See Table 3 in the Appendix.)

RBMA s Summary - 214 MPFS Final Rule 4 Interest Rate (Federal Register page 74239) In the CY 213 final rule, finalized a proposal to change the interest rates used in the calculation of costs per minute. The interest rates are now based on the Small Business Administration (SBA) maximum interest rates for different categories of loan size cost) and maturity (useful life). The interest rates are listed in Table 4 as follows: Equipment Price Useful Life Interest Rate <$25K <7 Years 7.5% $25K-5K <7 Years 6.5% >$5K <7 Years 5.5% <$25K 7+ Years 8.% $25-5K 7+ Years 7.% >5K 7+ Years 6.% Adjusting RVUs to Match PE Share of the Medicare Economic Index (MEI) (Federal Register page 74241) finalized its proposal to adjust the relationship of work, PE, and malpractice RVUs based on new MEI cost share data along with the necessary adjustments to the conversion factor and to PE and malpractice RVUs to maintain budget neutrality. (See the discussion on the MEI later in this summary.) While the agency does acknowledge that the increase in the work RVUs relative to PE RVUs will generally result in lower payments for practitioners who furnish more services with a higher proportion of PE RVU. They believe that the MEI cost share weights are the best reflection of the PFS component weights. Some commenters suggested that these changes be phased-in, however, the agency noted that the 211 rebasing of the MEI was not phased in. Therefore, the agency is finalizing the adjustment to the relationship between the work, PE, and malpractice RVUs to reflect the MEI cost share. Specific Practice Expense (PE) Calculations Recommendations 1. Changes to Direct PE Inputs for Specific Services (Federal Register page 74242) As noted in the NPRM, received comments received on the CY 213 final rule on direct PE, reviewed seven supply to determine the appropriateness of including them as direct costs. The seven items and the associated HCPCS codes are listed in Table 6 below. Supply Code Item Description Associated CPT Codes SK16 Device Shipping Cost 93271, 93229,93268 SK112 FedEx Cost (average across all 6465, 88363, 64653 zones SK113 Communication, wireless per 93229 service SK17 Fee, usage, 77423, 77422 cyclotron/accelerator, gamma knife, Lincac SRS system SK11 Fee, image analysis 9612, 9611, 99174 SK111 Fee, licensing, computer, psychology 9612, 9611, 9613, 9612 SD14 Bag system, 1ml (for angiography waste fluids) 93451,93452,93453, 93454,93455, 93456, 93457, 93458, 93459,9346,93461

RBMA s Summary - 214 MPFS Final Rule 5 For six of the items contained in Table 6, agreed with the commenters that the items should not be considered disposable supplies and that they are more appropriately categorized as indirect PE costs. Therefore, finalized its proposal to remove the following six items from the direct PE database for CY 214: device shipping cost (SK16); Federal express cost (SK112); communication, wireless per service (SK113); fee usage, cycletron/accelerator, gammaknife, Lincac SRS system (SK17); fee, image analysis (SK11); and fee, licensing, computer, psychology (SK111). In the case of the supply item called bag system, 1ml (for angiography waste fluids) (SD14), did not agree with the commenters that this item is analogous to the specimen disposal costs recommended for the surgical pathology codes. Instead the agency believes that this supply input represents only the costs of the disposable material items associated with the removal of waste fluids that typically result from a particular procedure. Further, they believe that a disposable supply is one that is attributable, in its entirety, to an individual patient for a particular service. The agency continues to believe that SD14 is a direct expense and therefore, does not propose to remove SD14 from the direct PE input database. 2. Direct PE Input Refinements based on Routine Data Review (Federal Register page 74244) The Agency reported that while reviewing the direct PE input database, they identified several discrepancies that they proposed to address for CY 214. One of the codes identified during the course of this review was CPT code 5171 (Change of cystostomy tube; complicated). The code was identified as one that had supply items with no quantities associated with them. Upon reviewing these items believes that the code should include the items at the quantities listed in Table 7. Table 7: Supply Items and Quantities for CPT code 5171 Supply Code Description of Supply Item Quantity SA69 Tray, suturing 1. SB7 Drape, sterile 16in x 29in 1. SC29 Needle 18-27g 1. SC51 Syringe, 1-12ml 1. SD24 Catheter, Foley 1. SD88 Guidewire 1. SF36 Suture, nylon, 3- to 6-, c 1. SG55 Gauze, sterile 4in x4 in 1. SG79 Tape, surgical paper 1in 6. (Micrpore) SH75 Water, sterile inj 3. SJ32 Lubricating jelly (K-Y)(5gm uou) 1. SJ41 Povidone soln (Betadine) 2. Additionally, Upon reviewing the direct PE for CPT code 5171 and the related code 5175 (Change of cystostomy tube; simple), also noted that the direct PE input database includes an anomalous.5 minutes of clinical labor time in the post-service period. The agency believes that this small portion of clinical labor time is the result of a rounding error in their data and should be removed from the direct PE input database.

RBMA s Summary - 214 MPFS Final Rule 6 3. Adjustments to Pre-Service Clinical Labor Minutes (Federal Register page 74244) finalized its proposal to reduce pre-service clinical labor minutes for the following codes based on recommendations from the American Medical Association (AMA) Relative Value Update Committee (RUC). Specifically, the RUC recommended that codes with day global periods include a maximum of 3 minutes of clinical labor time in the preservice period in a facility setting. The RUC identified a total of 48 codes that currently include more clinical labor time than this recommended maximum and provided with updated pre-service clinical labor minutes for these codes. Below is an excerpt from Table 9: CPT Code Short Descriptor Existing CL preservice facility minutes Proposed CL preservice minutes (RUC recommendations) 368 Insertion of Cannula 6 36861 Cannula declotting 37 3722 Transcatheter 45 Therapy Infuse 6126 Injection into brain 6 15 canal 615 Remove brain canal 6 15 fluid 6155 Injection into brain 6 15 canal 617 Brain shunt 6 15 procedure 62268 Drain spinal cord cyst 36 3 4. Direct PE Inputs for Stereotactic Radiosurgery (SRS) Services (CPT Codes 77372 and 77373) (Federal Register page 74245) Since 21, Medicare has used HCPCS G-codes, in addition to the CPT codes, for stereotactic radiosurgery (SRS) to distinguish robotic and non-robotic methods of delivery. Based on review of the current SRS technology, it is their understanding that most services currently furnished with linac-based SRS technology, including services currently billed using the non-robotic codes, incorporate some type of robotic feature. Therefore, believes that it is no longer necessary to continue to distinguish robotic versus non-robotic linac-based SRS through the HCPCS G-codes. These two codes, G339 and G34, describe robotic SRS treatment delivery and are contractor priced. CPT codes 77372 and 77373, which describe SRS treatment delivery without regard to the method of delivery, are currently paid in the nonfacility setting based on resource-based RVUs developed through the standard PE methodology. If the CY 214 OPPS proposal is implemented, it would appear that there would no longer be a need for G- codes to describe robotic SRS treatment and delivery. Prior to eliminating the contractor- priced G-codes and using the existing CPT code for PFS payment of services previously reported using G-codes, believes that it would be appropriate to ensure that the direct PE used to develop PE RVUs for CPT codes 77372 and

RBMA s Summary - 214 MPFS Final Rule 7 77373 accurately reflect the typical resources used in furnishing the services that would be reported in the non-facility setting in the absence of the robotic G-codes. sought comment form stakeholders on whether it made sense to the contractorpriced G-codes for PFS payment. did not propose to make this change for CY 214 instead asking for comments regarding whether or not the direct PE for CPT codes 77372 and 77373 would continue to accurately estimate the resources used in furnishing typical SRS delivery were there no coding distinction between robotic and non-robotic methods of delivery. They did receive comments from the AMA RUC which suggested that the PE for 77372 and 77373 do accurately estimate the resources used in furnishing typical SRS delivery. In the meantime, the agency will continue to evaluate this issue. Using OPPS and ASC Rates in Developing Practice Expense (PE) Relative Value Units (RVUs) (Federal Register page 74246) In the NPRM, proposed to begin capping payments for services performed in the nonfacility setting when those payments are greater than what is paid when the same service is performed in the hospital outpatient department or ambulatory surgical center (ASC) facility setting. offered two arguments in support of this proposal. First, the policy is premised on the fact that the agency believes that there are greater indirect resource costs when a service is performed in a facility compared to the non-facility setting. Second the agency has concluded that the HOPPS and ASC cost data is more reliable than cost data collected in conjunction with the resource-based relative value scale (RBRVS). proposal would have affected approximately 2 codes including several related to interventional radiology and radiation oncology with the estimated impact being 2 percent and -4 percent, respectively. Based on the comments received by on this proposal, the agency has decided not to finalize its proposed policy. Instead, the agency will review the comments more thoroughly, including those that suggest improvements. At the conclusion of this review, the agency expects to develop a revised proposal for using OPPS and ASC rates in developing PE RVUs which we will propose through future notice and comment rulemaking. Ultrasound Room Equipment Recommendations (Federal Register page 74248) does not believe that all of the items listed in the ultrasound room packages are used for all ultrasound services. For example, does not believe that the typical ultrasound study would require the use of five different ultrasound transducers. However, the costs of all of these items are incorporated into the resource for every service for which the ultrasound room is a direct PE input, regardless of whether each of those items is typically used in furnishing the particular service. This increases the resource cost for every service that uses the room. In addition, became aware of articles in the press that cited ultrasound ranging from $7,9 for hand-held ultrasound to $2, for advanced. 1 In the proposed rule, sought comments from stakeholders, including the AMA RUC, on the items included in the ultrasound rooms, especially as compared to the items included in other rooms. At this time, states that they are unsure how to best reconcile the information disclosed by the manufacturer to the press and the prices submitted by the medical specialty society for use in updating the direct PE input prices. is seeking comment on the appropriate price to use as the typical cost for portable ultrasound units. As it stated in 1 http://www.jsonline.com/business/ge-seesstrong-future-with-its-ultrasound-businessuj8mn79-1953361.html

RBMA s Summary - 214 MPFS Final Rule 8 the proposed is not planning to revise the items, or to change the prices of items, included in these rooms. Instead, pending receipt and consideration of additional information, the direct PE input database will continue to include the current prices for the room, ultrasound, general (EL15), room, ultrasound, vascular (EL16), and ultrasound unit, portable (EQ25). New Equipment Inputs and Price Updates (Federal Register page 7425) finalized changes to the following ultrasound pricing based on RUC recommendations and stakeholder comments as follows. 1. Ultrasound Unit, portable, breast procedures 2. Endoscopic Ultrasound Processor 3. Bronchofibervideoscope 4. Endoscope, ultrasound probe, drive (ES15) Ultrasound Equipment Input Recommendations for Particular Services (Federal Register page 74251) For CPT code 76942 (Ultrasonic guidance for needle placement (for example, biopsy, aspiration, injection, localization device), imaging supervision and interpretation), agreed with the AMA RUC s recommendation to replace the current input of the room, ultrasound, general (EL15) with ultrasound unit, portable (EQ25). noted that this service is typically reported with other codes that describe the needle placement procedures and that the recommended change in from a room to a portable device reflects a change in the typical kinds of procedures reported with this image guidance service. In light of this change the agency decided to reconsider the procedure time assumption currently used in establishing the direct PE for this code, which is 45 minutes. As part of this reconsideration, reviewed the services reported with CPT code 76942 to identify the most common procedures furnished with this image guidance. determined that the code most frequently reported with CPT code 76942 is CPT 261 (Arthrocentesis, aspiration and/or injection; major joint or bursa (for example, shoulder, hip, knee joint, subacromial bursa). The assumed procedure time for this service is five minutes. reports that the procedure time assumptions for the vast majority of other procedures frequently reported with CPT code 76942 range from 5 to 2 minutes. Therefore, in addition to proposing the recommended change in associated with the code, the Agency proposed to change the procedure time assumption used in establishing direct PE for the service from 45 to 1 minutes, based on our analysis of 3 needle placement procedures most frequently reported with CPT code 76942. We noted that this reduced the clinical labor and minutes associated with the code from 58 to 23 minutes. received a number of comments that suggested that the AMA RUC is planning to conduct surveys and that will be better able to make changes once the results from the surveys is finalized. The agency responded that they believe they have adequate information currently available in Medicare claims database. Additional comments, suggested that had used incorrect assumptions regarding this code, not taking onto account the fact that CPT code 76942 includes supervision and interpretation, which represents both time and work that is separate from the surgical code and that the additional time included in the direct PE may reflect time in addition to the base procedure. In response, noted that they did not receive information from any commenters suggesting that the time allocated for these tasks was inadequate. Therefore, the agency is

RBMA s Summary - 214 MPFS Final Rule 9 finalizing the adjustment to the clinical labor minutes associated with this code, as proposed. Misvalued Codes (Federal Register page 74254) 1. Validation Projects (Federal Register page 74255) notes that in addition to the ongoing efforts to address misvalued codes through the typical and AMA RUC processes, they have entered into two contracts with outside entities to develop validation models for RVUs. During a 2-year project, the RAND Corporation will use available data to build a validation model to predict work RVUs and the individual components of work RVUs, time and intensity. The model design will be informed by the statistical methodologies and approach used to develop the initial work RVUs and to identify potentially misvalued procedures under current and AMA RUC processes. RAND will use a representative set of -provided codes to test the model. RAND will consult with a expert panel on model design issues and the test results. The second contract is with the Urban Institute. Given the central role of time in establishing work RVUs and the concerns that have been raised about the current time values, a key focus of the project is collecting data from several practices for services selected by the contractor. The data will be used to develop time estimates. Urban Institute will use a variety of approaches to develop objective time estimates, depending on the type of service, which will be a very resource-intensive part of the project. Objective time estimates will be compared to the current time values used in the fee schedule. The project team will then convene groups of physicians from a range of specialties to review the new time data and their potential implications for work and the ratio of work to time. 2. Publicly nominated codes (Federal Register page 74256) did not receive any publicly nominated potentially misvalued codes to be finalized in this Final rule. 3. Contractor Medical Director (CMD) Identified Potentially Misvalued Codes (Federal Register page 74256) previously proposed the codes listed below as potentially misvalued. Table 12: CPT Codes for Ultrasound Guidance CPT Code Short Descriptor 7693 Echo guide for cardiocentesis 76932 Echo guide for heart biopsy 7694 US guide tissue ablation 76948 Echo guide ova aspiration 7695 Echo guidance radiotherapy 76965 Echo guidance radiotherapy However, in response to comments that received, the agency decided to remove code 76936 from the list of potentially misvalued codes. Specifically, the comments stated that 76936 should be removed from the list because it is not an image guidance technique used to supplement a surgical procedure and the Agency agreed.

RBMA s Summary - 214 MPFS Final Rule 1 Multiple Procedure Payment Reduction (Federal Register page 74261) did not propose and, therefore, is not finalizing any new multiple procedure payment reduction (MPPR) CY 214. But, the agency continues to look at expanding the MPPR based on efficiencies when multiple procedures are furnished together. Any specific proposals would be presented in future rulemaking and subject to further public comment. Malpractice RVUs (Federal Register page 74263) For CY 214, will continue their current approach for determining malpractice RVUs for new/revised codes. The agency will publish a list of new/revised codes and the malpractice crosswalks used for determining their malpractice RVUs in the final rule with comment period. The CY 214 malpractice RVUs for new/revised codes were implemented in the CY 214 PFS final rule with comment period. These RVUs will be subject to public comment. They will then be finalized in the CY 215 PFS final rule with comment period. Technical Refinement to the Medicare Economic Index (MEI) (Federal Register page 74264) For CY 214, is finalizing revisions to the MEI based on the recommendations of the MEI Technical Advisory Panel (TAP) and new cost and price proxy data. They are not rebasing the MEI and will continue to use the data from 26 to estimate the cost weights, since these are the most recently available, relevant, and complete data available to develop these weights. For CY 214, has proposed to implement 1 of the 13 recommendations made by the MEI Technical Advisory Panel TAP. These proposed changes only involve revising the MEI categories, cost shares, and price proxies. is not proposing to rebase the MEI at this time because the MEI TAP concluded that there is not a reliable, ongoing source of data to maintain the MEI. In the meantime, the MEI TAP has recommended that Office of the Actuary (OACT) identify and evaluate additional data sources that may allow for more frequent updates to the MEI s cost categories and their respective weights. Establishing CY 214 RVUs (Federal Register page 74278) 1. CY 213 Interim Final Work RVUs Considered by the Refinement Panel (Federal Register page 7428) multispecialty refinement panel approved an increase in the work relative values for arterial and venous PTA: TABLE 23 CODES REVIEWED BY THE 213 MULTI-SPECIALTY REFINEMENT PANEL HCPCS code Short descriptor CY 213 interim final work 5.75 4.71 7.5 7.5.7.47 1.25 1.5 2. 2.5 3. 3.56 AMA RUC/ HCPAC recommended work RVU Refinement panel median rating 6.6 5.1 9. 1..92.73 1.37 1.77 2.8 3.34 4. 4.2 CY 214 RVW 35475... 35476... 93655... 93657... 95886... 95887... 9598... 9599... 9591... 95911... 92912... 95913... Angioplasty, arterial... Angioplasty, venous... Arrhythmia ablation add-on... Afibablation add-on... EMG extremity add-on... EMG non-extremity add-on... Nerve conduction studies; 3 4 studies... Nerve conduction studies; 5 6 studies... Nerve conduction studies; 7 8 studies... Nerve conduction studies; 9 1 studies... Nerve conduction studies; 11 12 studies... Nerve conduction studies; 13 or more studies... 6.6 5.1 9. 1..92.73 1.37 1.77 2.8 3.34 4. 4.2 6.6 5.1 7.5 7.5.86.71 1.25 1.5 2. 2.5 3. 3.56

RBMA s Summary - 214 MPFS Final Rule 11 2. CY 213 Interim Final Work RVUs (Federal Register page 7428) finalized its decision with respect to CY 213 codes with interim work values. Radiology codes with finalized interim values are presented below:

RBMA s Summary - 214 MPFS Final Rule 12

RBMA s Summary - 214 MPFS Final Rule 13 Interim Final Work RVUs for New/Revised/Potentially Misvalued Codes (Federal Register page 74323) evaluated the RUC s recommended work RVUs for new or revised codes for CY 214. Table 27 (see Appendix) contains actions. For some procedures, lowered the RUC s recommended value. The values are interim and subject to public comments. actions towards the RUC s values start on page 74333. Establishing Interim Final Direct PE RVUs for CY 214 (Federal Register page 74343) reviews the RUC s recommended practice expense relative values (PERVUs) for new or revised services. The agency may accept or revise the RUC s recommendations. Table 28 (see Appendix) contains those procedures where accepted the RUC s practice expense recommendations. Table 29 (see Appendix) shows those procedures for which disagreed with the RUC s recommendations. Importantly, lowered the and clinical staff for CT head (codes 745-747) and MRI brain (codes 7551-7553). Geographic Practice Cost Indices (GPCIs) (Federal Register page 7438) Section 1848(e)(1)(C) of the Act requires that if more than 1 year has elapsed since the date of the last previous GPCI adjustment, the adjustment to be applied in the first year of the next adjustment shall be 1/2 of the adjustment that otherwise would be made. Therefore, since the previous GPCI update was implemented in CY 211 and CY 212, Therefore is finalizing its proposal to phase in 1/2 of the latest GPCI adjustment in CY 214. Additionally, the 1. floor created by the American Taxpayer Relief Act (ATRA) expires on December 31, 213. The updated GPCI values were calculated by a contractor to. There are three GPCIs (work, PE, and MP), and all GPCIs are calculated through comparison to a national average for each type. Additionally, each of the three GPCIs relies on its own data source(s) and methodology for calculating its value as described below.

RBMA s Summary - 214 MPFS Final Rule 14 After consideration of the public comments received on the CY 214 GPCI update, is finalizing the CY 214 GPCI update as proposed. Specifically, the Agency is using updated BLSO ES data (29 through 211) as a replacement for 26 through 28 data for purposes of calculating the work GPCI and the employee compensation component and purchased services component of the PE GPCI. We are also using updated ACS data (28 through 21) as a replacement for 26 through 28 data for calculating the office rent component of the PE GPCI, and updated malpractice premium data (211 and 212) as a replacement for 26 through 27 data to calculate the MP GPCI. is considering options for changing the locality configurations and will provide information including a detailed analysis of the impact of the changes for physicians in future rulemaking. would also provide opportunities for public input in this process. Incident To (Federal Register page 7441) has finalized its proposal to amend current regulations to make compliance with state law a requirement for all incident to services. In addition to health and safety benefits, believes would accrue to the Medicare patient population, this approach would assure that federal dollars are not expended for services that do not meet the standards of the states in which they are being furnished, and provides the ability for the federal government to recover funds paid where services and supplies are not furnished in accordance with state law. Collecting Data on Services Furnished in Off-Campus Hospital Provider-Based Departments (Federal Register page 74427) In the proposed rule, observed that upon acquisition of a physician practice, hospitals frequently treat the practice locations as off- campus provider-based departments of the hospital and bill Medicare for services furnished at those locations under the OPPS. In order to better understand the growing trend toward hospital acquisition of physician offices and subsequent treatment of those locations as off-campus provider-based outpatient departments, considered collecting information that would allow them to analyze the frequency, type, and payment for services furnished in off-campus providerbased hospital departments. has considered several potential methods. Claims-based approaches could include (1) creating a new place of service code for off-campus departments of a provider, comparable to current place of service codes such as 22 Outpatient and 23 Emergency Room-Hospital when physician services are furnished in an off-campus provider-based department, or (2) creating a HCPCS modifier that could be reported with every code for services furnished in an off-campus provider-based department of a hospital for hospital outpatient claims. In addition, also considered asking hospitals to break out the costs and charges for their provider-based departments as outpatient service cost centers on the Medicare hospital cost report. While did not finalize a process and/or methodology for collection of this information data, the agency did receive a number of comments including some suggesting the use of a new Place of Service (POS) modifier. Specifically, some commenters believed a HCPCS modifier would be the least administratively burdensome as hospitals and physicians already report a number of claims-based modifiers. These commenters and others recommended that should consider the establishment of a new Place of Service (POS) code since they believed it would be less administratively burdensome than attaching a modifier to each service on the claim that was furnished in an off-campus provider-based department. Additionally, some commenters stated that establishing a new POS code would work better under the PFS than the OPPS since under the OPPS a single claim was more likely to contain lines for services furnished in both on-campus and off-campus parts of the hospital on the same day for the same beneficiary.

RBMA s Summary - 214 MPFS Final Rule 15 Ultrasound Screening for Abdominal Aortic Aneurysms (AAA) (Federal Register page 74437) modified coverage of AAA screening consistent with the recommendations of the USPSTF to eliminate the one-year time limit with respect to the referral for this service. This modification will allow coverage of AAA screening for eligible beneficiaries without requiring them to receive a referral as part of the initial preventive physical examination (IPPE).An eligible beneficiary for purposes of this covered service, is an individual that meets the following criteria: Has not been previously furnished AAA screening under the Medicare program; and Is included in at least one of the following risk categories: (1) has a family history of an abdominal aortic aneurysm; or (2) is a man aged 65 to 75 who has smoked at least 1 cigarettes in his lifetime. Liability for Overpayments to or on Behalf of Individuals including Payments to Providers or Other Persons (Federal Register page 74445) In accordance with the American Taxpayer Relief Act of 212, finalized its proposal to change the timeframe for which a provider is presumed for administrative purposes to be without fault for an overpayment from three years to five years. This presumption is negated if there is evidence to show that the provider or other person was responsible for causing the overpayment. Physician Compare Website (Federal Register page 74446) plans to expand its Physician Compare website to include performance and quality measures. The final rule outlines the next phase of the plan to publicly report physician performance information on Physician Compare. Physician Quality Reporting System (Federal Register page 74454) 2 The rule changes several of the quality reporting initiatives that are associated with PFS payments, including the Physician Quality Reporting System (PQRS) 3, as well as changes to the Physician Compare tool on the Medicare.gov website. Finally, the rule includes the implementation of the Value-Based Payment Modifier (Value Modifier) that affects payment rates to certain groups of 1+ based on the quality and cost of care they furnish to beneficiaries enrolled in the traditional Medicare Fee-for-Service program. Important 214 PQRS Changes The rule included several changes for the 214 PQRS program. Major changes 4 include: Total of 284 measures in 214 Increase in number of measures reported via claims and registry-based reporting mechanisms from three to nine Change in reporting threshold for both individuals and groups reporting individual measures via registry to 5 percent of the eligible professional s (EP s) applicable patients (from 8 percent) Elimination of option to report on claims-based measures groups 2 December 3, 213 listserve posting, 214 Physician Fee Schedule (PFS) Rule Updates Payment Policies and Quality Programs for Calendar Year 214 3 http://www.cms.gov/medicare/quality-initiatives-patient-assessment-instruments/pqrs/index.html 4 http://www.cms.gov/newsroom/mediareleasedatabase/fact-sheets/213-fact-sheets-items/213-11-27.html

RBMA s Summary - 214 MPFS Final Rule 16 Payment Adjustment Updates In addition, the rule the following: EPs and group practices that meet the criteria for 214 PQRS incentive will automatically avoid negative payment adjustment in 216 EPs using the claims and registry-based reporting mechanisms as well as the newly implemented qualified clinical data registry reporting mechanism may report three measures on 5 percent of their applicable patients to avoid 216 PQRS payment adjustments Elimination of option to report on claims-based measures groups to avoid future payment adjustments Group Practice Reporting Changes For groups who wish to participate using the Group Practice Reporting Option (GPRO) in 214, the rule included the following changes: Creation of new reporting mechanism, the certified survey vendor reporting mechanism, that allows a group of 25 or more EPs to count reporting of Consumer Assessment of Healthcare Providers and Systems Clinician & Group (CG CAHPS) survey measures towards meeting criteria for satisfactory reporting for the 214 PQRS incentive and 216 PQRS payment adjustment EHR Incentive Program (Federal Register page 74753) finalized new reporting options for: (1) Qualified Clinical Data Registries and (2) Comprehensive Primary Care Initiative, and (3) Electronically Specified Clinical Quality Measures. Self-Referral (Federal Register page 74791) The following codes were added to the list of codes subject to the self-referral Prohibition: o 9761 Low frequency non-thermal US o 33T Tear film img uni/bi w/i&r o 331T Heart symp image plnr o 332T Heart symp image plnr spect o 346T+ Ultrasound elastography o A952 Tc99 Tilmanocept diag.5mci o A9586 Florbetapir F18 o C9734 U/S trtmt, not leiomyomata Other Provisions of the 214 Final Rule Telehealth (Federal Register page 74399) Therapy caps (Federal Register page 7445) Chronic care management (Federal Register page 74414) Chiropractors billing E/M services (Federal Register page 74429) Medicare coverage of items and services under IDE clinical trials (Federal Register page 74429) Ambulance fee schedule (Federal Register page 74438) Clinical lab policies (Federal Register page 7444) Value-based modifier (Federal Register page 74746) E-Prescribing (Federal Register page 74787)

RBMA s Summary - 214 MPFS Final Rule 17 Appendix

RBMA s Summary - 214 MPFS Final Rule 18 TABLE 3: CPT Codes Subject to 9 Percent Equipment Utilization Rate Assumption 7336 MRI, temporomandibular joint(s) 745 Ct head/brain w/o dye 746 Ct head/brain w/ dye 747 Ct head/brain w/o & w/ dye 748 Ct orbit/ear/fossa w/o dye 7481 Ct orbit/ear/fossa w/ dye 7482 Ct orbit/ear/fossa w/o & w/ dye 7486 Ct maxillofacial w/o dye 7487 Ct maxillofacial w/ dye 7488 Ct maxillofacial w/o & w/ dye 749 Ct soft tissue neck w/o dye 7491 Ct soft tissue neck w/ dye 7492 Ct soft tissue neck w/o & w/ dye 7496 Ct angiography, head 7498 Ct angiography, neck 754 MRI orbit/face/neck w/o dye 7542 MRI orbit/face/neck w/ dye 7543 MRI orbit/face/neck w/o & w/dye 7544 Mr angiography head w/o dye 7545 Mr angiography head w/dye 7546 Mr angiography head w/o & w/dye 7547 Mr angiography neck w/o dye 7548 Mr angiography neck w/dye 7549 Mr angiography neck w/o & w/dye 7551 MRI brain w/o dye 7552 MRI brain w/dye 7553 MRI brain w/o & w/dye 7554 Fmri brain by tech 7125 Ct thorax w/o dye 7126 Ct thorax w/ dye 7127 Ct thorax w/o & w/ dye 71275 Ct angiography, chest 7155 MRI chest w/o dye 71551 MRI chest w/ dye 71552 MRI chest w/o & w/ dye 71555 MRI angio chest w/ or w/o dye 72125 CT neck spine w/o dye 72126 Ct neck spine w/dye 72127 Ct neck spine w/o & w/dye 72128 Ct chest spine w/o dye

RBMA s Summary - 214 MPFS Final Rule 19 TABLE 3: CPT Codes Subject to 9 Percent Equipment Utilization Rate Assumption 72129 Ct chest spine w/dye 7213 Ct chest spine w/o & w/dye 72131 Ct lumbar spine w/o dye 72132 Ct lumbar spine w/dye 72133 Ct lumbar spine w/o & w/dye 72141 MRI neck spine w/o dye 72142 MRI neck spine w/dye 72146 MRI chest spine w/o dye 72147 MRI chest spine w/dye 72148 MRI lumbar spine w/o dye 72149 MRI lumbar spine w/dye 72156 MRI neck spine w/o & w/dye 72157 MRI chest spine w/o & w/dye 72158 MRI lumbar spine w/o & w/dye 72159 Mr angio spone w/o&w/dye 72191 Ct angiography, pelv w/o & w/ dye 72192 Ct pelvis w/o dye 72193 Ct pelvis w/ dye 72194 Ct pelvis w/o & w/ dye 72195 MRI pelvis w/o dye 72196 MRI pelvis w/ dye 72197 MRI pelvis w/o &w/ dye 72198 MRI angio pelvis w/ or w/o dye 732 Ct upper extremity w/o dye 7321 Ct upper extremity w/dye 7322 Ct upper extremity w/o & w/dye 7326 Ct angio upper extr w/o & w/dye 73218 MRI upper extr w/o dye 73219 MRI upper extr w/dye 7322 MRI upper extremity w/o & w/dye 73221 MRI joint upper extr w/o dye 73222 MRI joint upper extr w/dye 73223 MRI joint upper extr w/o & w/dye 73225 Mr angio upr extr w/o&w/dye 737 Ct lower extremity w/o dye 7371 Ct lower extremity w/dye 7372 Ct lower extremity w/o & w/dye 7376 Ct angio lower ext w/o & w/dye 73718 MRI lower extremity w/o dye 73719 MRI lower extremity w/dye 7372 MRI lower ext w/ & w/o dye

RBMA s Summary - 214 MPFS Final Rule 2 TABLE 3: CPT Codes Subject to 9 Percent Equipment Utilization Rate Assumption 73721 MRI joint of lwr extre w/o dye 73722 MRI joint of lwr extr w/dye 73723 MRI joint of lwr extr w/o & w/dye 73725 Mr angio lower ext w or w/o dye 7415 Ct abdomen w/o dye 7416 Ct abdomen w/ dye 7417 Ct abdomen w/o & w/ dye 74174 Ct angiography, abdomen and pelvis w/o & w/ dye 74175 Ct angiography, abdom w/o & w/ dye 74176 Ct abdomen and pelvis w/o dye 74177 Ct abdomen and pelvis w/dye 74178 Ct abdomen and pelvis w/ and w/o dye 74181 MRI abdomen w/o dye 74182 MRI abdomen w/ dye 74183 MRI abdomen w/o and w/ dye 74185 MRI angio, abdom w/ or w/o dye 74261 Ct colonography, w/o dye 74262 Ct colonography, w/ dye 75557 Cardiac mri for morph 75559 Cardiac mri w/stress img 75561 Cardiac mri for morph w/dye 75563 Cardiac mri w/stress img & dye 75565 Card mri vel flw map add-on 75571 Ct hrt w/o dye w/ca test 75572 Ct hrt w/3d image 75573 Ct hrt w/3d image, congen 75574 Ct angio hrt w/3d image 75635 Ct angio abdominal arteries 7638 CAT scan follow up study 7758 MRI, one breast 7759 MRI, broth breasts 7778 Ct bone density, axial 7784 MRI bone marrow

RBMA s Summary - 214 MPFS Final Rule 21 Table 27: Interim Final Work RVUs for Select New/Revised/Potentially Misvalued Codes HCPCS Code Long Descriptor CY 213 Work RVU AMA RUC/ HCPAC Recommended Work RVU CY 214 Work RVU Time Refinement 1981 1982 1983 1984 1985 Biopsy, breast, with placement of breast localization device(s) (eg, clip, metallic pellet), when performed, and imaging of the biopsy specimen, when performed, percutaneous; first lesion, including stereotactic guidance Biopsy, breast, with placement of breast localization device(s) (eg, clip, metallic pellet), when performed, and imaging of the biopsy specimen, when performed, percutaneous; each additional lesion, including stereotactic guidance (list separately in addition to code for primary procedure) Biopsy, breast, with placement of breast localization device(s) (eg, clip, metallic pellet), when performed, and imaging of the biopsy specimen, when performed, percutaneous; first lesion, including ultrasound guidance Biopsy, breast, with placement of breast localization device(s) (eg, clip, metallic pellet), when performed, and imaging of the biopsy specimen, when performed, percutaneous; each additional lesion, including ultrasound guidance (list separately in addition to code for primary procedure) Biopsy, breast, with placement of breast localization device(s) (eg, clip, metallic pellet), when performed, and imaging of the biopsy specimen, when performed, percutaneous; first lesion, including magnetic resonance guidance New 3.29 3.29 No New 1.65 1.65 No New 3.1 3.1 No New 1.55 1.55 No New 3.64 3.64 No 1986 19281 Biopsy, breast, with placement of breast localization device(s) (eg, clip, metallic pellet), when performed, and imaging of the biopsy specimen, when performed, percutaneous; each additional lesion, including magnetic resonance guidance (list separately in addition to code for primary procedure) Placement of breast localization device(s) (eg, clip, metallic pellet, wire/needle, radioactive seeds), percutaneous; first lesion, including mammographic guidance New 1.82 1.82 No New 2. 2. No

RBMA s Summary - 214 MPFS Final Rule 22 HCPCS Code Long Descriptor CY 213 Work RVU AMA RUC/ HCPAC Recommended Work RVU CY 214 Work RVU Time Refinement 19282 19283 Placement of breast localization device(s) (eg, clip, metallic pellet, wire/needle, radioactive seeds), percutaneous; each additional lesion, including mammographic guidance (list separately in addition to code for primary procedure) Placement of breast localization device(s) (eg, clip, metallic pellet, wire/needle,radioactive seeds), percutaneous; first lesion, including stereotactic guidance New 1. 1. No New 2. 2. No 19284 19285 Placement of breast localization device(s) (eg, clip, metallic pellet, wire/needle, radioactive seeds), percutaneous; each additional lesion, including stereotactic guidance (list separately in addition to code for primary procedure) Placement of breast localization device(s) (eg, clip, metallic pellet, wire/needle, radioactive seeds), percutaneous; first lesion, including ultrasound guidance New 1. 1. No New 1.7 1.7 No 19286 19287 19288 Placement of breast localization device(s) (eg, clip, metallic pellet, wire/needle, radioactive seeds), percutaneous; each additional lesion, including ultrasound guidance (list separately in addition to code for primary procedure) Placement of breast localization device(s) (eg clip, metallic pellet, wire/needle, radioactive seeds), percutaneous; first lesion, including magnetic resonance guidance Placement of breast localization device(s) (eg clip, metallic pellet, wire/needle, radioactive seeds), percutaneous; each additional lesion, including magnetic resonance guidance (list separately in addition to code for primary procedure) New.85.85 Yes New 3.2 2.55 No New 1.51 1.28 No

RBMA s Summary - 214 MPFS Final Rule 23 HCPCS Code Long Descriptor CY 213 Work RVU AMA RUC/ HCPAC Recommended Work RVU CY 214 Work RVU Time Refinement 34841 Endovascular repair of visceral aorta (eg, aneurysm, pseudoaneurysm, dissection, penetrating ulcer, intramural hematoma, or traumatic disruption) by deployment of a fenestrated visceral aortic endograft and all associated radiological supervision and interpretation, including target zone angioplasty, when performed; including one visceral artery endoprosthesis (superior mesenteric, celiac or renal artery) New C C N/A 34842 Endovascular repair of visceral aorta (eg, aneurysm, pseudoaneurysm, dissection, penetrating ulcer, intramural hematoma, or traumatic disruption) by deployment of a fenestrated visceral aortic endograft and all associated radiological supervision and interpretation, including target zone angioplasty, when performed; including two visceral artery endoprostheses (superior mesenteric, celiac and/or renal artery[s]) New C C N/A 34843 Endovascular repair of visceral aorta (eg, aneurysm, pseudoaneurysm, dissection, penetrating ulcer, intramural hematoma, or traumatic disruption) by deployment of a fenestrated visceral aortic endograft and all associated radiological supervision and interpretation, including target zone angioplasty, when performed; including three visceral artery endoprostheses (superior mesenteric, celiac and/or renal artery[s]) New C C N/A 34844 Endovascular repair of visceral aorta (eg, aneurysm, pseudoaneurysm, dissection, penetrating ulcer, intramural hematoma, or traumatic disruption) by deployment of a fenestrated visceral aortic endograft and all associated radiological supervision and interpretation, including target zone angioplasty, when performed; including four or more visceral artery endoprostheses (superior mesenteric, celiac and/or renal artery[s]) New C C N/A

RBMA s Summary - 214 MPFS Final Rule 24 HCPCS Code Long Descriptor CY 213 Work RVU AMA RUC/ HCPAC Recommended Work RVU CY 214 Work RVU Time Refinement 34845 34846 34847 Endovascular repair of visceral aorta and infrarenal abdominal aorta (eg, aneurysm, pseudoaneurysm, dissection, penetrating ulcer, intramural hematoma, or traumatic disruption) with a fenestrated visceral aortic endograft and concomitant unibody or modular infrarenal aortic endograft and all associated radiological supervision and interpretation, including target zone angioplasty, when performed; including one visceral artery endoprosthesis (superior mesenteric, celiac or renal artery) Endovascular repair of visceral aorta and infrarenal abdominal aorta (eg, aneurysm, pseudoaneurysm, dissection, penetrating ulcer, intramural hematoma, or traumatic disruption) with a fenestrated visceral aortic endograft and concomitant unibody or modular infrarenal aortic endograft and all associated radiological supervision and interpretation, including target zone angioplasty, when performed; including two visceral artery endoprostheses (superior mesenteric, celiac and/or renal artery[s]) Endovascular repair of visceral aorta and infrarenal abdominal aorta (eg, aneurysm, pseudoaneurysm, dissection, penetrating ulcer, intramural hematoma, or traumatic disruption) with a fenestrated visceral aortic endograft and concomitant unibody or modular infrarenal aortic endograft and all associated radiological supervision and interpretation, including target zone angioplasty, when performed; including three visceral artery endoprostheses (superior mesenteric, celiac and/or renal artery[s]) New C C N/A New C C N/A New C C N/A