New Medicare Rules Ease Regulations, Expose Physician Performance

By Infinx
January 30, 2018

The Centers for Medicare and Medicaid Services (CMS) continually adjusts, changes and creates new Medicare rules and requirements that regulate reimbursement (the Medicare Physician Fee Schedule). As a physician, you must keep up-to-date on on these rules to get paid for care delivered to your Medicare patients. However, this can be an arduous task due to the sheer number of changes that CMS makes in any given year.

In this blog, we explore three recent Medicare Rule changes of which every physician should be aware. These changes increase exposure on performance rankings, ease restrictions on hip and cardiac bundled payments, and increase payment categories for rural health clinics.

Did you know physician performance is now available to the public?

One of the new rules for 2018 is that CMS increased the amount of quality information on its physician performance to the Physician Compare website. For the first time, five-star ratings have been added to physician profiles, making it easy for patients to see physician performance in several different categories of care for 2016. CMS has posted rankings by types of care in several different specialties:

  • Preventive care: General health
  • Preventive care: Cancer screening
  • Patient safety
  • Care planning
  • Diabetes
  • Heart disease
  • Respiratory diseases
  • Behavioral health

The new rating system reports data from a subset of Physician Quality Reporting System (PQRS) quality measures. These data report benchmarked performance rates grouped by practice types in 2016. They give patients a granular look at physician performance in several different, and highly specific, areas:

  • #06: Giving antiplatelet blood thinners to patients with heart disease
  • #47: Older patients who have an advanced care plan
  • #48: Evaluating loss of bladder control in older women
  • #51: Spirometry evaluation
  • #226: Screening for tobacco use and providing help quitting when needed
  • #238: Limiting high-risk medicine use in older adults
  • #412: Signed opioid treatment agreements for patients who are prescribed opioids.

Physicians can sign in to the provider quality portal to review their profile and rankings. Unfortunately, the window in which physicians can comment on or edit their rankings has passed.

Other information CMS has made public includes:

  • 2016 Physician Quality Reporting System (PQRS) measures (clinician and group)
  • 2016 CAHPS for PQRS measures (group)
  • 2016 non-PQRS QCDR measures (clinician and group)

Did you know there are new rules for hip and cardiac bundles?

Another new CMS rule for 2018 may please some providers, especially those practicing in rural areas. As of January 1, 2018, CMS canceled mandatory bundled payments for hip fractures and cardiac care. CMS says it made the change to “offer greater flexibility and choice for hospitals” that care for Medicare patients. The changes affect the regulations within the CMS Comprehensive Care for Joint Replacement (CJR) model.

CMS also shrunk the number of geographic areas that have to participate in CJR from 67 to 34 areas. In a nod to rural physicians and hospitals, CMS made participation in CJR voluntary instead of mandatory for providers in those 34 geographic areas.

Did you know there are changes to the value modifier?

The Value Modifier isn’t new. It has been rolled out in phases gradually since 2015 and determines physician Medicare payments based on quality and cost performance measures. New CMS rules as part of phase 4 of the rollout became effective on January 1, 2018, and expand the types of providers that will receive reimbursement under the program. Now physician assistants, nurse practitioners, clinical nurse specialists, and certified registered nurse anesthetists, “who are solo practitioners or in groups of 2 or more eligible professionals” will receive reimbursement based on their 2016 performance.

Did you know there is added reimbursement for rural clinics?

This year new Medicare rules have established new rural health clinic “Care Management Services” that are primarily expanded payment categories for rural health clinics. Reimbursement is now available for:

  1. Chronic Care Management(CCM)
  2. General Behavioral Health Integration services
  3. Psychiatric Collaborate Care Model (CoCM)

According to CMS, the opportunity for reimbursement occurs when “20 minutes or more of CCM or general BHI services are furnished, and G0511 is billed either alone or with other payable services.”

When it comes to CoCM, the opportunity for reimbursement begins when “70 minutes or more of initial psychiatric CoCM services or 60 minutes or more of subsequent psychiatric CoCM services are furnished, and G0512 is billed either alone or with other payable services on an RHC claim.”

Staying apprised of CMS changes is never easy, but it is essential. These new Medicare rules discussed above directly affect practice and hospital reimbursement. Complying with performance and quality criteria this year will affect your reimbursements two years down the road. As we’ve seen here, the good news is that CMS seems to be listening to physician groups who say the regulations are too onerous, and they are loosening up the reins a bit.

About the Author



Infinx provides innovative and scalable payment lifecycle solutions for healthcare practices. Combining an intelligent, cloud-based platform driven by AI with our trained and certified coding and billing specialists, we help clients realize revenue, enabling them to shift focus from administrative details to billable patient care.

Leave A Comment