Cardiology Coding Alert


Keep Tabs on Conversion Factor and Advance Care Planning Updates With 2016 MPFS Overview

Find answers to questions about ‘incident to’ and global periods.

The 2016 Medicare Physician Fee Schedule (MPFS) Final Rule With Comment Period indicates cardiology can expect the year’s fee schedule to have a 0 percent impact on cardiology’s total allowed charges. But the MPFS has more to share than the percent of total impact. Let our experts walk you through some MPFS highlights you need to know.

Size Up ‘Incident To’ Language

The Medicare concept of billing  “incident to” a physician means a non-physician practitioner (NPP) can bill under the national provider identifier (NPI) of a supervising physician (who is present in the office) for 100 percent reimbursement. You can bill this way only for an established patient receiving service under a care plan put in place by a physician in the practice.

In the July 15 proposed 2016 MPFS, CMS listed potential changes that left many in the industry confused about who may bill “incident to” services.

Final rule: In response to comments regarding the proposed “incident to” change, CMS states in the final rule, “The proposed policy was not intended to require that the supervising physician or other practitioner must be the same individual as the physician or other practitioner who orders or refers the beneficiary for the services, or who initiates treatment. Rather, we intended to clarify that under circumstances where the supervising practitioner is not the same as the referring, ordering, or treating practitioner, only the supervising practitioner may bill Medicare for the incident to service.”

Still relevant: CMS also proposed that the person providing the incident-to service do so in accordance with state law and is licensed to do it. The incident-to provider also cannot have been excluded from any federal health care program or have had their enrollment revoked for any reason. In other words, just because the service is billed under a supervising doctor’s number doesn’t mean it’s OK for the performing NPP to be excluded from Medicare. These guidelines will still apply in 2016.

Don’t Write Off Global Periods

At the end of 2014, CMS put forth a proposal in the Federal Register that shocked many coding professionals. Under the plan, the current 10-day global codes would transition to 0-day in 2017, and the 90-day global codes would change to 0-day in 2018. The result could be a pay cut for surgeons, says Michael A. Ferragamo, MD, FACS, clinical assistant professor at the State University of New York at Stony Brook.

Update: The MPFS final rule notes that the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), enacted earlier this year, prohibits CMS “from implementing the policy established in the CY 2015 PFS final rule with comment period that would have transitioned all 10-day and 90-day global surgery packages to 0-day global periods.”

Outlook: “It’s hard to say definitively if the removal of global period would be good or bad for physicians as I think there are good and bad aspects,” says Marcella Bucknam, CPC, CPC-I, CCS-P, CPC-H, CCS, CPC-P, COBGC, CCC, internal audit manager with Peace Health in Vancouver, Wash. “Certainly the potential is there for surgeons to make more money, especially for patients who are very sick and require more follow up or for patients who develop complications. At this time, Medicare bundles all of that.” On the other hand, Bucknam says surgeons would need to change their thinking and their documentation, improving the details they include, for post-operative visits or face drastic reductions in reimbursement.

The Heart Rhythm Society, in its comments on the proposed MPFS, indicated concerns with the elimination of global periods because basic E/M reimbursement wouldn’t take into account the actual resources an electrophysiologist uses during follow-up care (

Change may still come: “Unfortunately, we will likely see this pay cut in global payments in the near future,” Ferragamo says.

Bucknam agrees: “I do think that CMS will eventually eliminate global periods one way or the other,” she says. “Consider the proposals to bundle payments for hospital care. Hospitals do not have global period for surgery. That is particularly for physicians. If payments are bundled, I think it is likely the global period concept will not apply. There are also some other new payment methodologies that are being tossed about that would work much better if a global period wasn’t part of the equation.”

CMS action: The 2016 MPFS final rule states that beginning no later than Jan. 1, 2017, CMS will develop a process “to gather information needed to value surgical services from a representative sample of physicians… [including] the number and level of medical visits furnished during the global period and other items and services related to the surgery, as appropriate.” Then, “beginning in CY 2019, [CMS] must use the information collected as appropriate, along with other available data, to improve the accuracy of valuation of surgical services under the PFS.”

Handle Conversion Factor Ups and Downs

The conversion factor at the end of 2015 is 35.9335. The MPFS Final Rule indicates the 2016 conversion factor is a little lower at 35.8279.

The change is a combination of an increase of 0.5 percent required by MACRA and a reduction based on a budget neutrality adjustment and target recapture, which is related to an adjustment based on misvalued codes.

Recall that you calculate MPFS fees by multiplying the conversion factor times relative value units (RVUs) and then adjusting based on geographic location.

Reel in Advance Care Planning Reimbursement

You may see payment for advance care planning in 2016. The 2016 MPFS will change the status of advance care planning (ACP) codes 99497 and 99498 (Advance care planning including the explanation and discussion of advance directives such as standard forms [with completion of such forms, when performed], by the physician or other qualified health care professional …) from I (not valid) to A (active).

The example the rule gives is a “68 year old male with heart failure and diabetes on multiple medications seen by his physician for the E/M of these two diseases, including adjusting medications as appropriate.  In addition to discussing the patient’s short-term treatment options, the patient may express interest in discussing long-term treatment options and planning, such as the possibility of a heart transplant if his congestive heart failure worsens and advance care planning including the patient’s desire for care and treatment if he suffers a health event that adversely affects his decision-making capacity. In this case the physician would report a standard E/M code for the E/M service and one or both of the ACP codes depending upon the duration of the ACP service. However the ACP service as described in this example would not necessarily have to occur on the same day as the E/M service.”

In line with the CPT® descriptor’s reference to “the physician or other qualified healthcare professional,” physicians or NPPs may report the service. According to the Final Rule, “we expect the billing physician or NPP to manage, participate, and meaningfully contribute to the provision of the services, in addition to providing a minimum of direct supervision.”