United States: CMS Releases Proposed 2015 Physician Fee Schedule And Outpatient Prospective Payment System Rules

On July 3, 2014, the Centers for Medicare and Medicaid Services ("CMS") released its proposed Calendar Year ("CY") 2015 Physician Fee Schedule ("PFS") Proposed Rule, to be published in the Federal Register on July 11, 2014. The rule proposes the 2015 relative value units ("RVUs") for the PFS and other Medicare Part B payment policies, as well as a number of other changes, the most significant of which are summarized briefly in the list below.

Also on July 3rd, CMS released its CY 2015 Hospital Outpatient Prospective Payment and Ambulatory Surgical Center Payment Systems Proposed Rule, to be published in the Federal Register on July 14, 2014. The rule proposes revisions to the Medicare hospital outpatient prospective payment system ("OPPS"), including an outpatient department fee schedule increase of 2.1%. The rule also proposes revisions to the Medicare ambulatory surgical center ("ASC") payment system, including a rate increase of 1.2%. Other proposed changes of significance are summarized briefly below.

Comments on these proposed rules are due by September 2, 2014.

Additional Topics Covered in the 2015 PFS Proposed Rule

  • Misvalued Codes. CMS identifies 65 proposed potentially misvalued CPT codes as part of a newly-established statutory category of codes that account for the majority of spending under the PFS. The proposed list includes skin biopsies, ultrasound therapy, hearing tests, and chest and knee x-rays.
  • Telehealth. CMS proposes the addition of several new services to its list of covered telehealth services, including psychoanalysis, family psychotherapy, annual wellness visits (initial and subsequent visits), and prolonged services in an outpatient setting.
  • Chronic Care Management. CMS proposes RVUs for chronic care management services (e.g., 0.61 Physician Work RVUs), proposes to revise the physician supervision requirements for such services, and proposes to require chronic care management practitioners to utilize electronic health record technology certified to meet at least the 2014 Edition meaningful use criteria.
  • Medicare Shared Savings Program Quality Metrics. CMS proposes to expand and modify the list of quality performance standards from the current 33 measure set to a 37 measure set by adding 12 new measures and retiring 8 measures in order to improve alignment with reporting requirements under PQRS and the EHR Incentive Program. Performance under the new measures would be assessed by CMS based on claims data or from a patient survey.
  • Physician Quality Reporting System (PQRS). CMS proposes to require reporting on all available PQRS cross-cutting measures for eligible professionals or group practices using qualified registries to report PQRS measures. Eligible providers affiliated with Critical Access Hospitals will be able to report using all methods—including claims-based reporting—in 2015. CMS will change the annual reporting deadline from February 28th to March 31st following the end of the calendar year reporting period and is seeking comment on whether to propose more frequent data submissions during the reporting period.
  • Physician Compare Website. CMS continues to increase the scope of publicly available physician performance data and will publicly report data in 2016 for physician groups with as few as two physicians. CMS also seeks comment on the development of performance benchmarks using the methodology published in the 2011 Accountable Care Organization (ACO) Final Rule and composite performance scores derived from PQRS measures with respect to both physician groups and individual physicians.
  • Sunshine Act Reporting Changes. CMS proposes to delete the definition of "covered device" as duplicative, proposes to remove the exclusion for speaker payments at continuing education events, proposes required reporting of marketed drug names, and proposes the required reporting of stocks, options, and ownership interests as distinct categories of payment.
  • Services Furnished at Rural Health Clinics and Federally Qualified Health Centers. CMS proposes to remove the employment requirement for services furnished by nurses, medical assistants and other auxiliary personnel that are "incident to" Rural Health Clinic & Federally Qualified Health Center visits.

Additional Topics Covered in the 2015 OPPS Proposed Rule

  • Packaging Policies. CMS proposes to conditionally package certain ancillary services when they are integral, ancillary, supportive, dependent or adjunctive to a primary service. Preventive services will continue to be paid separately. In addition, CMS is not proposing to package certain psychiatry and counseling-related services. CMS is also not proposing to package certain low cost drug administration services.
  • Comprehensive APCs. CMS proposes to implement comprehensive Ambulatory Payment Classifications ("APC") with a set of 28 comprehensive APCs that provide a single Medicare payment and single beneficiary copayment for a primary service and all adjunctive services and supplies.
  • Rural Adjustments. CMS proposes to continue the 7.1% adjustment to OPPS payments for certain rural sole community hospitals, including essential access community hospitals.
  • Requests for Expansion of Physician-Owned Hospitals. CMS proposes to permit physician-owned hospitals to use data from certain internal or external data sources, in addition to HCRIS data, to support expansion requests.
  • Physician Certification. CMS proposes to require physician certification for hospital inpatient admissions only for long-stay cases and outlier cases.
  • Medicare Advantage and Part D Appeals Process. CMS proposes to establish a three level appeals process for Medicare Advantage organizations and Part D sponsors that would be applicable to CMS-identified overpayments associated with data submitted by such organizations and sponsors.
  • Hospital Outpatient Quality Reporting (OQR) Program. CMS will impose a two percent reduction to unadjusted national OPPS rates and the minimum unadjusted and national unadjusted applicable payment rates for the full calendar year (CY) 2015 for hospitals that failed to meet the OQR reporting requirements. For the CY 2017 payment determination, CMS is not proposing new requirements for chart-abstracted data submission, but is adding an additional claims-based measure for colonoscopy. CMS is also proposing a four-month period for review and corrections of chart-abstracted data for the OQR Program following the close of the quarterly reporting period.
  • Ambulatory Surgery Center Quality Reporting (ASCQR) Program. As with the OQR Program, CMS proposes adding a Medicare Fee for Service claims-based colonoscopy measure to the ASCQR Program for the CY 2017 payment determination and subsequent years. CMS also will continue to apply a 2.0 percentage point reduction to the annual update for ASCs that failure to meet the reporting requirements of the ASCQR Program.

The content of this article is intended to provide a general guide to the subject matter. Specialist advice should be sought about your specific circumstances.

To print this article, all you need is to be registered on Mondaq.com.

Click to Login as an existing user or Register so you can print this article.

Similar Articles
Relevancy Powered by MondaqAI
In association with
Related Topics
Similar Articles
Relevancy Powered by MondaqAI
Related Articles
Related Video
Up-coming Events Search
Font Size:
Mondaq on Twitter
Register for Access and our Free Biweekly Alert for
This service is completely free. Access 250,000 archived articles from 100+ countries and get a personalised email twice a week covering developments (and yes, our lawyers like to think you’ve read our Disclaimer).
Email Address
Company Name
Confirm Password
Mondaq Topics -- Select your Interests
 Law Performance
 Law Practice
 Media & IT
 Real Estate
 Wealth Mgt
Asia Pacific
European Union
Latin America
Middle East
United States
Worldwide Updates
Registration (you must scroll down to set your data preferences)

Mondaq Ltd requires you to register and provide information that personally identifies you, including your content preferences, for three primary purposes (full details of Mondaq’s use of your personal data can be found in our Privacy and Cookies Notice):

  • To allow you to personalize the Mondaq websites you are visiting to show content ("Content") relevant to your interests.
  • To enable features such as password reminder, news alerts, email a colleague, and linking from Mondaq (and its affiliate sites) to your website.
  • To produce demographic feedback for our content providers ("Contributors") who contribute Content for free for your use.

Mondaq hopes that our registered users will support us in maintaining our free to view business model by consenting to our use of your personal data as described below.

Mondaq has a "free to view" business model. Our services are paid for by Contributors in exchange for Mondaq providing them with access to information about who accesses their content. Once personal data is transferred to our Contributors they become a data controller of this personal data. They use it to measure the response that their articles are receiving, as a form of market research. They may also use it to provide Mondaq users with information about their products and services.

Details of each Contributor to which your personal data will be transferred is clearly stated within the Content that you access. For full details of how this Contributor will use your personal data, you should review the Contributor’s own Privacy Notice.

Please indicate your preference below:

Yes, I am happy to support Mondaq in maintaining its free to view business model by agreeing to allow Mondaq to share my personal data with Contributors whose Content I access
No, I do not want Mondaq to share my personal data with Contributors

Also please let us know whether you are happy to receive communications promoting products and services offered by Mondaq:

Yes, I am happy to received promotional communications from Mondaq
No, please do not send me promotional communications from Mondaq
Terms & Conditions

Mondaq.com (the Website) is owned and managed by Mondaq Ltd (Mondaq). Mondaq grants you a non-exclusive, revocable licence to access the Website and associated services, such as the Mondaq News Alerts (Services), subject to and in consideration of your compliance with the following terms and conditions of use (Terms). Your use of the Website and/or Services constitutes your agreement to the Terms. Mondaq may terminate your use of the Website and Services if you are in breach of these Terms or if Mondaq decides to terminate the licence granted hereunder for any reason whatsoever.

Use of www.mondaq.com

To Use Mondaq.com you must be: eighteen (18) years old or over; legally capable of entering into binding contracts; and not in any way prohibited by the applicable law to enter into these Terms in the jurisdiction which you are currently located.

You may use the Website as an unregistered user, however, you are required to register as a user if you wish to read the full text of the Content or to receive the Services.

You may not modify, publish, transmit, transfer or sell, reproduce, create derivative works from, distribute, perform, link, display, or in any way exploit any of the Content, in whole or in part, except as expressly permitted in these Terms or with the prior written consent of Mondaq. You may not use electronic or other means to extract details or information from the Content. Nor shall you extract information about users or Contributors in order to offer them any services or products.

In your use of the Website and/or Services you shall: comply with all applicable laws, regulations, directives and legislations which apply to your Use of the Website and/or Services in whatever country you are physically located including without limitation any and all consumer law, export control laws and regulations; provide to us true, correct and accurate information and promptly inform us in the event that any information that you have provided to us changes or becomes inaccurate; notify Mondaq immediately of any circumstances where you have reason to believe that any Intellectual Property Rights or any other rights of any third party may have been infringed; co-operate with reasonable security or other checks or requests for information made by Mondaq from time to time; and at all times be fully liable for the breach of any of these Terms by a third party using your login details to access the Website and/or Services

however, you shall not: do anything likely to impair, interfere with or damage or cause harm or distress to any persons, or the network; do anything that will infringe any Intellectual Property Rights or other rights of Mondaq or any third party; or use the Website, Services and/or Content otherwise than in accordance with these Terms; use any trade marks or service marks of Mondaq or the Contributors, or do anything which may be seen to take unfair advantage of the reputation and goodwill of Mondaq or the Contributors, or the Website, Services and/or Content.

Mondaq reserves the right, in its sole discretion, to take any action that it deems necessary and appropriate in the event it considers that there is a breach or threatened breach of the Terms.

Mondaq’s Rights and Obligations

Unless otherwise expressly set out to the contrary, nothing in these Terms shall serve to transfer from Mondaq to you, any Intellectual Property Rights owned by and/or licensed to Mondaq and all rights, title and interest in and to such Intellectual Property Rights will remain exclusively with Mondaq and/or its licensors.

Mondaq shall use its reasonable endeavours to make the Website and Services available to you at all times, but we cannot guarantee an uninterrupted and fault free service.

Mondaq reserves the right to make changes to the services and/or the Website or part thereof, from time to time, and we may add, remove, modify and/or vary any elements of features and functionalities of the Website or the services.

Mondaq also reserves the right from time to time to monitor your Use of the Website and/or services.


The Content is general information only. It is not intended to constitute legal advice or seek to be the complete and comprehensive statement of the law, nor is it intended to address your specific requirements or provide advice on which reliance should be placed. Mondaq and/or its Contributors and other suppliers make no representations about the suitability of the information contained in the Content for any purpose. All Content provided "as is" without warranty of any kind. Mondaq and/or its Contributors and other suppliers hereby exclude and disclaim all representations, warranties or guarantees with regard to the Content, including all implied warranties and conditions of merchantability, fitness for a particular purpose, title and non-infringement. To the maximum extent permitted by law, Mondaq expressly excludes all representations, warranties, obligations, and liabilities arising out of or in connection with all Content. In no event shall Mondaq and/or its respective suppliers be liable for any special, indirect or consequential damages or any damages whatsoever resulting from loss of use, data or profits, whether in an action of contract, negligence or other tortious action, arising out of or in connection with the use of the Content or performance of Mondaq’s Services.


Mondaq may alter or amend these Terms by amending them on the Website. By continuing to Use the Services and/or the Website after such amendment, you will be deemed to have accepted any amendment to these Terms.

These Terms shall be governed by and construed in accordance with the laws of England and Wales and you irrevocably submit to the exclusive jurisdiction of the courts of England and Wales to settle any dispute which may arise out of or in connection with these Terms. If you live outside the United Kingdom, English law shall apply only to the extent that English law shall not deprive you of any legal protection accorded in accordance with the law of the place where you are habitually resident ("Local Law"). In the event English law deprives you of any legal protection which is accorded to you under Local Law, then these terms shall be governed by Local Law and any dispute or claim arising out of or in connection with these Terms shall be subject to the non-exclusive jurisdiction of the courts where you are habitually resident.

You may print and keep a copy of these Terms, which form the entire agreement between you and Mondaq and supersede any other communications or advertising in respect of the Service and/or the Website.

No delay in exercising or non-exercise by you and/or Mondaq of any of its rights under or in connection with these Terms shall operate as a waiver or release of each of your or Mondaq’s right. Rather, any such waiver or release must be specifically granted in writing signed by the party granting it.

If any part of these Terms is held unenforceable, that part shall be enforced to the maximum extent permissible so as to give effect to the intent of the parties, and the Terms shall continue in full force and effect.

Mondaq shall not incur any liability to you on account of any loss or damage resulting from any delay or failure to perform all or any part of these Terms if such delay or failure is caused, in whole or in part, by events, occurrences, or causes beyond the control of Mondaq. Such events, occurrences or causes will include, without limitation, acts of God, strikes, lockouts, server and network failure, riots, acts of war, earthquakes, fire and explosions.

By clicking Register you state you have read and agree to our Terms and Conditions