General Overview of the Proposed 2016 Physician Fee Schedule

The Social Security Act (the Act) requires the Centers for Medicare & Medicaid Services (CMS) to establish payments under the Physician Fee Schedule (PFS) based on national uniform relative value units (RVUs) that account for the relative resources used in providing a service. The Act requires that RVUs be established for three categories of resources: work, practice expense and malpractice expense. The Act also requires CMS to establish by regulation each year’s payment amounts for all physicians’ services paid under the PFS, incorporating geographic adjustments to reflect the variations in the costs of furnishing services in different geographic areas. There are over 1 million physicians, other practitioners, and medical suppliers that receive Medicare payment under the PFS for more than 7,400 services.

In this proposed rule released on July 8, 2015, CMS establishes RVUs for Calendar Year (CY) 2016 for the PFS and other Medicare Part B payment policies to ensure that CMS payment systems are updated to reflect changes in medical practice and the relative value of services, as well as changes in the statute. In addition, this proposed rule includes discussions and proposals regarding:

• Potentially Misvalued PFS Codes
• Telehealth Services
• Advance Care Planning Services
• Establishing Values for New, Revised, and Misvalued Codes
• Target for Relative Value Adjustments for Misvalued Services
• Phase-in of Significant RVU Reductions
• “Incident to” policy
• Portable X-Ray Transportation Fee
• Updating the Ambulance Fee Schedule regulations
• Changes in Geographic Area Delineations for Ambulance Payment
• Chronic Care Management Services for RHCs and FQHCs
• HCPCS Coding for RHCs
• Payment to Grandfathered Tribal FQHCs that were Provider-Based Clinics on or before April 7, 2000
• Payment for Biosimilars under Medicare Part B
• Physician Compare Website
• Physician Quality Reporting System
• Medicare Shared Savings Program
• Electronic Health Record Incentive Program
• Value-Based Payment Modifier and the Physician Feedback Program

CMS is accepting comments on the proposed rule until 5 p.m. ET on September 8, 2015. The final rule will be released by November 1, 2015 and will go into effect on January 1, 2016.

Changes to RVUs and Reimbursements for Spine Codes

ISASS staff looked at commonly used CPT codes for spine and compared the 2015 final RVUs and reimbursements to the proposed 2016 RVUs and reimbursements in the Excel spreadsheet linked below. There are approximately 205 codes listed. If you are curious about a procedure you do not see listed in the spreadsheet, please email ISASS/IASP Director of Health Policy and Advocacy, Liz Vogt (liz@isass.org) and she will pull the information for you. Be sure to pay particular attention to the last column in the spreadsheet labeled “Difference in Reimbursement from 2015 to 2016” as it shows the difference in reimbursement from 2015 to 2016. The following is a list of codes with a change in reimbursement greater than $100:

• CPT 22112 (remove part thoracic vertebra) -$152.35
• CPT 22586 (pre-sacral fuse with instrumentation L5-S1) -$228.64
• CPT 22812 (anterior fusion, 8 or more vertebral segments) +$236.99
• CPT 22857 (lumbar artificial discectomy) +$211.29
• CPT 22857 (lumbar artificial discectomy) +$211.29
• CPT 22862 (revise lumbar artificial disc) +$651.32
• CPT 27279 (MIS SIJ fusion) +$148.71
• CPT 27280 (open SIJ fusion) +$303.03
• CPT 63182 (laminectomy and section of dentate ligaments, with or without dural graft, cervical, more than 2 segments) -$298.76
• CPT 63195 (laminectomy with cordotomy, thoracic) +$432.74
• CPT 63250 (laminectomy for excision or occlusion of arteriovenous malformation of spinal cord, cervical) -$198.20
• CPT 63306 (vertebral corpectomy, intradural, thoracic by thoracolumbar approach) +$351.10
• CPT 63307 (vertebral corpectomy, intradural, lumbar or sacral by transpirational or retroperitoneal approach) +$151.34

Important Links

Comparison of 2015 RVUs and Reimbursements for Spine Codes to Proposed 2016 RVUs and Reimbursements →

Summary of the Proposed 2016 Physician Fee Schedule for ISASS Members (PDF) →

Full Text of Proposed Rule →

CMS Fact Sheet →

CMS Power Point Presentation →

Submit Individual Comments to CMS on the Proposed Rule →

Note: Click on the blue “Comment Now!” button in the upper right hand corner.