News and noteworthy information for October:


Medicare Administrative Contractor News

NGS Medicare – Draft LCD for MIS SIJ Fusion (DL36406)

CGS Medicare – Draft LCD for MIS SIJ Fusion (DL36494)

On October 2, National Government Services, Inc. (NGS) (the Medicare Administrative Contractor covering Illinois, Minnesota, Wisconsin, Connecticut, New York, Maine, Massachusetts, New Hampshire, Rhode Island and Vermont) released a positive draft Local Coverage Determination (LCD) for minimally invasive sacroiliac joint fusion (MIS SIJ fusion) and on October 16, CGS Administrators, LLC (CGS) (the Medicare Administrative Contractor covering Kentucky and Ohio) released an identical positive draft LCD. Both draft LCDs reference ISASS prevalence data and coverage criteria for coverage of MIS SIJ fusion and propose coverage of the procedure when eight specific coverage criteria have been met. NGS is accepting public comments on the draft LCD until December 12, 2015. CGS is accepting public comments on the draft LCD until December 7, 2015. ISASS will be submitting comment letters in support of both draft LCDs. If you practice in one of the NGS or CGS covered states, consider submitting a comment letter in support of the draft LCD. Comments can be emailed to NGS Medical Directors at or to CGS Medical Directors


GAO appoints HHS Advisory Committee on Physician Payment Models

On October 9, the Government Accountability Office (GAO) appointed 11 members to a new committee that will provide recommendations on physician payment models to the Secretary of Health and Human Services (HHS) as required by the 2015 Medicare Access and CHIP Reauthorization Act (MACRA). The following individuals were appointed to the Physician-Focused Payment Model Technical Advisory Committee and will serve staggered terms of one to three years:


Developing New Physician Payment Models: Comprehensive Care for Joint Replacement Model—A Preview of What’s to Come in Spine

Morgan P. Lorio, MD, FACS, Chair of ISASS Coding & Reimbursement Task Force

Article Preview:

In July 2015, the Centers for Medicare and Medicaid Services (CMS) proposed a new payment model called Comprehensive Care for Joint Replacement (“Model”). The Model bundles Medicare payment for lower extremity joint replacements (hip and knee) and holds the hospital in which the joint replacement surgery takes place accountable for the costs and outcomes of the surgery throughout the episode of care. The Model defines the episode of care as the surgery and the 90-day post-surgical period. The Model is set to take effect on January 1, 2016 for a 5-year period in 75 geographic areas throughout the United States; most hospitals, physicians and post-acute providers in these areas are required to participate. According to CMS, the Model encourages patient-centered care and greater coordination among hospitals, physicians, home health care agencies and nursing/rehabilitation facilities through incentives and/or penalties to hospitals based on the costs and outcomes during each episode of care. …

…Fee-for-service will soon be a thing of the past as CMS continues to consistently identify high-expenditure, high-utilization procedures and develop bundles and/or alternate payment models. Spine is next. Implications for ACDF and TLIF are obvious. As spine surgeons, we cannot be caught flat-footed and must be ready to respond with our solutions for an alternate payment model that works and makes sense for spine surgeons and patients. … I encourage you to read the proposed rule in addition to the AMA comment letter and the AAOS comment letter to CMS on this Model and think about (1) how does this model work or not work? (2) how should spine surgeons prepare for the day that CMS announces its “Comprehensive Care for Spine Model”? It is my intention to engage ISASS membership to start a dialogue on alternate payment models and develop ways that we spine surgeons can advocate for functional payment and delivery models.

Full article available here.

AMA Comment Letter

AAOS Comment Letter


Request for Information on New Provisions of MACRA

On October 2, the Centers for Medicare and Medicaid Services (CMS) released a Request for Information (RFI) for the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA). This RFI seeks public comment by October 30 on Section 101 of MACRA, which:

The RFI and instructions about how to submit comments are available at The comment period, which was originally 30 days and scheduled to close on November 2, 2015, will now close on November 17, 2015. The complete Medicare Access and CHIP Reauthorization Act of 2015 can be viewed at and the RFI extension is available at the Federal Register:


Physician Compare Preview Period

On October 5, the Centers for Medicare and Medicaid Services (CMS) opened the 30-day preview period for the 2014 quality measures that will be reported on Physician Compare later this year. You can access the secured measures preview site now through the PQRS portal-Provider Quality Information Portal. To learn more about which measures will be publicly reported and how to preview your measures, visit the Physician Compare Initiative page. The preview period ends on November 6, 2015.


Informal Review Request Period for the 2016 Value Modifier

On October 19, the Centers for Medicare and Medicaid Services (CMS) opened the informal review period for the 2016 Value Modifier. The 2014 Annual Quality and Resource Use Reports (QRURs) are now available for every group practice and solo practitioner nationwide; QRURs show how groups and solo practitioners performed in 2014 on the quality and cost measures used to calculate the 2016 Value Modifier. For groups with 10 or more eligible professionals that are subject to the 2016 Value Modifier, the QRUR shows how the Value Modifier will apply to physician payments under the Medicare Physician Fee Schedule for physicians who bill under the group’s Taxpayer Identification Number in 2016.  For all other groups and solo practitioners, the QRUR is for informational purposes only and will not affect their payments under the Medicare PFS in 2016.

For groups with 10 or more eligible professionals that are subject to the 2016 Value Modifier, the informal review period provides an opportunity to request a correction of a perceived error in the 2016 Value Modifier calculation. You can request an information review of your 2016 Value Modifier determination now through November 9, 2015. Authorized representatives of group and solo practitioners can access the 2014 Annual QRURs on the CMS Enterprise Portal using an Enterprise Identify Data Management account.  For more information on how to access the 2014 Annual QRURs, visit How to Obtain a QRUR. Additional information about the 2014 QRURs and how to request an informal review is available on the 2014 QRUR website.


Physician Quality Reporting System Payment Adjustment and Informal Review Process

On September 11, the Centers for Medicare & Medicaid Services (CMS) began distributing letters to Physician Quality Reporting System (PQRS) individual Eligible Professionals and group practices about the 2016 PQRS negative payment adjustment. The letter indicates that an individual or group did not satisfactorily report 2014 PQRS quality measures in order to avoid the 2.0% 2016 negative PQRS payment adjustment.

If you believe that you have been incorrectly assessed the 2016 PQRS negative payment adjustment, you can submit an informal review through November 9, 2015. All informal review requests must be submitted via a web-based tool, the Quality Reporting Communication Support Page, during the informal review period. For details regarding the 2016 PQRS payment adjustment, please see the Payment Adjustment Information page of the PQRS website and click on the payment adjustment toolkit.


CMS Issues Final Electronic Health Record Rules

The Centers for Medicare & Medicaid Services (CMS) and the Office of the National Coordinator for Health Information Technology (ONC) recently announced the release of final rules for the Medicare and Medicaid Electronic Health Record (EHR) Incentive Programs and the 2015 Edition Health IT Certification Criteria. The rules were published on October 16, 2015, and are currently on display in the Federal Register.

The EHR Incentive Programs final rule provides new criteria that eligible professionals, eligible hospitals, and critical access hospitals must meet in order to successfully participate in the EHR Incentive Programs. The final rule outlines program requirements in 2015 through 2017 (Modified Stage 2) and Stage 3 in 2018 and beyond, and includes a 60-day comment period for Stage 3. According to the American Medical Association (AMA), the Stage 3 rule will continue to threaten physicians with a regulatory gauntlet that could lead to less time with patients, more poorly performing EHRs and costly penalties for non-compliance. The AMA is urging all physicians to submit comments to CMS on Stage 3 of Meaningful Use and how it can be improved and better aligned with the new Merit-Based Incentive Payment System and alternative payment models. ISASS recently signed onto an AMA letter to Congress urging Congressional intervention with CMS and legislative action to refocus the program. 

For more information about the EHR Incentive Programs final rule, view the CMS Final Rule Fact Sheet or read the full text of the rule.

To learn more about the ONC 2015 Edition Health IT Certification Criteria final rule, visit:


Budget Agreement Reached Between Congressional Leaders and Administration

In the final days of October, Congressional leaders and the White House struck a deal to raise the debt limit and agreed to spending targets for the federal budget for the next two fiscal years. The draft bill released on October 26 will extend the debt ceiling to March 2017 and raise the discretionary spending caps imposed in 2011 under sequestration by $80 billion above current levels. The additional spending authority will be split evenly between defense and non-defense spending. The bill also addresses an impending spike in Medicare Part B premiums for some seniors. The cost will be offset in part by implementing site-neutral payments for new provider-based hospital outpatient departments – those that open after the bill is signed into law. Beginning January 1, 2017, these departments would not be eligible for reimbursements under the outpatient prospective payment system but would instead be eligible for reimbursements from either the ambulatory surgical center or physician payment systems. The bill also would extend the 2% Medicare sequester for an additional year.


President Obama Announces Joint Effort to Combat Opioid Abuse

On October 21, President Obama issued a Presidential Memorandum to all federal agencies to require federal employees, federal contractors and federal clinical residents/trainees who prescribe controlled substances to complete training on appropriate and effective prescribing of pain medications within 18 months, and a refresher course every three years. The Memorandum also directed agencies that provide health care services or benefits to submit a plan within 90 days to address any identified barriers to accessing medication-assisted treatment (buprenorphine, buprenorphine-naloxone combination products, methadone, and naltrexone — in combination with counseling, other behavioral therapies, and patient monitoring) to provide treatment for opioid use disorders. In addition, over 40 provider groups, state and local governments and private sector companies committed to increase prescriber training, access to medication-assisted treatment, and use of state prescription drug monitoring programs.

View the White House press release here.


2016 Final Physician Fee Schedule & Hospital Outpatient and ASC Final Rule

On or before November 1, the Centers for Medicare and Medicaid Services (CMS) will issue the final 2016 Physician Fee Schedule and the final 2016 Hospital Outpatient and Ambulatory Surgical Center payment and policy rule. Watch for additional updates from ISASS on these issues.


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