November 9, 2015

The national average Medicare anesthesia conversion factor (CF) effective January 1, 2016 will be $22.4426, down from $22.6093 in 2015, which is a decrease of $0.1667 per anesthesia unit.  Geographically-adjusted CFs for the 90-odd Medicare localities are not yet available.

The general Medicare physician fee schedule CF, which is used to calculate payments for visit services and pain medicine and other non-anesthesia procedures, will be $35.8279, a decrease of 10.56 cents per relative value unit (RVU).  CMS announced the new CFs in the Final Rule containing Revisions to Payment Policies under the Physician Fee Schedule and Other Revisions to Part B for CY 2016, released on October 30.

After the elimination of the Sustainable Growth Rate (SGR) formula in last spring’s Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), we had hoped to see the last of the “negative updates” or cuts in Medicare payment rates.  MACRA replaced the SGR with a 0.5 percent increase in the CFs each year until 2019.  In the Final Rule, however, after applying the 0.5 percent update, CMS adjusted the CFs downward by 0.02 percent for budget neutrality and by a new 0.77 percent “target recapture amount.”  The target recapture is an artifact of 2014 legislation that set a target reduction for adjustments for allegedly misvalued codes in each of the next three years.  The target for 2016 is 1.0 percent of spending on physician services.  CMS identified 0.23 percent worth of specific misvalued procedures and the balance will come from the 0.77 percent across-the-board reductions.  

The anesthesia CF came in for an additional 0.445 percent reduction reflecting changes to the valuation of practice expenses and malpractice insurance costs.  In assessing practice expenses, CMS applied a time adjustment of 33 percent for medical direction of two to four cases to avoid overstating the amount of time spent by the anesthesiologists involved in concurrent services.

Other changes announced in the Final Rule of significance to anesthesiologists include a reduction in the number of available PQRS measures to 281.  The measures eliminated include #193, Perioperative Temperature Management.  Measure #44, Preoperative Beta-Blocker in Patients with Isolated CABG Surgery, will be reportable only through a registry in 2016.  The elimination of the claims-based reporting option for most anesthesia measures is going to present a challenge for many anesthesia groups.  As then-ASA President J.P. Abenstein, M.S.E.E., M.D. wrote in his letter of September 8, 2015, containing ASA’s comments on the proposed fee schedule rule:

We are apprehensive that should all proposals for measures be finalized as proposed, anesthesiologists reporting via claims would have just one measure to report–PQRS #76:  Prevention of Central Line Catheter (CVC)-Related Bloodstream Infections. Such a scenario would make measure reporting for many of our practices impractical.

There are five new measures that can be reported by anesthesiologists—but only using a registry-based method of reporting, despite ASA’s and others’ urging that claims-based reporting remain an option.

The new PQRS measures include #424, a revised Perioperative Temperature Management  measure that requires recording of  at least one body temperature greater than or equal to 35.5 degrees Celsius (or 95.9 degrees Fahrenheit) within the 30 minutes immediately before or the 15 minutes immediately after anesthesia end time.  The four other new measures, all of which are already used in the Anesthesia Quality Institute’s National Anesthesia Clinical Outcomes Registry Qualified Clinical Data Registry (QCDR), like #424, are:

• Measure # 404:  Anesthesiology Smoking Abstinence;
• Measure # 426:  Post-Anesthetic Transfer of Care Measure: Procedure Room to a Post Anesthesia Care Unit (PACU) (using a checklist or protocol);
• Measure # 427:  Post-Anesthetic Transfer of Care: Use of Checklist or Protocol for Direct Transfer of Care from Procedure Room to Intensive Care Unit (ICU), and
• Measure # 430:  Prevention of Post-Operative Nausea and Vomiting (PONV) – Combination Therapy.

CMS is adding a reporting option that will allow group practices to report quality measure data using a QCDR.  This option should be helpful to groups (consisting of two or more eligible professionals) that choose the QCDR option since their performance will be analyzed at the group level, i.e., CMS will examine whether a sufficient number of measures and domains were reported for 50 percent of the group’s patients rather than for 50 percent of the individual physician’s patients. 

One of a number of other provisions in the Final Rule that will also be of interest to anesthesiologists involve the procedures that CMS believes to be potentially misvalued and that the AMA/Specialty Society Relative Value Update Committee will be asked to review.  These procedures include anesthesia for upper and lower gastrointestinal endoscopy, emergency intubation and insertion of central venous and arterial catheters.  Any modifications will be implemented after next year’s rulemaking cycle.

We will provide more information on the PQRS changes and on other critical matters in the Final Rule, in upcoming Alerts.

With best wishes,

Tony Mira
President and CEO