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Medicare Advocacy

The AAO-HNS has a long history of working closely with the U.S. Department of Health and Human Services, the Centers for Medicare & Medicaid Services (CMS), and the CMS Innovation Center to maintain our visibility and credibility with national representatives regarding Medicare issues.

We believe that advocacy is the key to defining the future of otolaryngology. Medicare regulatory advocacy is a top priority of the AAO-HNS.

CMS Releases CY 2019 MPFS/QPP Proposed Rule

On July 12, 2018, the Centers for Medicare & Medicaid Services (CMS) released the CY 2019 Proposed Rule for the Medicare Physician Fee Schedule (MPFS). While in previous years regulations for the Quality Payment Program (QPP) were released independently, the 2019 MPFS proposed rule includes proposals related to Medicare physician payment, as well as the QPP. You may view the proposed rule here

CMS proposes an updated CY 2019 conversation factor of $36.0463, which reflects the 0.25 percent update specified by the Medicare Access and CHIP Reathorization Act (MACRA) and a budget neutrality adjustment of -0.12 percent. Overall, this is a slight increase from the current conversion factor of $35.9996.

While the AAO-HNS physician leaders and staff are still reviewing the nearly 1,500 pages of the proposed rule, a few items specifically impacting the specialty should be noted. First, the rule proposes replaces existing E/M coding documentation guidelines for office and outpatient visits and collapsing payments from five levels to either two or three levels. Further, the rule proposes a 50 percent multiple procedure reduction when reporting an E/M service and a procedure on the same date.

The Merit-based Incentive Payment System (MIPS) portion of the proposed rule retains the low-volume threshold, but adds a third criteria of providing <200 covered professional services to Part B patients, as well as an opt-in mechanism. Payment adjustments could be as high as +7 percent or as low as -7 percent, and eligible clinicians must use the 2015 Edition certified EHR technology (CEHRT) in Year 3. The rule also further modifies the weighting for the four performance categories:

  • Quality: 45%
  • Cost: 15%
  • Promoting Interoperability (formerly Advancing Care Information): 25%
  • Improvement Activities: 15%

To review a more in-depth review of requirements for Year 3 of the QPP (CY 2019), visit

Once our analysis of the proposed rule is complete, additional fact sheets and resources will be available for AAO-HNS members. The Academy plans to submit comprehensive comments to CMS by the September 10 deadline.

CY 2018 Medicare Physician Fee Schedule Final Rule Summary  

  • On November 2, 2017, CMS posted the final rule for payments under the Medicare Physician Fee Schedule (MPFS) for calendar year (CY) 2018. 
  • In addition to annual payment and policy updates, the MPFS addresses a number of important issues directly affecting Otolaryngologists for the coming year. 
  • For CY 2018, CMS has finalized the conversion factor at $35.9996.
  • In addition, CMS finalized its proposal outlined in the CY 2018 MPFS Proposed Rule regarding valuation of existing and newly developed Functional Endoscopic Sinus Surgery (FESS) and balloon sinus dilation (BSD) codes.
  • The new codes were developed in conjunction with the American Rhinologic Society (ARS) and the American Academy of Otolaryngic Allergy (AAOA).  The values, as finalized, represent payment decreases for the FESS codes ranging from -7.9% to -23.6%. The BSD codes, which had been surveyed more recently in 2011, accordingly had values more consistent with their previous valuation
  • After considering stakeholder feedback, including extensive comments filed by the AAO-HNS in response to the proposed rule, CMS elected to accept RUC-recommended values for all otolaryngology services.
  • This was a significant win for the Academy given that the CY 2018 MPFS Proposed Rule suggested certain policy changes which would have reduced RUC-recommended values for all otolaryngology services reviewed during this year’s RUC cycle. 
  • A table with the finalized values for the FESS and BSD codes, as compared to 2017, is available here
  • Additionally, federal law specifies that for services not reported with new or revised codes, if the total RVUs for a service for a year would otherwise be decreased by an estimated 20 percent or more as compared to the total RVUs for the previous year, the applicable adjustments in work, PE, and MP RVUs shall be phased in over a two-year period. Otolaryngology had only three services on this list for CY 2018.For a more detailed summary of the final rule, please click here

CMS Releases Final Rule for CY 2018 Medicare Physician Fee Schedule - 11/9/2017

  • On November 2, CMS released the CY 2018 Medicare Physician Fee Schedule (MPFS). Read the final rule here.
  • Review the CMS fact sheet here.
  • For a more detailed summary of the proposed rule, members can access here

2018 Hospital Outpatient Prospective Payment System (OPPS) and Ambulatory Surgical Center (ASC) Payment System Final Rule: New FESS/BSD Payment Rates

  • Currently, ASC payment rates are tied to data derived from the OPPS.
  • In the CY2018 OPPS and ASC proposed rule, the AAO-HNS expressed concern about the difference between OPPS payments relative to ASC payments, particularly, the new endoscopy sinus surgery bundled codes.
  • CMS finalized the policy that will pay for the new bundled procedures involving two services, but pays $0 for an additional procedure.
  • This results in a 38 percent reduction, or a reduction of $1,635 for a bilateral procedure (from $4,270 in CY 2017 to $2,562 in CY 2018).
  • We noted concern that the lack of appropriate payment for ASCs may result in moving the more complex cases to the OPPS setting instead of the lower cost ASC setting, thereby adding cost into the health care system.
  • We further noted that we do not believe payment of the new bundled codes as the same as the individual sinus codes makes logical sense.
  • In our proposed rule comments, we recommended that CMS determine some other payment for the new FESS/BSD bundled codes that more accurately reflects the costs and resources utilized by ASCs. To read the submitted letter, please click here.
  • CMS finalized without modification the proposed ASC payment rates. However, in response to our comments, CMS noted that the OPPS cost data informs ASC payment rates and that CMS will re-visit the payment rate for the new endoscopic sinus codes as data become available to ensure the payment rate is aligned with ASC’s costs.

CMS Listened! AAO-HNS and IAC comment on Medicare Hospital Inpatient Prospective Payment System’s (IPPS) public display of accreditation status

  • CMS decided not to finalize their proposal to require all Medicare advanced diagnostic imaging final accreditation survey reports as well as acceptable plans of correction (POC) in the FY 2018 IPPS Final Rule.
  • The Academy agreed with comments from the Intersocietal Accreditation Commission (IAC) that any additional transparency that would have been achieved by the proposal would not outweigh the administrative burden on advanced diagnostic imaging accrediting organizations.
  • Further, it could have had adverse effects on the nature of private accreditation processes and resulted in the release of information that is difficult for consumers to access and understand.
  • On September 7, the AAO-HNS sent a letter to CMS Administrator Seema Verma thanking the agency for taking our comments into consideration and for not implementing the proposal.
  • To read the submitted letter on the final rule, please click here. Access the comments. 
  • To read the submitted letter on the proposed rule, please click here. Access the comments