This article was originally published on January 8, 2016. That same day, CMS issued an “Emergency Update to the CY 2016 Medicare Physician Fee Schedule” that affected the therapy and radiology fee schedules. The changes resulted in minor reductions to the fee schedules for a majority of the therapy and radiology codes.  Most of the codes were reduced by a few cents, while a small number were reduced by approximately one dollar. 

On January 19, 2016 we removed the superseded fee schedules from this article and replaced with the updated ones. See links below.

With the New Year upon us, all of us at HW&Co. would like to wish you a happy, healthy and prosperous New Year. As always, the New Year brings many changes to the Long-Term Care Industry. We are pleased to provide you with updates on some of these changes.


2016 Part B Fee Schedules

After years and years of political wrangling, Congress finally passed a permanent “doc fix” in April 2015.  The Medicare Access and CHIP Reauthorization Act of 2015 replaced the Sustainable Growth Rate (SGR) formula with new systems for establishing payment updates to the Medicare Part B physician fee schedules.  As a result, for at least the next few years, we have some certainty in the Part B payment rate updates.  The physician fee schedules for 2016 through 2019 will receive annual .5% updates.  After 2019, the payment updates will be impacted by various value-based purchasing models, mostly based on physician quality reporting.

The bill provides for a .5% update to the Part B fee schedules effective January 1, 2016.   However, in conjunction with the final rule for the 2016 physician fee schedules, various adjustments to some of the underlying factors that are used to calculate the payments will be made effective January 1, 2016.  As a result, the changes to the payments for each code will vary, in some case widely, from the reported .5% update.

The Therapy fee schedules provided below are effective from January 1, 2016 through December 31, 2016.  It is important to forward the fee schedules to your business office personnel to use for January bills. The schedules are available in PDF format in the links below.  Our Revenue Cycle Consultants are available to assist with any billing questions you may have. In addition, if you use PointClickCare, the Part B fee schedules are automatically updated in your system.

Many of the fee schedules change or are updated on a quarterly basis. Please review the appropriate schedule based on the Centers for Medicare &; Medicaid Services (CMS) updates. Check the CMS website on a regular basis for updates to these schedules. Please note that these schedules are not all-inclusive. We have attempted to limit this information to the most commonly used Healthcare Common Procedure Coding System (HCPCS) codes for long-term care facilities.

Many providers use only the therapy fee schedules. We have provided the lab, radiology, PEN and DMEPOS schedules in order to help you identify potential cost savings for your Medicare Part A and Managed Care residents. The fee schedules may be useful in negotiating and verifying the rates being paid to ancillary service providers and will provide guidance to ensure you are paying a cost effective rate.

Ohio Medicare Part B Fee Schedules

1. Therapy 2016 Ohio (updated January 19, 2016)

2. Radiology 2016 Ohio (updated January 19, 2016)

3. Laboratory 2016 Ohio

4. PEN 2016 Ohio

5. Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) Items:        o DMEPOS 2016 PO


o DMEPOS 2016 SD

o DMEPOS 2016 SU

DMEPOS 2016 Nonbill

Please note two changes to the PEN and DMPOS fee schedules effective January 1, 2016. First, the PEN fee schedules are now calculated for each state, rather than nationally, as they were previously calculated.  Second, Medicare has added rural payment rates for certain DMEPOS payment codes.  The delineation of non-rural and rural is based on zip code.  In the attached DMEPOS-Supplies and DMEPOS-Non-Billable fee schedules, if a payment is shown in the rural column for a specific code, rural providers will receive that fee schedule amount.  If no payment is shown in the rural column, rural providers will receive the non-rural fee schedule amount.

Therapy Caps Exception Process Extended

The bill passed by Congress also included an extension of the therapy caps exception process through December 31, 2017. The caps for physical and speech therapy (combined) and occupational therapy will be $1,960 for 2016.  The manual review process for beneficiaries that reach $3,700 of therapy services was also extended through December 31, 2017.

Multiple Procedure Payment Reduction Remains in Effect

The Multiple Procedure Payment Reduction (MPPR), which was introduced effective January 1, 2011, remains in effect for 2016. The MPPR cuts the practice component of the fee schedule payment for certain HCPCS codes by 50% when more than one kind of therapy is provided to a resident in a single day. Congress enacted a 25% reduction in the Physician Payment and Therapy Relief Act of 2010 and later increased the reduction to 50%.

For 2016, the MPPR covers therapy services billed under 47 different HCPCS codes.  The last column of the therapy fee schedules provided above shows the payment that would be made under the MPPR for the affected therapy codes.

January 1, 2016 Ohio SNF Medicaid Rates

Medicaid rates for most Ohio nursing facilities were recalculated on January 1, 2016 using June 30, 2015 and September 30, 2015 Medicaid case mix scores.  These are the last rates that will be calculated using the current prices and the RUG-III case mix grouper.  Effective July 1, 2016, the rates will be calculated using rebased prices and the RUG-IV case mix scores for December 31, 2015 and March 31, 2016.

The updated rates will impact payments from both traditional Medicaid and MyCare Ohio Medicaid.  It is important that you review these calculations closely as any errors must be corrected within 30 days of the receipt of your rate letter.  In addition, be sure to review your MyCare payments carefully, as the MyCare plans have had issues updating the rates in the past.  Please contact us if you would like any assistance in reviewing your January 1, 2016 Medicaid rate.

Make Sure your PS&R System Login is Active!

In 2015, CMS’s IACS system, which housed the PS&R; system, migrated to the Enterprise Identity Management System (EIDM).  IACS users with existing logins should have been migrated automatically.  However, passwords expire every 60 days and must be changed.  In addition, to avoid being locked out, the PS&R; system must be accessed at least once every six months.  We recommend you address any password or log in issues now to avoid delays in accessing your PS&R; reports when cost reports are due in May.

Please contact your HW Healthcare Advisor if you have any questions on accessing the PS&R system.

Other Important Year End Reminders

As we move into the New Year, we invite you to review our previous E-Blast that included discussion of many important Medicaid, Medicare and MyCare Ohio topics.  Topics included the PELI survey, 2016 coinsurance and deductible amounts and an update on Medicaid rates.  Should you have any questions, please do not hesitate to contact us.