Advocacy














AMDA Submits Comments on CY2015 Proposed Physician Fee Schedule

Last week, AMDA-The Society for Post-Acute and Long-Term Care Medicine submitted comments to the Centers for Medicare & Medicaid Services (CMS) on the Physician Fee Schedule, Clinical Laboratory Fee Schedule, Access to Identifiable Data for the Center for Medicare and Medicaid Innovation Models & Other Revisions to Part B for Calendar Year (CY) 2015; Proposed Rule.

AMDA’s comments focused on the following proposals within the rule (bolded for emphasis):

  • Chronic Care Management Services (CCM)
  • Value-Based Payment Modifier (VBM)
  • Physician Compare Website
  • Physician Payment, Efficiency, and Quality Improvement (PQRS)
  • EHR Incentive Program (Meaningful Use)

Chronic Care Management

AMDA applauded CMS’ ongoing effort and for the first time recognition of the need to provide reimbursement for chronic care management – a long underappreciated and undervalued service. However, AMDA also stated that CMS’ proposal misses the mark on addressing the needs of the most complex patients that many AMDA members take care of. For the last three years, AMDA worked with a group of stakeholders on a CPT code that would serve the needs of this complex population. Rather than finalizing the RUC recommended non-face-to-face CPT code, however, CMS proposes a G code with lower reimbursement and what AMDA believes to be too burdensome requirements. AMDA stated that the “complexity and the cost for practices to fulfill all the requirements of the code will provide too great a burden for most practices to undertake these services. ”One such requirement is the 24/7 access to electronic health records that many practices do not yet have.

The big concern is that rather than focusing and helping practices that serve the most complex population provide this much needed service, this code looks to benefit larger practices and reach a broader population of patients with two or more chronic conditions. In addition, the G code requirements do not make it clear whether the service can be billed in the assisted living and domiciliary settings. AMDA stated that since in these settings “staff may or may not be employed by a physician, many physicians still provide the types of service this code intend to reimburse.” AMDA suggested to CMS that “these service should be reimbursable whether the physician or hired staff provides the services described.”

Value-Based Payment Modifier

AMDA expressed great concern about CMS’ proposals to continue the implementation of the value-based payment modifier (VBM). CMS proposed to increase financial penalties from 2 to 4 percent and continued to expand the program to apply to practices of 10 or more in order to comply with the statutory deadline to apply the modifier to all physicians by 2017. AMDA’s letter expressed concern over this proposal stating that “while CMS proposes to continue to expand the program and increase the penalty amount, the agency did not provide any response or discussion to AMDA’s concerns about physician who practice in PA/LTC facilities that have significantly higher cost scores than their peers in office-based practices and other settings and how they would be unfairly penalized in this system.” The issue arises from the fact that the CMS “specialty adjustment” does not take into account the higher cost settings of care, like nursing facilities, and all of family or internal medicine are compared on the same scale regardless of settings.

Over the past year, AMDA has engaged in dialogue with CMS to find solutions to this problem. AMDA is concerned that the VBM as is currently applied will do very little, if anything, to improve quality in PA/LTC and in fact, may hurt patient access to quality physician care by imposing significant financial penalties for physicians committed to taking care of these patients. Preliminary analysis by several large PA/LTC groups have shown that physicians who take care of these patients do in fact score unfavorable under VBM simply by virtue of the setting they practice in creating an unfair system. AMDA’s comments pointed to a report by Harold Miller, CEO at the Center for Healthcare Quality and Payment Reform, that came to a similar conclusion stating that “effective-risk based systems should compare spending on subgroups of patient with similar needs or risk factors, including functional limitations such as socio-economic factor that lead to different outcomes for different patients.” A recently formed AMDA task-force on this issue will continue to dialogue with CMS to resolve these issues.

For more discussion on these and other topics enumerated above please read the entire AMDA response here.

CMS Releases 2015 Physician Fee Schedule Proposed Rule

On July 3, 2014, the Centers for Medicare & Medicaid Services (CMS) released a proposed rule updating policies and payment rates for physician and other health care provider services paid under the Medicare Physician Fee Schedule (PFS) for calendar year (CY) 2015.

Last year, CMS finalized a separate payment for a chronic care management (CCM) code, outside of a face-to-face visit, for managing the care of Medicare patients with two or more chronic conditions beginning in 2015. Through this year’s rule, CMS is proposing details relating to the implementation of this new code, including payment rates. In addition, CMS is proposing a new process for establishing PFS payment rates that will be more transparent and allow for greater public input prior to payment rates being set. Under the new process, payment changes will go through notice and comment rulemaking before being adopted beginning for 2016.

The proposed rule also sets forth changes for quality reporting programs including, the Physician Quality Reporting System (PQRS), Medicare Shared Savings Program, and Medicare Electronic Health Record (EHR) Incentive Program, as well as changes to the Physician Compare tool on the Medicare.gov website. Finally, the rule continues the phased-in implementation of the physician value-based payment modifier (Value Modifier), created by the Affordable Care Act, that would affect payments to physicians and physician groups, as well as other eligible professionals, based on the quality and cost of care they furnish to beneficiaries enrolled in the traditional Medicare fee-for-service program.

The proposed rule will be published in the Federal Register on July 11, 2014. Comments on the proposed rule are due by September 2, 2014.

Highlights of Provisions Included in the CY Proposed Rule

Conversion Factor: CMS proposes a drop in the current conversion factor (CF) of $35.8228 down to $35.7977. The Protecting Access to Medicare Act of 2014 (PAMA) replaced the 24 percent reduction in the PFS with a 0.5 percent update through the end of this year; however, the law provides a 0 percent update for services furnished on or after January 1, 2015 through March 31, 2015. The estimates reflected for skilled nursing facility services in the proposed rule are based upon the CF being applicable throughout the year are delineated in the table below:

Code Total 2015 RVUs 2015 Payment Rate (CF=35.7997) Total 2014 RVUs 2014 Payment Rate (CF=35.8228) Percentage Change
2014-2015
99304 2.57 $92.01 2.61 $93.5 -0.01%
99305 3.67 $131.38 3.72 $133.26 -0.0141%
99306 4.69 $167.9 4.71 $168.73 -0.0049%
99307 1.24 $44.39 1.25 $44.78 -0.0086%
99308 1.94 $69.45 1.93 $69.14 0.0045%
99309 2.56 $91.65 2.54 $90.99 0.01%
99310 3.8 $136.04 3.78 $135.41 0.0046%
99315 2.05 $73.39 2.05 $73.44 -0.0006%
99316 2.96 $105.97 2.94 $105.32 0.0062%
99318 2.7 $96.66 2.69 $96.36 0.0031%
% = (new-old)/old

Sustainable Growth Rate (SGR): This year's proposed rule does not project the sustainable growth rate (SGR) for CY 2015, although prior to the PAMA enactment, CMS estimated the PFS update for CY 2015 would be -20.9 percent. When adjustments to the relative value scale were combined with the CF change, the net reduction in payment rates would have been 24 percent. In most prior years, Congress has taken action to avert fee schedule cuts before taking effect.

Primary care and complex chronic care management: Medicare continues to emphasize primary care management services by beginning to make separate payment for chronic care management (CCM) services beginning in 2015. In last year’s final rule, CMS established policy to make separate payment for non-face-to-face chronic care management services for Medicare beneficiaries who have multiple, significant chronic conditions (two or more). Chronic care management services include regular development and revision of a plan of care, communication with other treating health professionals, and medication management.

This proposed rule addresses three aspects of CCM services. CMS proposes a payment rate of $41.92 for the code that can be billed no more frequently than once per month per qualified patient. CMS also proposes to allow greater flexibility in the supervision of clinical staff providing CCM services. Finally, CMS is not proposing to establish separate standards that practitioners and practices furnishing this service would have to meet, as they had indicated last year. Upon further review, CMS felt the scope of service requirements for CCM, most of which were finalized last year, would be sufficient for practitioners to deliver CCM. CMS is proposing one additional requirement – standards for electronic health records – and seek comment on whether additional standards are needed. Payment for CCM is only one part of a multi-faceted CMS initiative to improve Medicare beneficiaries’ access to primary care. Models being tested through the Innovation Center will continue to explore other primary care innovations.

Telehealth Services: CMS is proposing to add the following services to the list of services that can be furnished to Medicare beneficiaries under the telehealth benefit: annual wellness visits, psychoanalysis, psychotherapy, and prolonged evaluation and management services.

Physician Compare Website: CMS is proposing to increase the measures available for public reporting of group-level measures by making all 2015 PQRS GPRO measure sets across reporting mechanisms, GPRO web interface, registry, and EHR, available for reporting on Physician Compare in CY 2016 for groups of 2 or more EPs. All measures reported by Shared Savings Programs ACOs would be available for public reporting on the website as well. All measures must meet the public reporting criteria of a minimum sample size of 20 patients.

CMS will include an indicator of which reporting mechanism was used and only measures deemed statistically comparable would be included on the site. All measures will be reported on a downloadable file however not all of the measures will actually be included on the website. CMS will analysis data, consumer test, and gather stakeholder feedback to determine specifically which measures are published on the profiles pages on the website.

In the 2014 PFS Final rule CMS finalized that 20 2014 PQRS measures for individual EPs collected via registry, EHR, or claims would be available for public reporting in late 2014, if technically feasible. CMS plans on expanding this public reporting for individual EPs in two ways. First, they propose to publicly report the same 20 measures for 2013 PQRS date in early 2015. Second, they propose making all individual EP-level PQRS measure collected via registry, EHR, or claims available for public reporting on the website for data collected in 2015 to be publically reported in alter CY 2016, if technically feasible.

CMS seeks comments on creating composites and publish composite scores by grouping measures based on the PQRS measures groups, for both group-level and individual level reporting. CMS would analyze data collected in 2015 and conduct psychometric and statistical analyses to create composites for PQRS measure groups including: Coronary Artery Disease; Diabetes Mellitus; Preventive Care; Rheumatoid Arthritis; Total Knee Replacement; General Surgery; Oncology. CMS would analyze component measures that use up each of these measure groups to see if a statistically viable composite can be constructed with the data reported for 2015. Similar to composite scores CMS will create benchmarks in 2016 using the same methodology currently used under the Shared Savings Program.

Finally, CMS proposes to make available on Physician Compare the 2015 Qualified Clinical Data Registry (QCDR) measure data collected at the individual measure level or aggregated to a higher level of the QCDR's choosing, if technically feasible.

Physician Payment, Efficiency, and Quality Improvement- Physician Quality Reporting System (PQRS): For the 2017 PQRS reporting period EPs would report on at least 9 measures, covering at least 3 domains AND report each measure for at least 50% of the EPs Medicare Part B FFS patients. If less than 9 measures apply to the EP, the EP would report up to 8 measures AND report each measure for at least 50 percent of their Medicare Part B patients.

Of measures reported, if the EP sees at least 1 Medicare patient in a face-to-face encounter the EP would report on at least 2 newly proposed cross-cutting measures.

CMS proposes to add 28 new individual measures and two group measures, and remove 73 measures from reporting for the PQRS bringing the total measure set to 240.

ACO (Shared Savings) Skilled Nursing Facility 30-day All Cause Readmission Measure (SNFRM): The measure estimates the risk-standardized rate of all-cause, unplanned, hospital readmission for patients who have been admitted to a SNF within 30days of discharge from a prior inpatient admission to a hospital, CAH, or a psychiatric hospital and is based on 12 months of SNF admissions data. Even when the ACO does not include post-acute facilities formally as part of its organization, ACO providers/suppliers furnish other services that have the potential to affect post-acute care outcomes. Thus, CMS feels this measure would emphasize the importance of coordinating the care beneficiaries across these sites of care. Additionally, CMS feels that since the measure is calculated from claims, there would not be a burden on AOs to collect this information.

Value-Based Modifier (VBM): CMS proposes to apply the Value Modifier beginning in CY 2017 to physicians in groups with two or more EPs and to physicians who are solo practitioners, as well as to non-physician EPs in groups with two or more EPs and to non-physician EPs who are solo practitioners. This proposal completes the phase-in of the Value Modifier to all EPs as required by law.

CMS proposes to increase the negative payment adjustment under the VBM from -2.0 percent in 2016 to -4.0 percent in 2017. CMS is further proposing to increase the maximum downward adjustment under the quality-tiering methodology to -4.0 percent for groups and solo practitioners classified as low quality/high cost and to set the adjustment to -2.0 percent for groups and solo practitioners classified as either low quality/average cost or average quality/high cost. In addition, CMS proposes to increase the maximum upward adjustment under the quality-tiering methodology in the CY 2017 payment adjustment period to +4.0x ('x' represents the upward payment adjustment factor) for groups and solo practitioners classified as high quality/low cost and to set the adjustment to +2.0x for groups and solo practitioners classified as either average quality/low cost or high quality/average cost.

EHR Incentive Program: CMS in CY 2015 is proposing that EPs would not be required to ensure that their CEHRT product are recertified to the most recent version of the electronic specifications for the CQMs. CMS notes that although they are proposing not requiring recertification, EPs must still report the most recent version of the electronic specifications for the CQMs.

AMDA staff and the Public Policy Committee are reviewing the proposed rule and will provide further information and comments at a later date.

You can view the entire proposed rule by clicking here.

CMS Fact Sheet with additional information can be viewed by clicking here.


CMS Final 2014 Fee Schedule Includes SGR Cuts and Changes to Quality Reporting Initiatives; Finalizes Payment for Complex Chronic Care Management

On November 27, 2013, the Centers for Medicare & Medicaid Services (CMS) issued a final rule that updates the payment policies and payment rates for services furnished under the Medicare Physician Fee Schedule (PFS) on or after January 1, 2014. In addition to policies affecting the calculation of payment rates, this final rule identifies potentially misvalued codes, adds procedures to the telehealth list, finalizes a policy for chronic care management services for CY 2015, applying therapy caps to outpatient therapy services furnished by CAHs, requires the compliance with state law as a condition of payment for services furnished incident to physician and other practitioner services, revising physician value-based payment modifier and the physician feedback reporting program, and updating the physician compare website, physician quality reporting system, electronic prescribing (ERx) incentive program, and Medicare shared savings program.

In the final rule, CMS projects a steep across-the-board reduction in payment rates, based on the Sustainable Growth Rate (SGR) formula. If it goes into effect, the conversion factor would be reduced by 20.1 percent for services in 2014. The CY 2014 conversion factor is $27.2006, which reflects a smaller reduction in the conversion factor than the 24.4 percent reduction that was projected in March 2013. The smaller reduction is due in part to a 4.72 percent adjustment to the conversion factor to offset the decrease in Medicare physician payments that would otherwise have occurred due to the CY 2014 rescaling of the RVUs so that the proportions of total payments for the work, practice expense, and malpractice RVUs match the proportions in the final revised Medicare Economic Index (MEI) for CY 2014. CMS projects that total payments under the fee schedule in 2014 will be approximately $87 billion.

Should Congress avert the SGR cut, AMDA estimates the conversion factor to be 35.6656 which would result in a slight increase to payment for skilled nursing facility evaluation and management codes (see Tables 1 and 2 below for more detailed information).


**The CY 2014 conversion factor is $27.2006, which reflects a smaller reduction in the conversion factor than the 24.4 percent reduction that CMS projected in March 2013
**The figures do not include any geographic adjustments.
*** Source Medicare Program; Payment Policies under the Physician Fee Schedule, Five-Year Review of Work Relative Value Units, Clinical Laboratory Fee Schedule: Signature on Requisition, and Other Revisions to Part B for CY 2014, Addendum B


*Payments based on the 2013 conversion factor of 34.0230, are estimated at 35.6656 based on expert calculations if SGR is repealed.
**The figures do not include any geographic adjustments.
*** Source Medicare Program; Payment Policies under the Physician Fee Schedule, Five-Year Review of Work Relative Value Units, Clinical Laboratory Fee Schedule: Signature on Requisition, and Other Revisions to Part B for CY 2014, Addendum B

Primary Care and Chronic Care Management: Medicare will begin making a separate payment for chronic care management services beginning in 2015. In last year's final rule, CMS established separate payment for transitional care management services for a beneficiary making the transition from a facility to the community setting. In this final rule, CMS further emphasize our support for advanced primary care through our establishment of policies to facilitate separate payment for non-face-to-face chronic care management services for Medicare beneficiaries who have multiple (two or more), significant chronic conditions. This reinforces Department of Health and Human Services (HHS) efforts to support care management through payment reform and incentives and is consistent with HHS’ Strategic Framework on Multiple Chronic Conditions. Chronic care management services include the development, revision, and implementation of a plan of care; communication with the patient, caregivers, and other treating health professionals; and medication management. Medicare beneficiaries with multiple chronic conditions who wish to receive these services can choose a physician or other eligible practitioner from a qualified practice to furnish these services over 30-day periods.

The rule indicates that CMS intends to establish practice standards necessary to support payment for furnishing care management services through future notice-and-comment rulemaking.

Telehealth Services: CMS is modifying regulations describing the geographic criteria for eligible telehealth originating sites to include health professional shortage areas (HPSAs) located in rural census tracts of urban areas as determined by the Office of Rural Health Policy. CMS believes this change will more appropriately allow sites located within HPSAs in MSAs that have rural characteristics to qualify as originating sites and improve access to telehealth services in shortage areas. They are also establishing a policy to determine geographic eligibility for an originating site on an annual basis, consistent with other telehealth payment policies. This change will avoid mid-year changes to geographic designations (sometimes without advance notice to Medicare beneficiaries and providers) that could result in unexpected disruptions to established telehealth originating sites and avoid the need to make mid-year Medicare telehealth payment policy changes. In addition, CMS is updating the list of eligible Medicare telehealth services to include transitional care management services.

Revisions To The Practice Expense Geographic Adjustment: As required by the Medicare law, CMS adjusts payments under the PFS to reflect the local cost of operating a medical practice as compared to the national average. CMS calculates separate geographic practice cost indices (GPCIs) to adjust the work, practice expenses (PE), and malpractice cost components of each payment. The law requires that CMS review the GPCIs every three years and adjust them as appropriate with a two-year phase-in of the new GPCIs. CMS is finalizing new GPCIs using updated data. The updated GPCIs will be phased in over CY 2014 and CY 2015. Additionally, CMS will apply the statutorily mandated 1.5 work GPCI floor in Alaska and the 1.0 PE GPCI floor for frontier states (Montana, Nevada, North Dakota, South Dakota, and Wyoming), which have no expiration date. There is separate statutory 1.0 work GPCI floor that is scheduled to expire under current law on December 31, 2013. Therefore, the finalized GPCIs reflect the expiration of the 1.0 work GPCI floor.

Compliance with State Law for Incident To Services: CMS is requiring as a condition of Medicare payment that "incident to" services be furnished in compliance with applicable state law. This policy strengthens program integrity by allowing Medicare to deny or recoup payments when services are furnished not in compliance with state law. CMS also eliminated redundant regulations for each type of practitioner by consolidating the "incident to" requirements for all practitioners that are permitted to bill Medicare directly for their services, reducing the regulatory burden and making it less difficult for practitioners to determine what is required in order to bill Medicare for "incident to" services.

Physician Quality Reporting System
The rule included several changes for the 2014 PQRS program. Major changes include:
  • Total of 284 measures in 2014.
  • Increase in number of measures reported via claims and registry-based reporting mechanisms from 3 to 9.
  • Change in reporting threshold for both individuals and groups reporting individual measures via registry to 50% of the eligible professional’s (EP’s) applicable patients (from 80%).
  • Elimination of option to report on claims-based measures groups.
In addition, the rule established the following:
  • EPs and group practices that meet the criteria for 2014 PQRS incentive will automatically avoid negative payment adjustment in 2016.
  • EPs using the claims and registry-based reporting mechanisms as well as the newly implemented qualified clinical data registry reporting mechanism may report 3 measures on 50% of their applicable patients to avoid 2016 PQRS payment adjustments.
  • Elimination of option to report on claims-based measures groups to avoid future payment adjustments.
For groups who wish to participate using the Group Practice Reporting Option (GPRO) in 2014, the rule included the following changes:
  • Creation of new reporting mechanism, the certified survey vendor reporting mechanism, that allows a group of 25 or more EPs to count reporting of Consumer Assessment of Healthcare Providers and Systems Clinician & Group (CG CAHPS) survey measures towards meeting criteria for satisfactory reporting for the 2014 PQRS incentive and 2016 PQRS payment adjustment.
  • Finally, the rule includes the implementation of the Value-Based Payment Modifier (Value Modifier) that affects payment rates to certain groups of 10+ based on the quality and cost of care they furnish to beneficiaries enrolled in the traditional Medicare Fee-for-Service program.
AMDA will provide more details of relevant sections of the rule in future editions of Health Policy Advisor. The final rule can be viewed at: http://federalregister.gov/inspection.aspx. CMS will accept comments on the final rule with comment period until January 27, 2014. AMDA will carefully review and comment as needed.



CMS Proposed Fee Schedule Includes SGR Cuts and Changes to Quality Reporting Initiatives; Payment for Complex Chronic Care Management

On July 8, 2013, the Centers for Medicare & Medicaid Services (CMS) issued a proposed rule that would update payment policies and payment rates for services furnished under the Medicare Physician Fee Schedule (PFS) on or after January 1, 2014. Currently, Medicare only pays for primary care management services as part of a face-to-face visit. In the proposed rule, in order to support primary care, CMS proposes to make a separate payment to physicians for managing select Medicare patients' care needs beginning in 2015. The proposed rule also proposes changes to several of the quality reporting initiatives that are associated with PFS payments — the Physician Quality Reporting System (PQRS), the Medicare Electronic Health Record (EHR) Incentive program, as well as changes to the Physician Compare tool on the Medicare.gov website. Finally, the rule continues the phased-in implementation of the physician value-based payment modifier (Value Modifier), created by the Affordable Care Act, that would affect payments to physician groups based on the quality and cost of care they furnish to beneficiaries enrolled in the traditional Medicare fee-for-service program.

Sustainable Growth Rate (SGR): The proposed rule does not include any provisions on the physician fee schedule update or SGR as these calculations are determined under a prescriptive statutory formula that cannot be changed by CMS. The final figures are announced in the final rule in November. In March, CMS estimated the physician fee schedule update would be -24.4 percent. In prior years, Congress has taken action to avert a large reduction in physician fee schedule rates before they went into effect. The Administration supports legislation to permanent address the flaws in the SGR that would provide more stability for Medicare beneficiaries and providers while promoting efficient, high quality care. The percent change to the physician fee schedule conversion factor may be different than the update because of various required budget neutrality adjustments described in the rule. The anticipated conversion factor (CF) for 2014 is $25.7109 adjusted to 26.8199 to include a budget neutrality adjustment as compared to the current 2013 CF of $34.0230. If the cut is averted the projected conversion factor would be based on 2013 rate and adjusted for budget neutrality at 35.6653. Nursing facility services will see a decrease in relative value units due to a CMS projected decrease in practice expense.

Table 1

Table 2

Primary Care and Complex Chronic Care Management: Medicare continues to emphasize primary care management services with a proposal for separate payment for complex chronic care management services beginning in 2015. In last year's final rule, CMS established separate payment for transitional care management (TCM) services for a beneficiary making the transition from a facility stay back to the community.

In this proposed rule, CMS emphasizes advanced primary care through their proposal to pay separately for complex chronic care management services, beginning in CY 2015. Specifically, CMS proposes to pay for non-face-to-face complex chronic care management services for Medicare beneficiaries who have multiple, significant chronic conditions (two or more). Complex chronic care management services include regular physician development and revision of a plan of care, communication with other treating health professionals, and medication management. Medicare will make separate payment to physicians through two G-codes for establishing of a plan of care and furnishing care management over 90-day periods. To be eligible for these services, CMS proposes that beneficiaries also must have had an Annual Wellness Visit (or an Initial Preventive Physical Examination (IPPE), if applicable) -- as the Annual Wellness Visit can serve as an important foundation for establishing a plan of care. CMS also propose that a single practitioner furnish these services and that they must have the beneficiary's consent to receiving these services over a one-year period.

The proposed rule indicates that CMS intends to establish practice standards necessary to support payment for furnishing complex care coordination management services. Potential standards include access at the time of service to Electronic Health Records (EHR) that meet the HHS certification criteria and written protocols for many aspects of care management implementation, such as specific steps for monitoring medical and functional patient needs. The rule solicits comment on the potential for CMS to recognize a patient-centered medical home (PCMH) designation by private organizations as one means for a practice to demonstrate that it has met the requisite practice standards. CMS plans to address policy regarding the practice standards, including PCMH recognition, through separate notice-and-comment rulemaking.

Telehealth Services: CMS is proposing to modify our regulations describing eligible telehealth originating sites to include health professional shortage areas (HPSAs) located in rural census tracts of urban areas as determined by the Office of Rural Health Policy. CMS believes this change will more appropriately identify sites within urban HPSAs that have rural characteristics and improve access to telehealth services in shortage areas. In addition, CMS is proposing to add transitional care management services to the list of eligible Medicare telehealth services.

Revisions To The Practice Expense Geographic Adjustment: As required by the Medicare law, CMS adjusts payments under the PFS to reflect local differences in practice costs. CMS assigns separate geographic practice cost indices (GPCIs) to the work, practice expenses (PE), and malpractice cost components of each of more than 7,000 physicians' services. Also, the law requires that we assess the GPCIs every three years and adjust them as appropriate with a two-year phase-in of the new GPCIs. CMS is proposing new GPCIs using updated data. In addition, CMS is changing the weights assigned to each GPCI (work, PE and malpractice) consistent with the recommendations of the Medicare Economic Index (MEI) Technical Advisor Panel (see below) that increases the weight of work and reduces the weight of practice expense. These new GPCIs would be phased in over CY 2014 and CY 2015. These changes are budget neutral. The statutory work GPCI "floor" of 1.0 is scheduled to expire under current law on December 31, 2013. The proposed GPCIs reflect the elimination of the work "floor" and as a result 51 localities will have a work GPCI below 1.

CMS will accept comments on the proposed rule until Sept. 6, 2013, and will respond to them in a final rule with comment period to be issued on or about Nov. 1, 2013. AMDA is reviewing and will submit comments.

For more information, see: www.federalregister.gov/inspection.aspx#special



Update. This table shows the updated payment rates as a result of the American Tax Payer Relief Act passed on January 1, 2013.

Code

Total 2013 RVUs 2013 Payment Rate
(CF=34.0230)
Total 2012 RVUs 2012 Payment Rate
(CF=34.0376)
Percentage Change
2012-2013

993042.69 $91.522.64 $89.861.85%
993053.82 $129.973.73 $126.962.37%
993064.82 $163.994.73 $161.001.86%
993071.28 $43.551.25 $42.542.37%
993081.99 $67.711.94 $66.032.54%
993092.61 $88.802.55 $86.80 2%
993103.88 $132.013.79 $129.002.33%
99315 2.1 $71.45 2.05 $69.782.39%
993163.01 $102.412.94 $100.072.34%
993182.75 $93.562.7 $91.901.81%



A Comprehensive Look at the New Transitional Management Codes

In the CY 2013 Physician Fee Schedule (PFS) proposed rule, the Centers for Medicare & Medicaid Services (CMS) proposed to address the significant non-face-to-face work involved in coordinating services for a beneficiary after discharge from a hospital or SNF. Specifically, CMS proposed to create a HCPCS G-code to describe care management involving the transition of a beneficiary from care furnished by a treating physician during a hospital stay (inpatient, outpatient observation services, or outpatient partial hospitalization), a SNF stay, or community mental health center (CMHC) partial hospitalization program to care furnished by the beneficiary's primary physician in the community within 30 calendar days following the date of discharge. In response to comments, the final rule adopts two new CPT transitional care management codes, 99495 and 99496, which distinguish between moderate and high complexity services, instead of the single proposed G-code. The nomenclature for CPT 99495 and 99496 is given below.

  • 99495 Transitional Care Management Services with the following required elements:

    • Communication (direct contact, telephone, electronic) with the patient and/or caregiver within 2 business days of discharge.
    • Medical decision making of at least moderate complexity during the service period.
    • Face-to-face visit, within 14 calendar days of discharge.

  • 99496 Transitional Care Management Services with the following required elements:

    • Communication (direct contact, telephone, electronic) with the patient and/or caregiver within 2 business days of discharge.
    • Medical decision making of high complexity during the service period.
    • Face-to-face visit, within 7 calendar days of discharge.

CMS says it considers the requirement for a face-to-face visit in association with the non-face-to-face tasks of TCM to be a short-term, transitional strategy while CMS further explores further improvements to advanced primary care payment. CMS also emphasizes that the above new CPT codes do not specify the location/setting for the required face-to-face visit. CMS also notes that incorporating such a visit into the TCM codes will help beneficiaries understand their coinsurance liability better.

In the PFS proposed rule, CMS invited comment on whether it should require a face-to-face visit on the same day as a patient's discharge from hospital, SNF or other settings (in relation to TCM services). CMS says that commenters were almost uniformly opposed to a requirement for a same day visit and does not adopt such a requirement. However, CMS emphasizes that physicians should conduct the face-to-face visit as quickly as medically necessary after discharge in order to address patient care needs.

With respect to the required post-discharge communication with patients (now incorporated into CPT 99495 and 99496), commenters recommended that CMS change "business days" to "calendar days." CMS refuses to do this, but notes that the CPTTCM codes specify that business days are Monday through Friday, except holidays, without respect to normal practice hours or date of notification of discharge. Also, if two or more separate attempts are made in a timely manner, but are unsuccessful and other TCM criteria are met, the service may be reported. CMS emphasizes, however, that it expects attempts to communicate to continue until they are successful.

Despite its decision to adopt CPT 99495 and 99496, CMS says it does not agree with the American Medical Association's recommendation that the physician must have an established relationship with the patient prior to the discharge to report the CPTTCM codes.CMS is concerned that such a requirement would prevent some vulnerable patients from benefiting from TCM services. CMS says it will develop additional Medicare-specific guidance for the use of the TCM codes to allow a physician to bill the codes for new patients (although payment for the codes will be the same for both new and established patients). CMS adds that it believes the typical case will involve provision of TCM services to an established patient, and relative values for codes are established on the basis of the typical patient. CMS also notes that physicians may choose to bill other appropriate codes (for example, new patient E/M codes) that better describe the services furnished.

The final rule states that TCM services are for a patient whose medical and/or psychosocial problems require moderate or high complexity medical decision making during transitions in care from an inpatient hospital setting (including acute hospital, rehabilitation hospital, long-term acute care hospital), partial hospitalization, observation status in a hospital, or skilled nursing facility/nursing facility, to the patient's community setting (home, domiciliary, rest home, or assisted living). It adds that TCM commences upon the date of discharge and continues for the next 29 days. The final rule also provides two lists of non-face-to-face services (repeated below), which CMS expects will be routinely provided as part of TCM services "unless the practitioner's reasonable assessment of the patient indicates that a particular service is not medically indicated or needed."

The first list of non-face-to-face services, which CMS says would be provided by clinical staff, under the direction of the physician or other qualified health care professional, includes the following:

  • Communication (direct contact, telephone, electronic) with the patient and/or caregiver within 2 business days of discharge.
  • Communication with home health agencies and other community services utilized by the patient.
  • Patient and/or family/caretaker education to support self-management, independent living, and activities of daily living.
  • Assessment and support for treatment regimen adherence and medication management.
  • Identification of available community and health resources.
  • Facilitation access to care and services needed by the patient and/or family.

The second list of non-face-to-face services, which CMS says would be provided by the physician or other qualified health care provider, includes the following:

  • Obtaining and reviewing the discharge information (for example, discharge summary, as available, or continuity of care documents).
  • Reviewing need for or follow-up on pending diagnostic tests and treatments.
  • Interaction with other qualified health care professionals who will assume or reassume care of the patient's system-specific problems.
  • Education of patient, family, guardian, and/or caregiver.
  • Establishment or reestablishment of referrals and arranging for needed community resources.
  • Assistance in scheduling any required follow-up with community providers and services.

The final rule also says that TCM requires a face-to-face visit, initial patient contact, and medication reconciliation within specified time frames (for medication reconciliation, this is said to be no later than the date of the face-to-face visit). The final rule also notes that the first face-to-face visit is part of the TCM service but that additional E/M services may be reported separately. In addition, for purposes of the medical decision making incorporated into the TCM codes, the final rule refers readers to definitions in the E/M Services Guidelines. Required documentation for the TCM codes includes the timing of the initial post discharge communication with the patient or caregivers, the date of the face-to-face visit, and the complexity of medical decision making.

In the proposed rule, CMS proposed to preclude a physician to report both a discharge management code and a TCM code but now accepts the AMA/RUC recommendation (as supported by a number of commenters) to allow this. However, CMS says it continues to be concerned that there could be some overlap in the actual work involved in providing the two services, and will monitor claims data to ascertain the extent to which the same physician bills for both the discharge day management and TCM services. CMS adds that it will analyze whether it may be appropriate to develop a payment adjustment that recognizes overlap in resources in the future. CMS also emphasizes that the E/M service required for the CPTTCM codes cannot be furnished by the same physician or nonphysician practitioner on the same day as the discharge management service; in other words, the E/M services furnished on the day of discharge as part of the discharge management service cannot simultaneously be counted as satisfying the TCM face-to-face visit requirement.

In response to comments, CMS agrees to allow reporting of emergency department visits when also billing the CPTTCM codes. On the other hand, the final rule states that a physician or other qualified health care professional who reports the TCM codes may not report any of the following during the time period covered by the TCM codes:

  • Care plan oversight services (99339, 99340, 99374-99380);
  • Prolonged services without direct patient contact (99358, 99359);
  • Anticoagulant management (99363, 99364);
  • Medical team conferences (99366-99368);
  • Education and training (98960-98962, 99071, 99078);
  • Telephone services (98966-98968, 99441-99443);
  • End stage renal disease services (90951-90970);
  • Online medical evaluation services (98969, 99444);
  • Preparation of special reports (99080);
  • Analysis of data (99090, 99091);
  • Complex chronic care coordination services (99481X-99483X); and
  • Medication therapy management services (99605-99607).

In the proposed rule, CMS indicated that a physician or qualified nonphysician practitioner billing for a procedure with a 10- or 90-day global period would not be allowed to bill for post-discharge transitional care management because CMS considers such management included in the post-operative portion of the global period. CMS now finalizes this policy. CMS acknowledges that the AMA RUC recommends that specialists work with the CPT Editorial Panel to develop a new code for those cases in which comprehensive TCM services are furnished along with the services already bundled into global surgical services, but does not comment on this recommendation.

In the proposed rule, CMS had indicated that the TCM codes could be billed only once per patient within 30 days of discharge and only by a single physician. CMS now finalizes these policies. CMS also notes that billing of the TCM codes will occur at the conclusion of the period for providing TCM services, 30 days post discharge. CMS adds that it expects most community physicians who furnish TCM services will be primary care physicians and practitioners but notes that there will be circumstances in which cardiologists, oncologists, or other specialists will be in the best position to furnish TCM services. CMS also says that among nonphysician qualified health care professionals, only nurse practitioners, physician assistants, clinical nurse specialists and certified nurse midwives could bill for TCM services. In response to comments, CMS explicitly says that psychologists are not licensed to perform TCM services and declines to create a special TCM G-code for them.

Further, CMS notes that "limited-license practitioners" (optometrists, podiatrists, and doctors of dental surgery or dental medicine), by virtue of their scope of practice, would also not be able to furnish the comprehensive medical evaluation and management services described by the TCM codes.In addition, since rural health clinics are not paid under the PFS, CMS says that physicians and other rural health clinic providers whose services are paid within the rural health clinic all-inclusive rate cannot bill using the CPTTCM codes for services furnished in the rural health clinic.

In response to comments, CMS notes that the TCM codes may not be billed when patients are discharged to a SNF; however, when SNF patients are discharged from the SNF to the community or to a nursing facility (even when the SNF and nursing facility are part of the same entity or located in the same building), the physician or practitioner who furnishes TCM services can use the TCM codes to bill for those services.

CMS acknowledges comments recommending that it monitor readmissions for patients receiving TCM services to determine if these services positively impact beneficiary outcomes, and says it will consider how to incorporate such monitoring into its existing initiatives.

In response to MedPAC and other comments expressing concern about potential confusion over which physician or practitioner is providing the bulk of TCM services (and therefore should be the one billing for a TCM code), CMS provides a lengthy discussion about the role of the discharging physician, which CMS believes would include the following:

  • Informing beneficiaries that they should receive TCM services from their doctor or other practitioner after their discharge, and that Medicare will pay for those services;
  • Asking the beneficiary to identify the practitioner whom he or she wishes to furnish these TCM services;
  • If the beneficiary does not have a preference for the physician who would furnish these services, suggesting a specific physician who might be in the best position to furnish them; and
  • Recording the community physician who will be providing TCM services in the discharge medical record and the discharge instructions for patients (which CMS says "could be helpful").

In the CY 2013 PFS proposed rule, the CMS-proposed payment for the proposed TCM G-code involved the following:

  • A work RVU identical to that for CPT 99238 (Hospital discharge day management; 30 minutes or less; work RVU = 1.28).
  • Physician times of 8 minutes pre-evaluation, 20 minutes intra-service, and 10 minutes immediate post-service.
  • Clinical labor inputs cross-walked from CPT 99214 (Level 4 established patient office or other outpatient visit).
  • Malpractice expense crosswalked from CPT code 99214.

The final rule instead accepts AMA RUC recommendations for the CPT 99495, a work RVU of 2.11 with 40 minutes of intra-service time. CMS also accepts the AMA RUC-recommended work value of 3.05 for CPT 99496 but reduces the intra-service time to 50 minutes (from the recommended 60 minutes). The RUC recommendations were based on a multi-specialty survey of 110 physicians. CMS also accepts the RUC's recommended malpractice crosswalks for CPT 99495 and 99496, and most of the RUC's recommended PE inputs for them. The sole exception is that CMS increases the clinical labor time for a RN/LPN nurse blend dedicated to non-face-to-face care management activities from 60 minutes to 70 minutes.

In terms of the required budget neutrality adjustment, the proposed rule had estimated that the new TCM G-code would be billed 10 million times in CY 2013. The AMA RUC commented that 2 million would be a more reasonable assumption. In the final rule, CMS assumes 5.7 million claims after adjusting its earlier estimate for readmissions. CMS also disagrees with the RUC's assumption that 60 percent of the TCM claims would be for CPT 99495 and 40 percent for CPT 99496, saying that a 75/25 split would be a more reasonable assumption. CMS notes that it partially offset the cost of the TCM services with the cost of the existing visits assumed to be billed as part of the CPTTCM codes (in other words, CMS acknowledges that many of the these visits would have been separately billed under current policy). CMS rejects comments urging it to assume that some of the costs would be offset by reduced readmissions, saying that the statute does not permit costs or savings from outside of the PFS to be used in the PFS budget neutrality calculation. CMS also argues that it lacks the authority to add the new TCM codes to the list of primary care services eligible for incentive payments under the Primary Care Incentive Payment Program (PCIP). However, CMS says that the allowed charges for the TCM services will not be included in the denominator when calculating a physician's or practitioner's percent of allowed charges that were primary care services for purposes of PCIP eligibility; this removes the risk that the TCM payments could make some practitioners ineligible for the PCIP.

Commenters requested that CMS waive beneficiary cost-sharing for the TCM services but CMS says it does not believe it has the authority to do so.


CMS Issues Physician Fee Schedule Final Rule

On November 1, 2012, the Centers for Medicare & Medicaid Services (CMS) released the 2013 Medicare physician fee schedule (MPFS) final rule with comment period. The rule will take effect January 1, 2013 with a comment period that closes on December 31, 2012.

The rule includes new payments for care-coordination services in the month following patient discharges. As a result of this proposal payments to family physicians would get an approximately 7 percent pay increase and other practitioners practicing primary care services between a 3 and 5 percent increase. AMDA will provide more detailed information on how long-term care practitioners can take advantage of these codes in future issues of Health Policy Advisor.

In responding to the proposed rule on this measure, Charles Crecelius, MD, PhD, CMD, AMDA Past President and Chair of the AMDA Public Policy Committee stated "Acknowledging and paying for transitions of care is an important step to improving patient care and safety. AMDA will continue to support CMS and RUC efforts to improve reimbursement for undervalued and underappreciated services."

These increases would however be offset by a statutorily required 26.5 percent across-the-board reduction to Medicare payment rates as a result of the sustainable growth rate (SGR). Congress has acted in the past to avert such cuts and AMDA will continue to work with Congress to repeal and replace this flawed formula. If Congress does avert the cut, nursing homes codes will get a 1-2 percent increase in payment due to an increase in practice expense (PE) relative value unit (RVU) as detailed in the following tables.

Table 1: Proposed CY2013 Payments With $25.0008 Conversion Factor Reflecting the 26.5% Cut
Code

Total 2013 RVUs 2013 Payment Rate
(CF=25.0008)
Total 2012 RVUs 2012 Payment Rate
(CF=34.0376)
Percentage Change
2012-2013

993042.69$67.252.64$89.86-25.16%
993053.82$95.503.73$126.96-24.78%
993064.82$120.504.73$161.00-25.15%
993071.28$32.001.25$42.54-24.77%
993081.99$49.751.94$66.03-24.65%
993092.61$65.252.55$86.80-25%
993103.88$97.003.79$129.00 -24.80%
993152.1$52.502.05$69.78-24.76%
993163.01$75.252.94$100.07-24.80%
993182.75$68.752.7$91.90-25.19%
%= (new-old)/old

Table 2: Potential Payments With $34.0066 Conversion Factor Reflecting the Averted Cut
Code

Total 2013 RVUs 2013 Payment Rate
(CF=34.0066*)
Total 2012 RVUs 2012 Payment Rate
(CF=34.0376)
Percentage Change
2012-2013

993042.69$91.482.64$89.861.80%
993053.82$129.913.73$126.962.32%
993064.82$163.914.73$161.001.81%
993071.28$43.531.25$42.542.32%
993081.99$67.671.94$66.032.49%
993092.61$88.762.55$86.802%
993103.88$131.953.79$129.002.28%
993152.1$71.412.05$69.782.34%
993163.01$102.362.94$100.072.29%
993182.75$93.522.7$91.901.76%
*this conversion factor is estimated by AMDA policy experts

The final rule also includes the following provisions:

  • Implementation of the physician value-based payment modifier
  • Changes to the PQRS and the Electronic Prescribing (eRx) Incentive Program – as well as the Medicare Electronic Health Records (EHR) Incentive Pilot Program which promotes the use of health information technology;
  • Durable medical equipment (DME) face-to-face requirement as a condition of payment for certain high-cost Medicare DME items;
  • Next steps to enhance the Physician Compare website, including posting names of practitioners who, as part of the Million Hearts campaign, successfully report measures to prevent heart disease;
  • Expands access to services that can be provided by non-physicians practitioners. The rule allows Certified Registered Nurse Anesthetists (CRNAs) to be paid by Medicare for providing all services that they are permitted to furnish under state law;
  • Allows Medicare to pay for portable x-rays ordered by nurse practitioners, physician assistants and other non-physician practitioners.

The final rule with comment period will appear in the November 16 Federal Register. AMDA will post more detailed summaries of various provisions in the rule in future editions of the Health Policy Advisor.


Update on 2012 Medicare Physician Payment Rates

The payroll tax extension legislation that was passed by Congress and signed by the President on December 23, 2011, delayed the 27.4 percent Medicare physician payment cut for two months.  It also extended the floor on the work geographic practice cost index (GPCI), and extended the therapy caps exception process.

The two-month extension provided for a zero percent update to the Medicare conversion factor. However, the final rule indicated that there would be a 0.18% increase in the conversion factor for budget neutrality. This change was effective January 1, 2012.  The budget neutrality increase is due to the Centers for Medicare & Medicaid Services (CMS) adoption of the RVS Update Committee recommendations for mis-valued codes.  The 2011 conversion factor was $33.9764.  The 2012 conversion factor will now be $34.0376.

Because Congress acted so late in 2011 to prevent the payment cut, claims must still be held for a period of time to allow CMS time to develop the new payment rate files and the Medicare claims administration contractors time to install and test the files. CMS expects that most, if not all contractors will be ready to process claims under the revised rates on or before January 18, 2012.

The table below lists the physician fee schedule update for the nursing facility codes with the new updates reflected. The figures do not include any geographic adjustments.

Code

2011 Pay
(CF =33.9764)

2012 Pay
(CF =34.0376)

Change in Pay
2011-2012

% Change in Pay
2011-2012

99304

$88.00

$89.86

$1.86

2.1%

99305

$123.67

$126.96

$3.29

2.7%

99306

$157.31

$161.00

$3.69

2.3%

99307

$42.13

$42.54

$0.41

1%

99308

$64.89

$66.03

$1.14

1.8%

99309

$85.28

$86.80

$1.52

1.8%

99310

$126.39

$129.00

$2.61

2.1%

99315

$61.50

$69.78

$8.28

13.5%

99316

$79.84

$100.07

$20.23

25.3%

99318

$90.04

$91.90

$1.86

2.1%

Source:Medicare Program; Payment Policies under the Physician Fee Schedule, Five-Year Review of Work Relative Value Units, Clinical Laboratory Fee Schedule: Signature on Requisition, and Other Revisions to Part B for CY 2012, Addendum B

If Congress fails to pass a new extension or address the SGR after the two-month extension, the 27.4 percent cuts could be implemented. See article below with table showing new rates if a cut occurs.


AMDA Analyzes 2012 Medicare Physician Fees

The Centers for Medicare & Medicaid Services (CMS) has released its final fee schedule rule officially titled Medicare Program; Payment Policies under the Physician Fee Schedule, Five-Year Review of Work Relative Value Units, Clinical Laboratory Fee Schedule: Signature on Requisition, and Other Revisions to Part B for CY 2012. CMS proposes that the conversion factor for 2012 will be $23.9635.  Almost every year for more than a decade, Congress has acted to temporarily prevent the pay cuts from taking effect. Therefore, AMDA’s analysis of the fee schedule includes calculations with and without the 2012 reduction.

The table below lists the physician fee schedule update for the nursing facility codes if the pay reduction does not take effect. The figures do not include any geographic adjustments.

Code

2011 Pay
(CF = 33.9764)

2012 Pay
(CF = 33.9764)

Change in Pay 2011-2012

% Change in Pay 2011-2012

99304

$88.00

$89.70

$1.70

1.9%

99305

$123.67

$126.73

$3.06

2.5%

99306

$157.31

$160.71

$3.40

2.2%

99307

$42.13

$42.47

$0.34

0.8%

99308

$64.89

$65.91

$1.02

1.6%

99309

$85.28

$86.64

$1.36

1.6%

99310

$126.39

$128.77

$2.38

1.9%

99315

$61.50

$69.65

$8.15

13.3%

99316

$79.84

$99.89

$20.05

25.1%

99318

$90.04

$91.74

$1.70

1.9%

The table below lists the physician fee schedule update for the nursing facility codes if the final rule’s 27.4 percent for services in 2012 takes effect. The figures do not include any geographic adjustments.

Code

2012 Current Law Conv Factor ($24.6712)

2012 Pay
 (CF = $24.6712)

Current Law Change in Pay 2011-2012

% Change in Current Law Pay 2011-2012

% Change in Current Law  Pay 2011-2012

99304

$24.6712

$65.13

-$22.87

-26.0%

-26.0%

99305

$24.6712

$92.02

-$31.65

-25.6%

-25.6%

99306

$24.6712

$116.69

-$40.62

-25.8%

-25.8%

99307

$24.6712

$30.84

-$11.29

-26.8%

-26.8%

99308

$24.6712

$47.86

-$17.03

-26.2%

-26.2%

99309

$24.6712

$62.91

-$22.37

-26.2%

-26.2%

99310

$24.6712

$93.50

-$32.89

-26.0%

-26.0%

99315

$24.6712

$50.58

-$10.92

-17.8%

-17.8%

99316

$24.6712

$72.53

-$7.31

-9.2%

-9.2%

99318

$24.6712

$66.61

-$23.43

-26.0%

-26.0%

The table below lists the Relative Value Units (RVU) for the nursing facility codes. The table includes the recent increase in physician work RVUS for the nursing facility discharge day management codes (99315, 99316) AMDA achieved recently.


Code

2012 Work RVU

2012 Practice Expense RVU

2012 Malpractice RVU

2011 Total RVUs

2012 Total RVUs

% Change in RVUs 2011-2012

99304

1.64

0.86

0.14

2.59

2.64

1.93%

99305

2.35

1.18

0.2

3.64

3.73

2.47%

99306

3.06

1.44

0.23

4.63

4.73

2.16%

99307

0.76

0.45

0.04

1.24

1.25

0.81%

99308

1.16

0.71

0.07

1.91

1.94

1.57%

99309

1.55

0.92

0.08

2.51

2.55

1.59%

99310

2.35

1.3

0.14

3.72

3.79

1.88%

99315

1.28

0.69

0.08

1.81

2.05

13.26%

99316

1.9

0.94

0.1

2.35

2.94

25.11%

99318

1.71

0.89

0.1

2.65

2.7

1.89%

Source: Medicare Program; Payment Policies under the Physician Fee Schedule, Five-Year Review of Work Relative Value Units, Clinical Laboratory Fee Schedule: Signature on Requisition, and Other Revisions to Part B for CY 2012, Addendum B.

Additional areas in the final rule:
Physician Quality Reporting System
In terms of criteria for satisfactory reporting for 2012, the proposed rule requested public comment on whether geriatricians should be included in the proposed CY 2012 core measure reporting requirement. AMDA had commented that geriatrics should be included as a specialty for mandatory reporting purposes when and if the measures include consideration of the special characteristics of this population.  

CMS decided not to finalize the proposed requirement stating that the agency had “insufficient time to properly update our analysis systems to check for an eligible professional’s specialty, [therefore CMS is] not finalizing our proposed requirement that physicians practicing in internal medicine, family practice, general practice, and cardiology report on at least 1 Physician Quality Reporting System core measure.”


Physician Fee Schedule Finalizes Higher Values for NF Discharge Codes

The Centers for Medicare & Medicaid Services (CMS) has released its final fee schedule rule officially titled Medicare Program; Payment Policies under the Physician Fee Schedule, Five-Year Review of Work Relative Value Units, Clinical Laboratory Fee Schedule: Signature on Requisition, and Other Revisions to Part B for CY 2012. The rule finalizes CMS’ acceptance of an increase in recommendations for the nursing facility discharge day management services work relative value units AMDA, the American Academy of Family Physicians, and the American Geriatrics Society presented in October 2010.

Code                                                       Current RVU       2012 RVU
99315 Nursing fac discharge day               1.13                        1.28
99316 Nursing fac discharge day               1.50                        1.90

AMDA projects that the acceptance of the recommendation to increase the physician work values for the nursing facility discharge codes is $4,317,621.

(The payment impact = change in work RVUs * allowed services * 2011 conversion factor.)


Code

2010 Work RVU

RUC rec Work RVU

Change in Work RVUs

2009 Allowed Services

2011 Conversion Factor

Payment Impact

99315

1.13

1.28

0.15

271,831

33.9764

$1,385,376

99316

1.5

1.9

0.4

215,756

33.9764

$2,932,245

 

 

 

 

 

Total

$4,317,621

“The increased values are very appropriate and place the discharge codes in line with the reimbursement for the rest of the family of nursing home codes.  AMDA appreciates the response we had from survey respondents who were instrumental in deriving these values,” said Charles Crecelius, MD, PhD, CMD, who presented on behalf of AMDA before the RUC.

The final rule also announced that Medicare payment rates will be reduced by 27.4 percent for services in 2012 unless Congress intervenes. This reduction is less than the 29.5 percent reduction that CMS had estimated in March of this year because Medicare cost growth has been lower than expected. The conversion factor for 2012 will be $ $24.6712.   

Clinical Laboratory Fee Schedule: Signature on Requisition
In CMS’ 2011 Physician Fee Schedule Final Rule, they proposed to retract the policy that required a physician’s or nurse practitioner’s (NPP) signature on requisitions for clinical diagnostic laboratory tests paid on the basis of the clinical laboratory fee schedule. After careful consideration of all comments received from stakeholders, CMS is finalizing their proposal to retract the policy and reinstate the prior policy that the signature of the physician or NPP is not required on a requisition.

This requirement was scheduled to go into effect January 1, 2011. However, AMDA opposed this requirement and urged CMS to delay implementation of this provision. AMDA pointed out that implementing this requirement is particularly troublesome in skilled nursing facilities. In the 2009 Medicare Fee Schedule proposed rule, CMS acknowledged that the complexity of care required by many residents of SNFs may be significantly greater than the complexity of care generally associated with patients receiving office visits. AMDA agreed, stating that most of these medically complex patients require frequent and immediate laboratory tests.

In the letter to CMS, AMDA pointed out that many laboratory test orders come in the middle of the night, “If a physician is not present at the nursing facility when the resident may need the test, this could cause a delay in diagnosis, because some physicians will wait until the morning to order tests. In turn, this failure to diagnosis may lead to worsening conditions or an unexpected discharge from the nursing facility and into a hospital emergency room.”

In December 2010, CMS delayed implementation of this requirement. Soon after, CMS discovered how difficult and burdensome this requirement would be to physicians and NPPs. It was then CMS decided to retract the policy. AMDA also sent a letter to CMS supporting their decision.

CMS based this decision on comments from stakeholders, such as an example in the long term care setting, when a physician may not be available in person on a daily basis. CMS states in the final rule “we now believe we underestimated the potential impact [this policy would have] on beneficiary health and safety…we understand there are concerns that certain populations of patients, such as nursing home patients [who] may have laboratory tests ordered urgently by a distant physician or NPP to obtain information that is imminently needed in order to assess a need for immediate referral to a hospital, or emergency department.”

Following a release of the final rule, Department of Health and Human Services Secretary Kathleen Sebelius issued a statement acknowledging that physicians are facing steep payment cuts as a result of a flawed 1997 law. She states “Almost every year for more than a decade, doctors have faced this annual threat and the Congress has in turn acted to temporarily prevent these deep reductions from taking effect. We have not and will not let deep cuts to doctors’ payments occur.  The Obama Administration is 100 percent committed to fixing the flawed Medicare payment system and protecting Medicare beneficiaries’ access to doctors.”

Another important area within the final rule included CMS’ decision not to finalize their proposal to have the American Medical Association/Specialty Society Relative Value Scale Update Committee (RUC) review Evaluation and Management (E/M) codes that were noted as the highest Physician Fee Schedule expenditures for each specialty. AMDA opposed the proposal, which would have required a review of the nursing facility family of codes.

In a joint letter, AMDA, the American Academy of Home Care Physicians (AAHCP), and the American Geriatrics Society (AGS) recommended that cognitive services could be properly valued by restructuring the CPT codes to accurately describe the services physicians perform by considering other related activities such as medication regimen review, advance directives/end-of-life care, coordination of care among multiple health professionals and the variety of non face-to-face services that are becoming increasingly prevalent, such as literature review and multi-platform communication.

The societies explained “The current CPT codes were developed more than 20 years ago and describe an episode of care for patients with defined problem(s) that were intended to be resolved within the timeframe of the visit event. They do not describe the longitudinal care provided to patients with multiple chronic conditions who require extensive care coordination, lifestyle education, and caregiver support – none fully valued in the mid-1980 Harvard Study and therefore not included even in today’s relative value unit (RVU) valuations.” CMS acknowledged the comment in the rule.

CMS stated its intent to continue to work with stakeholders on how to value and pay for primary care and patient-centered care management, and would welcome ideas from the medical community for how to improve care management through the provision of primary care services.

CMS’ decision was applauded by the AAHCP, AGS, and AMDA. Speaking for AAHCP Public Policy Chair, Dr. George Taler, Constance Row, Executive Director of the AAHCP said, “The AAHCP joins with its colleagues at the AGS and AMDA in welcoming CMS’s decision to withdraw its proposal for review of all E/M codes in favor of an approach that includes study of the results of existing chronic care management and payment structure initiatives and working with professional societies to fashion subsequent proposals. The AAHCP believes the Independence at Home demonstration, scheduled to begin in 2012 will contribute important information to the needed discussion of future directions.”

AGS Advisor to the RUC, Alan Lazaroff, MD, comments, "This is an important victory for AGS, along with our colleagues at AMDA - Long Term Care, and AAHCP. We are delighted that CMS has been so responsive to our concerns regarding E/M codes. We will continue to work hard to re-frame physician payments to more accurately reflect the work of geriatrics health professionals caring for older patients with multiple chronic and complex conditions. CMS' consideration of policy alternatives to the E/M review is a positive first step in the right direction."

AMDA Advisor to the RUC Dennis Stone, MBA, MD, CMD, agrees adding “CMS’ decision is a huge leap forward in our battle to identify and value managing the complexities of chronic disease and its multiple co-morbidities. Efforts to bundle this significantly unique body of work into the universal E/M codes has consistently run into the same wall as when the AMA tried to mandate universal documentation guidelines several years ago. A post-surgical visit is not a geriatric chronic disease visit in needed documentation or value.  CMS is now giving those who provide transitional coordination, complex medication regimen review, end-of-life care oversight the ability to do what other specialties have done for years...separately identify that work and get paid for it.  At last we might be able to say...'there’s an App for that’.”

Next week’s Health Policy Advisor will provide more analysis of the November 1st final rule.


NOTE: AMDA advocated before the AMA/Specialty Society Relative Value Scale Update Committee (RUC), which makes annual recommendations regarding new and revised physician services to the Centers for Medicare & Medicaid Services (CMS). In 2007 and 2010, the AMA RUC supported AMDA’s recommendation to CMS, and AMDA successfully obtained higher physician work values for the nursing facility family of codes. When AMDA has this representation, your professional voice is at its strongest. Please consider membership in the American Medical Association to ensure that AMDA can continue representing your needs at this critical time in medicine.

Facing 29.5% Physician Pay Cut in 2012, Berwick Calls for Permanent SGR Fix

The Centers for Medicare & Medicaid Services (CMS) has released its annual proposed fee schedule officially titled Medicare Program; Payment Policies Under the Physician Fee Schedule and Other Revisions to Part B for CY 2012. Medicare payment rates could be reduced by 29.5 percent for services in 2012, if the proposed rule takes effect. “This is the eleventh time the SGR formula resulted in a payment cut, although the cuts have been averted through legislation in all, but CY 2002,” states a CMS news release. 

“This payment cut would have serious consequences and we cannot and will not allow it to happen,” said Dr. Donald M. Berwick, CMS Administrator. “We need a permanent SGR fix to solve this problem once and for all. That’s why the President’s budget and his fiscal framework call for averting these cuts and why we are determined to pass and implement a permanent and sustainable fix.”

CMS proposes that the conversion factor for 2012 will be $23.9635. 

The table below lists the physician fee schedule update for the nursing facility codes. The figures do not include any geographic adjustments.

Code

Total 2012
RVUs

2012 Payment Rate
(CF=23.9635)

Total 2011RVUs

2011 Payment Rate
(CF=33.9764)

Percentage Change
2011-2012

99304

2.63

$63.02

2.59

$88.00

-28.38%

99305

3.73

$89.38

3.64

$123.67

-27.72%

99306

4.73

$113.35

4.63

$157.31

-27.95%

99307

1.25

$29.95

1.24

$42.13

-28.90%

99308

1.94

$46.49

1.91

$64.89

-28.36%

99309

2.55

$61.11

2.51

$85.28

-28%

99310

3.78

$90.58

3.72

$126.39

-28.33%

99315

2.05

$49.13

1.81

$61.50

-20.12%

99316

2.93

$70.21

2.35

$79.84

-12.06%

99318

2.69

$64.46

2.65

$90.04

-28.41%

The table below lists the payment rate if the conversion factor remains the same as 2011.


Code

Total 2012
RVUs

2012 Payment Rate
(CF=33.9764)

Total 2011RVUs

2011 Payment Rate
(CF=33.9764)

Percentage Change
2011-2012

99304

2.63

$89.36

2.59

$88.00

1.54%

99305

3.73

$126.73

3.64

$123.67

2.48%

99306

4.73

$160.71

4.63

$157.31

2.16%

99307

1.25

$42.47

1.24

$42.13

0.81%

99308

1.94

$65.91

1.91

$64.89

1.58%

99309

2.55

$86.64

2.51

$85.28

2%

99310

3.78

$128.43

3.72

$126.39

1.61%

99315

2.05

$69.65

1.81

$61.50

13.25%

99316

2.93

$99.55

2.35

$79.84

24.69%

99318

2.69

$91.40

2.65

$90.04

1.51%

The table below lists the Relative Value Units (RVU) for the nursing facility codes. The table includes the recent increase in physician work RVUS for the nursing facility discharge day management codes (99315, 99316) AMDA achieved recently.


Code

Work RVU

PE RVU

Malpractice
RVU

Total
RVUs

99304

1.64

0.85

0.14

2.63

99305

2.35

1.18

0.20

3.73

99306

3.06

1.44

0.23

4.73

99307

0.76

0.45

0.04

1.25

99308

1.16

0.71

0.07

1.94

99309

1.55

0.92

0.08

2.55

99310

2.35

1.29

0.14

3.78

99315

1.28

0.69

0.08

2.05

99316

1.90

0.93

0.1

2.93

99318

1.71

0.88

0.1

2.69

The proposed rule also implements or discusses provisions of the Affordable Care Act and the Medicare Improvements for Patients and Providers Act of 2008. In addition, this proposed rule discusses payments for the Physician Quality Reporting System; the Electronic Prescribing Incentive Program; and the Physician Resource-Use Feedback Program and the value modifier. AMDA is reviewing the proposed rule and will publish an analysis in future issues of Health Policy Advisor.

Comments on the proposed rule are due August 30, 2011. CMS will respond to comments in a final rule to be issued by November 1, 2011.


2009 CMS Utilization Data Shows the Effect of Coding and Relative Value Unit (RVU) Changes on Payments for Nursing Facility Codes

The Centers for Medicare & Medicaid Services (CMS) has released the 2009 utilization data that was used for the final rule Medicare Program; Proposed Revisions to Payment Policies Under the Physician Fee Schedule, and Other Part B Payment Policies for Calendar Year 2011. The data shows that while the number of services has increased by 2.1%, the total allowed charges went up nearly 7%. “This is a continued reflection of AMDA’s leadership in obtaining new and revised codes and then achieving increased work RVUs,” said AMDA Director of Government Affairs Kathleen Wilson, PhD. The new physician work values AMDA achieved for the nursing facility family of codes initially became effective on January 1, 2008.

Summary Table: Nursing Facility Codes Allowable Charges & Services


Utilization measure

2008

2009

Change

% Change

Allowed Charges
(all NF codes)

$2,023,047,920

$2,159,714,784

$136,666,864

6.8%

Allowed Services
(all NF codes)

25,695,586

26,221,066

$525,480

2.1%

 

Frequency Data for the Nursing Facility Services Family of Codes


Code

Allowed Charges 2008

2009  Allowed Charges

 Allowed Services 2008

2009 Total Allowed Services

99304

$26,333,087

$26,884,571

386,186

373,722

99305

$313,728,584

$334,279,339

2,552,928

2,572,848

99306

$458,246,920

$477,733,218

2,843,770

2,815,365

99307

$140,314,493

$147,138,661

3,800,580

3,775,527

99308

$494,308,472

$529,447,057

8,707,703

8,918,718

99309

$427,252,257

$468,755,186

5,663,345

5,979,330

99310

$121,915,997

$132,449,393

1,114,056

1,152,023

99315

$15,679,046

$15,692,831

283,742

275,667

99316

$14,693,001

$16,068,370

204,958

218,244

99318

$10,576,062

$11,266,158

138,318

139,622

To view the frequency data for all of the CPT codes, click here. Follow the link to the entitled “2009 Utilization Data Crosswalked to 2010 [ZIP, 11MB].”

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