On November 1st the Centers for Medicare and Medicaid Services (CMS) published updated payment policies and payment rates for physicians’ services furnished in 2012.
According to CMS, more than one million providers of health services to Medicare beneficiaries are paid under the Medicare Physician Fee Schedule (MPFS). An estimated $80 billion will be paid under the MPFS in 2012.
Changes in the fee schedule that impact payment policy and physician billing include:
Expanding CMS’ misvalued code initiative
Using a health risk assessment (HRA) in conjunction with Annual Wellness Visits (AWV) for which coverage began January 1, 2011 under the Affordable Care Act (ACA).
Expanding the list of services that can be furnished through telehealth to include smoking cessation services. Changes in the way additional services are added to the telehealth list will focus on the clinical benefit of making the service available.
Updating physician incentive programs including the Physician Quality Reporting System (PQRS), the e-Prescribing Incentive Program and the electronic Health Records Incentive Program.
Establishing a new value-based modifier that would reward physicians for providing higher quality and more efficient care.
Implementing the third year of a four-year transition to new practice expense relative value units, based on data from the Physician Practice Information Survey that was adopted in the MPFS CY2010 final rule.
E-Prescribing
CMS finalized the rules for the 2012 and 2013 e-prescribing incentive payment, and the 2013 and 2014 payment penalty programs. To qualify for incentive payments, physicians: a) may use claims, registry or electronic health record-based (EHR) reporting methods; and must electronically prescribe on the same day as the denominator service, and submit 25 claims containing the e-prescribing measure code (G8553) with one of the denominator codes. The incentive payment for 2012 is 1 percent, and for 2013 it is .5 percent of the total estimated allowed charges for professional services covered by Medicare Part B and furnished by an eligible professional.
Physician Quality Report System (PQRS)
As in prior years, there have been changes to the individual measures and measure groups. The final rule lists 211 individual measures, including 25 new ones; retains 44 EHR measures currently reportable in the EHR incentive program; and finalized 23 new measure groups, including eight new measures groups for reporting: Cardiovascular prevention; COPD; inflammatory bowel disease, sleep apnea, dementia, Parkinson’s, elevated blood pressure, and cataracts.
A complete listing of the 2012 measures is posted on the CMS website: www.cms.gov/PQRS/ [1].
CMS will provide interim feedback reports for physicians reporting individual measures and measure groups through claims-based reporting for 2012 and beyond. These reports will be a simplified version of annual feedback reports that CMS currently provides and will be based on claims for the first three months of each program year.
CMS will use 2012 as the reporting period for the 2015 PQRS penalty. If CMS determines that a physician or group practice (a group of 25 or more) has not satisfactorily reported quality data for the 2013 reporting period, then its 2015 payments will be reduced 1.5 percent.
Lab Test Signatures No Longer Required
CMS has retracted the requirement for physicians to sign paper lab requisitions for clinical diagnostic laboratory tests.
Annual Wellness Visit Changes
Criteria for a health risk assessment (HRA) to be used in conjunction with the annual wellness visit (AWV) has been adopted. The HRA is self-reported information which can be done by the patient alone or with assistance, takes no more than 20 minutes to complete and addresses demographic data, psychosocial risks, behavioral risks, activities of daily living (ADL)*, and instrumental ADLs**. The payment for AWV codes has been increased to recognize the additional office staff time required to administer the HRA to the Medicare population. CMS continues its policy of not covering a routine physical exam as part of these services.
Advanced Imaging Services Multiple Procedure Pricing
A 25 percent reduction to the payment for the professional component of second and subsequent advanced imaging services such as CT, MRI, PET, and MRA furnished by the same physician on the same patient in the same session on the same day will be applied. The highest fee schedule service will be allowed at 100 percent of the fee schedule. Subsequent advanced imaging services will be allowed at 50 percent for the technical component, as in the past, and 75 percent for the professional component.
* ADL: daily self-care activities within an individual’s place of residence.
** Instrumental ADL: housework, taking medications as prescribed, managing money, shopping for groceries, use of telephone/communication, using technology, and transportation within the community. Ω
