American Academy of Family Physicians
Tuesday May 06, 2014

Update on ICD-10 delay

A previous post noted that the Protecting Access to Medicare Act of 2014, which was enacted on April 1, 2014, said that the Secretary of Health and Human Services (HHS) may not adopt ICD-10 before Oct. 1, 2015. The law, however, did not limit when the Secretary could adopt ICD-10 beyond that date.

Accordingly, the Centers for Medicare & Medicaid Services (CMS) announced last week that the Secretary of HHS expects to release an interim final rule in the near future that will include a new compliance date that would require the use of ICD-10 beginning Oct. 1, 2015. The rule will also require Health Insurance Portability and Accountability Act covered entities to continue to use ICD-9 through Sept. 30, 2015.

CMS also announced that it has canceled the ICD-10 end-to-end testing that it otherwise planned to conduct during the week of July 21. CMS canceled the July testing due to the ICD-10 implementation delay and said additional opportunities for end-to-end testing will be available in 2015.

Meanwhile, the acknowledgment testing that occurred in March was apparently a success. CMS previously reported that from March 3 to March 7 they received approximately 127,000 ICD-10 acknowledgment test claims, representing about 5 percent of those who submit claims to Medicare. CMS and its contractors encountered no systems problems associated with those test claims. CMS had originally planned to offer another week of acknowledgment testing this month; there is no word yet on whether it will still do so or postpone that to 2015 as well.

– Kent Moore, Senior Strategist for Physician Payment for the American Academy of Family Physicians

Thursday May 01, 2014

Acting now to avoid a PQRS payment adjustment in 2016

While 2016 is more than a year and a half away, what you do in 2014 will determine whether or not you are subject to a Medicare payment adjustment under the Physician Quality Reporting System (PQRS) in 2016. In essence, you must satisfactorily report data on quality measures during 2014 to avoid the 2016 payment adjustment.

You can avoid the 2016 payment adjustment by meeting one of the following criteria during the one-year 2014 reporting period (Jan. 1-Dec. 31, 2014):

  • If participating as an individual eligible professional: Meet the criteria for satisfactory reporting adopted for the 2014 PQRS incentive. Or, participate in PQRS via qualified clinical data registry, qualified registry, or claims reporting and report at least three measures covering one National Quality Strategy (NQS) domain for at least 50 percent of your Medicare Part B fee-for-service (FFS) patients.

  • If participating as a group practice: Meet the Group Practice Reporting Option requirements for satisfactory reporting. Or, participate in PQRS via qualified registry reporting and report at least three measures covering one NQS domain for at least 50 percent of your group practice’s Medicare Part B FFS patients.

More information is available via the PQRS web page on the Centers for Medicare & Medicaid Services' website. You may especially want to look at their new fact sheet for guidance on how to avoid the 2016 PQRS payment adjustment. You can also contact the QualityNet Help Desk 7 a.m.-7 p.m. (Central Time), Monday through Friday, by calling 866-288-8912 (TTY: 877-715-6222) or by sending an email to

– Kent Moore, Senior Strategist for Physician Payment for the American Academy of Family Physicians

Tuesday Apr 22, 2014

Dealing with the opportunities and threats of the new Medicare data release

This month's release by the Centers for Medicare & Medicaid Services (CMS) of a public use file on Medicare physician utilization and payment data creates both opportunities and threats for family physicians. We're going to consider both.

On the plus side, the release of the Medicare data provides a great opportunity for the family medicine community to highlight the complexity of care that family physicians provide. Also, the data show wide variation in total payments made among various medical specialties, which reinforces the point that primary care physicians are underpaid relative to other specialists and sub-specialists. When that data set is further studied, it may make the case that family physicians, who provide comprehensive and time-intensive health care to their patients, are undervalued from a payer perspective.

On the other hand, the Medicare data set has lots of limitations. For example, physicians weren't given an opportunity to review the data for potential errors; the data don't measure the quality of care provided; there's no allowance for residents or nurse practitioners filing claims under a physician's national provider identifier, meaning the payment numbers could be inflated; Medicare payments may not always cover the costs of treatment, which makes the numbers an inaccurate portrayal of physician compensation; the data are not risk-adjusted, don't account for patient mix or include care for private insurance patients or Medicaid beneficiaries; the numbers don't reflect the often higher reimbursements provided in facility settings versus a physician's office; and they don't consider changes in Medicare's coding and billing rules that may different over time and across regions of the country.

Those weaknesses presents several threats:

•    Insurers, hospitals, and accountable care organizations could use the data to assess physicians’ charges and potentially drop those individuals deemed to be high-cost physicians.
•    Public and private insurers might use the data as a reason to impose additional prior authorization requests for expensive Part B drugs.
•    The data set has the potential to paint a negative picture of some physicians with patients, and it also has the potential to further enhance the perception that physicians are overpaid relative to the average U.S. worker.

Finally, the data may generate some difficult questions from patients or local media. Here are some points to emphasize if you find yourself in such a conversation:

•    Greater transparency in the health care system is a laudable goal, and there is potential value in the release of Medicare payment data for ensuring the quality of care for patients and efficient use of resources in the delivery of health care services.
•    Release of this data shines a light on the need to reform physician payment away from fee-for-service and toward payment for quality of care.
•    Data should include context and background on physician payments so that policy makers, patients, and the public understand the overall quality of care their physicians provide.
•    The data release still needs safeguards to ensure that neither false nor misleading conclusions are derived from this information, which has its limitations.
•    Medicare payment information by itself does not describe a physician’s practice.
•    Hopefully, researchers will use this data to understand and improve how health care dollars are spent, so that we can also improve the health of patients, families, and communities.

Whether the potential opportunities outweigh the potential threats remains to be seen. However, knowing what they are provides a starting point for trying to maximize the former while minimizing the latter. For more information on this subject, check out the AAFP's "Physician Payment Transparency" web page and read the frequently asked questions on the CMS website.

– Kent Moore, Senior Strategist for Physician Payment for the American Academy of Family Physicians

Monday Apr 21, 2014

Family physician compensation continues to disappoint

The income disparity for family medicine is taking a toll, according to a new survey.

In the Medscape Compensation Report for 2013, released earlier this week, physicians were asked if they still would have pursued a medical career if they had to do it all over again. Sixty-seven percent of family physicians surveyed said they would have but only 32 percent said they would have stuck with family medicine. By comparison, 58 percent of all physicians surveyed said they would still have gone into medicine with 47 percent sticking with their current specialty.

Other parts of the report reveal hints of what might be causing so many family physicians to wish they had a time machine.

For example, family physicians reported an average compensation of $176,000 last year, the second-lowest among the 25 specialties surveyed. Family medicine beat out only HIV/infectious disease physicians, who made an average of $174,000. The most lucrative specialties last year were orthopedics and cardiology, with average compensation of $413,000 and $351,000, respectively.

Only half of family physicians said they felt fairly compensated, which placed the specialty in about the middle of the pack. Dermatologists seemed to be the happiest with 65 percent expressing overall career satisfaction.

Forty-two percent of family physicians said they spent 40 hours or more each week serving patients while more than two-thirds said they saw 76 patients or more each week. Sixteen percent said they saw 125 patients or more each week.

In terms of family medicine practice environments, the researchers found the highest average compensation among those working in hospitals ($191,000), health care organizations ($190,000) and office-based multispecialty group practices ($187,000). The lowest average belonged to office-based solo physicians ($158,000).

Also, 29 percent of family physicians said they belonged to an accountable care organization (ACO) last year and another 11 percent said they plan to join within a year. By comparison, only 5 percent belonged to an ACO in 2011.

Wednesday Apr 16, 2014

Medicare releases physician claims data for public consumption

Last week, the Centers for Medicare & Medicaid Services (CMS) released on its website a data set detailing payments made in 2012 to more than 880,000 physicians from the Medicare Part B Fee-for-Service program.

The release of the physician claims data came in response to a legal challenge from the Wall Street Journal, which successfully argued for a federal judge to lift a 1979 injunction preventing CMS from publishing the information. CMS initially planned to evaluate requests for physician payment information on a case-by-case basis. But after receiving numerous requests for the Medicare data, CMS determined the Freedom of Information Act (FOIA) required it to make frequently requested materials available electronically and publicly release certain physician payment information on its website.

This information represents revenue from Medicare Part B services before the practice’s operating costs are deducted. It doesn't include information from Medicare Part A (Hospital Insurance), Part C (Medicare Advantage), Medicaid, Marketplace, or private insurance plans. The data also does not include information associated with clinical diagnostic laboratories or durable medical equipment. Further, this data set does not represent each medical practice’s entire patient panel, and it is not risk-adjusted for severity and complexity of patients treated by the physician. 

The file contains information on utilization, payment (allowed amount and Medicare payment), and submitted charges organized by National Provider Identifier, Healthcare Common Procedure Coding System code, and place of service.

Physicians and others can access this information by downloading files split by provider last name from the CMS web site. Alternatively, the New York Times and the Wall Street Journal have created tools to search this data by name, specialty, and city/ZIP code.

In future posts, we’ll talk about potential implications of this data release, further limitations of the data, and possible questions you may get from your patients. In the meantime, be aware that the data is out there and that CMS is not the only one looking at it anymore.

– Kent Moore, Senior Strategist for Physician Payment for the American Academy of Family Physicians

Wednesday Apr 09, 2014

SGR, ICD-10 not the only targets of adopted legislation

Last week's SGR legislation didn't just push back Medicare cuts and delay ICD-10 implementation.

A new blog post by Betsy Nicoletti notes that the 123-page bill passed by Congress and signed into law by President Obama also requires additional reporting for lab test reimbursements and creates greater scrutiny of CT scans.

Read the blog here:

Tuesday Apr 08, 2014

Another patch and more time to prepare for ICD-10

Following up last week's post, the Senate approved and the president signed a House bill that prevents steep cuts to Medicare physician payments from going into effect for one year. The bill (now law) also delays the conversion to ICD-10 diagnostic and procedure codes for at least one year.

The measure calls for a 0.5 percent increase in physician payments through Dec. 31, 2014, and no change from Jan. 1 through March 31, 2015. That means is that it will be another year before you have to worry about a potential cut in the Medicare physician payment rate. It also means that Congress has additional time to pass a permanent repeal of the Sustainable Growth Rate that has led to the current predicament. Such action in advance of the mid-term elections seems unlikely, however, given the current lack of agreement on how to pay for repeal.

On the plus side, the delay in ICD-10 does give physicians more time to prepare for that change, which will now occur on Oct. 1, 2015 (or later). Until then, everyone will continue to use ICD-9 codes. That said, you shouldn't use the delay in implementation as an excuse to delay preparation. Physicians, payers, and other users of ICD-10 should continue to move forward with preparation wherever they are in the process, and AAFP has resources to help its members do just that.

– Kent Moore, Senior Strategist for Physician Payment for the American Academy of Family Physicians

Monday Mar 31, 2014

SGR delay puts brakes on Medicare physician fee schedule claims

While physicians wait to see if Congress passes legislation today that avoids a 24 percent cut to Medicare payments, the continuing debate over the Sustainable Growth Rate (SGR) is already affecting claims.

The House of Representatives passed HR 4302 by voice vote on March 27. The bill would delay the SGR's mandated cuts for another 12 months. The Senate was scheduled today to take up the bill, or introduce its own version, ahead of the April 1 SGR deadline.

To give Congress more time, the Centers for Medicare & Medicaid Services (CMS) has instructed the Medicare Administrative Contractors (MACs) to hold claims containing services paid under the Medicare physician fee schedule (MPFS) for the first 10 business days of April (i.e., through April 14, 2014). This hold would affect only MPFS claims with dates of service on or after April 1. The hold should have minimal impact on physician cash flow because MACs under current law do not pay clean electronic claims any sooner than 14 calendar days (29 days for paper claims) after the date of receipt.

MACs will process and pay all claims for services delivered under normal procedures on or before March 31, regardless of any Congressional action – or inaction, as the case may be.

– Kent Moore, Senior Strategist for Physician Payment for the American Academy of Family Physicians

Thursday Mar 27, 2014

CMS institutes a reprieve in RAC operations

The Centers for Medicare & Medicaid Services (CMS) is in the middle of processing the next round of Recovery Audit Program contracts. To make sure the current Recovery Audit Contractors (RACs) complete their work before the current contracts expire, CMS has announced that it will wind down some of the RACs' operations.

Specifically, CMS says the RACs were to cease sending pre- and post-payment additional documentation requests (ADRs) by the beginning of March and review the ones they already have. RACs have until June 1, 2014, to send improper payment files to Medicare administrative contractors for adjustment.

As a reminder, if you have received an ADR from a RAC, you have 45 days to respond to it. The RACs, in turn, have up to 60 days to make a determination on the claim.

Besides giving the RACs time to complete their work, the CMS said the pause in RAC operations will allow it to continue refining and improving the Medicare Recovery Audit Program. For example, CMS is reviewing the ADR limits, timeframes for review, and communications between RACs and physicians. CMS has already announced a number of changes it plans to make to the RAC program with the next round of contractor awards. CMS invites physicians with additional questions to send them to for answers.

– Kent Moore, Senior Strategist for Physician Payment for the American Academy of Family Physicians

Wednesday Mar 12, 2014

Medicare clarifies expectations for certifying home health eligibility

If you certify your patients' eligibility for the Medicare home health benefit, the Centers for Medicare & Medicaid Services (CMS) has released clarified guidance on how to properly document the required face-to-face visit.

In a January Special Edition Article of Medicare Learning Network Matters, the CMS included helpful examples of correct and incorrect documentation. It also addresses the proper form and substance of the required documentation.

First, CMS emphasized that physicians must draft the encounter documentation in a narrative form that is dated, signed by the physician, and titled "Home Health Face to Face Encounter.” Simply listing the beneficiary’s diagnoses, recent injuries, or procedures is insufficient.  

CMS also said that the substance of the documentation must address the two qualifying elements of the Medicare benefit: that the beneficiary is homebound and requires intermittent skilled nursing services, physical therapy, or speech language pathology services. The narrative documentation should explain why the patient is homebound and what skilled care the beneficiary will need in his or her home.

Obviously, this documentation will be more germane to the home health agency getting paid than to your office. However, because following these documentation requirements may determine if that home health agency remains willing to work with you, following the directions may ultimately help you and your patients.

– Kent Moore, Senior Strategist for Physician Payment for the American Academy of Family Physicians

Tuesday Mar 04, 2014

Medicare plans additional testing for ICD-10

If you're not participating in this week's test of the ICD-10 coding change, you'll get a second chance soon.

Last week, the Centers for Medicare & Medicaid Services (CMS) announced that it would add a second week of acknowledgement testing for physicians and others who submit Medicare claims. It also provided more details about end-to-end testing with Medicare.

The announcement came in the form of an article revision on the Medicare Learning Network (MLN). According to the revision, CMS plans to offer a second week of acknowledgement testing in early May 2014.

The revised article also states that CMS will offer end-to-end ICD-10 testing in late July 2014 to a small sample group of providers. End-to-end testing tracks a claim from initial connectivity and claim submittal all the way through remittance advice (RA), denials, and refund requests. CMS’s goals for this test are to demonstrate that:

• Providers or submitters are able to successfully submit claims containing ICD-10 codes to the Medicare fee-for-service claims systems;

• CMS software changes made to support ICD-10 result in appropriately adjudicated claims (based on the pricing data used for testing purposes); and

• Accurate RAs are produced.

CMS will select more than 500 volunteer submitters for the project, choosing a broad cross-section of providers, suppliers, and other submitters and claims types. CMS will provide information on volunteering later this month and disseminate additional details about the test in a separate MLN Matters article.

– Kent Moore, Senior Strategist for Physician Payment for the American Academy of Family Physicians

Tuesday Feb 25, 2014

What's new with PQRS in 2014?

Time has almost run out on those participating in the Physician Quality Reporting System (PQRS) for the 2013 program year. But for those wanting to participate in 2014, it's time to prepare.

Some things to keep in mind in the new program year:

    •    This is the last year for which you can earn an incentive for satisfactorily reporting, and those who don't satisfy the 2014 PQRS quality measures will face a 2 percent payment adjustment (i.e. penalty) in 2016.
    •    Eligible professionals must report on nine measures across three National Quality Strategy domains through the use of claims, qualified registry, or electronic health record (EHR). In general, that’s an increase from 2013, when only three measures were typically required.
    •    Participants have fewer quality measures to choose to satisfy in 2014. The Centers for Medicare and Medicaid Services (CMS) has added 37 new individual measures and retired 45 from the 2013 list. That said, there are still plenty of measures from which to choose, and you should use the most current version of the 2014 PQRS measure specifications.
    •    Measure groups can only be reported through a qualified registry.
    •    EHR-based reporting is now available for groups participating in the Group Practice Reporting Option, and eligible professionals can now participate in the qualified clinical data registry (QCDR), a new reporting option for 2014. A list of CMS-designated QCDRs will be available on the CMS PQRS website in May 2014.
    •    Eligible professionals and group practices can no longer use the administrative claims-based reporting method to avoid a 2016 payment adjustment.

For more information, please review the "What's New in 2014" fact sheet. You can also visit the PQRS website or contact the PQRS Help Desk.

– Kent Moore, Senior Strategist for Physician Payment for the American Academy of Family Physicians

Tuesday Feb 18, 2014

HHS inspectors to review Medicare coding problems in 2014

It's a few months later than normal, but the U.S. Department of Health and Human Services (HHS) Office of Inspector General (OIG) has finally released the list of areas its auditors will target this year.

The OIG usually releases the document in the fall. However, the agency delayed its release until now to better align with priorities that the HHS has set for the year.

Some of the items in the 2014 Work Plan will be of interest to family physicians.

First, OIG will look into reports from Medicare contractors who say they've seen an increase in providers filing medical claims for different evaluation and management (E/M) services but using identical documentation. Medicare requires providers to select the billing code for a service on the basis of the unique content of the particular service and have documentation to support the level of service reported. The agency said it plans to review multiple E/M services associated with the same providers and beneficiaries to determine the extent of documentation vulnerabilities – and potentially inappropriate payments.

The OIG will also review the extent to which physicians and suppliers participated in Medicare and accepted claim assignment during 2012. As part of that review, OIG will assess the effects of participation and claim assignments on the Medicare program, such as noncompliance with assignment rules, and on beneficiaries, such as excessive billing of beneficiaries’ share of charges.

Third, OIG will review physicians’ coding on Medicare Part B claims to make sure they provided the proper place of service codes for services performed in ambulatory surgical centers and hospital outpatient departments. Prior OIG reviews have found a problem with incorrect coding of place of service on Part B claims. Mis-coding can have a big effect on program payments because Medicare pays a physician more when a service is performed in a non-facility setting, such as a physician’s office, than it does for services performed in a hospital outpatient department or, with certain exceptions, an ambulatory surgical center.

For a full list of issues, including others that may be relevant to your particular practice, consult the complete OIG 2014 work plan online.

– Kent Moore, Senior Strategist for Physician Payment for the American Academy of Family Physicians

Tuesday Feb 11, 2014

Medicare turns deaf ear to CPT changes on cerumen removal

Medicare payment policy doesn't always match the American Medical Association's Current Procedural Terminology (CPT).

The Centers for Medicare & Medicaid Services (CMS) provided another example of that recently in the final rule on the 2014 Medicare physician fee schedule.

For 2014, CPT revised its description of code 69210 to read, “Removal impacted cerumen requiring instrumentation, unilateral.” Previously, the code description read, “Removal impacted cerumen (separate procedure), 1 or both ears.” To account for situations in which the procedure is provided on both ears at the same encounter, CPT 2014 states, “For bilateral procedure, report 69210 with modifier 50.”

Unfortunately, CMS sees things differently. In the new 2014 fee schedule, CMS stated its opinion that the procedure will typically be done on both ears at the same encounter, because “the physiologic processes that create cerumen impaction likely would affect both ears.” CMS did not provide any evidence or citations to support this opinion.

CMS went on to say, “Given this, we will continue to allow only one unit of CPT 69210 to be billed when furnished bilaterally.” Consequently, CMS elected to maintain the 2013 work value of 0.61 for CPT code 69210 when the service is furnished.

The bottom line is that Medicare will pay you the same amount for 69210 whether you do one ear or two, even though the CPT descriptor now says it is for one ear only.

If only CMS could hear how ridiculous that sounds.

– Kent Moore, Senior Strategist for Physician Payment for the American Academy of Family Physicians

Tuesday Feb 04, 2014

Survey: Average family physician wait times are more than two weeks

The average wait time for a patient wanting to get an appointment with his or her family physician has dipped slightly from two years ago, a new study says. But patients are still having to wait two weeks or longer.

Health care consulting firm Merritt Hawkins, in a new report, says its survey of family physician offices in 15 U.S. metropolitan areas found an average appointment wait time of 19.5 days in 2013. By comparison, average appointment wait time was 20.3 days in 2009.

However, the researchers noted that average wait times equaled or exceeded 14 days in 10 of the 15 markets last year. In 2009, only eight markets equaled or exceeded the two-week mark.

The company surveyed almost 1,400 offices across the 15 metro areas in family medicine and four other specialties. Researchers considered family medicine essentially flat. Cardiologists (16.8 days) and dermatologists (28.8 days) saw their wait times increase while obstetricians/gynecologists (17.3 days) and orthopedists (9.9 days) saw a decrease.

Overall, the average wait time to see a physician across all specialties and markets decreased from 20.4 days in 2009 to 18.5 days in 2013.

Despite the decline, Merritt Hawkins warned that physicians unable to see patients within 14 days are likely busy and need the help of other physicians or advanced practitioners to handle the overflow.

The survey also found that the overall average acceptance of Medicaid patients has declined in the 15 markets over the past four years, falling to 45.7 percent in 2013, compared with 55.4 percent in 2009. An average of 76 percent of practices in the 15 markets accepted Medicare in 2013. Merritt Hawkins didn't survey for Medicare in its 2009 survey.

If you're looking for ways to get more patients into your practice faster, you can check out articles in Family Practice Management's Access to Care topic collection.

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