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Wednesday, January 27, 2010

2010 Medicare physician fee schedule: The saga continues

As you will recall, in our last installment (see "The perils of the 2010 Medicare physician fee schedule," Jan. 13, 2010), the 2010 Medicare physician fee schedule was headed down the tracks towards a "Bridge Out!!" sign after Feb. 28.  That is still the situation as I write this post, but two developments in the interim have made the ride a little more interesting. 

First, on Jan. 19, voters in Massachusetts elected a Republican to fill the seat of the late Senator Edward Kennedy.  That has, apparently, effectively put health care reform on hold, which has implications for the fee schedule, since the postponement of the cut in the 2010 Medicare physician fee schedule was intended to give Congress time to implement a long-term fix as part of health care reform.  According to folks inside the Beltway, there is still a lot of work going on with respect to the physician payment formula, but one has to wonder what impact last week's election results will have in this regard.

The other development of interest is that the Medicare conversion factor is actually higher now than it was in 2009.  According to MLN Matters article MM6796, published by the Centers for Medicare & Medicaid Services, the conversion factor for 2010 is currently $36.0846.  In 2009, it was $36.0666.  Apparently, the increase was due to some technical corrections in some of the relative value units (RVUs) in the fee schedule.  Admittedly, two cents per RVU is not much to get excited about, but it's an interesting development nonetheless. 

So, the wild ride continues with only a month to go before calamity may strike.  What twists and turns may appear between now and then?  Stay tuned!

Wednesday, January 13, 2010

The perils of the 2010 Medicare physician fee schedule

Like an old-time movie serial, my last post (see "A familiar tune" on Dec. 23, 2009) left the 2010 Medicare physician fee schedule dangling over a precipitous 21% drop and clinging to the hope that Congress and the President would intervene before time ran out on Dec. 31. 

As we resume our story, we find that the fee schedule was, indeed, rescued (at least temporarily) by Congressional and Presidential action.  Specifically, in late December, Congress passed, and the President signed, the Department of Defense Appropriations Act of 2010, which provides for a zero percent update to the 2010 Medicare physician fee schedule for a two month period, Jan. 1, 2010 through Feb. 28, 2010.  That essentially means that the Medicare conversion factor (i.e., the dollar multiplier that translates relative value units, or RVUs, into payment amounts under the Medicare physician fee schedule) will stay at the 2009 level through the first two months of 2010.  Physicians may still see some changes in Medicare payment allowances from 2009 levels due to changes in RVUs, but for many of the services most commonly provided by family physicians, those RVU changes are positive. 

In an interesting sub-plot, the Centers for Medicare and Medicaid Services (CMS) has extended the period during which physicians may change their Medicare participation or non-participation status for 2010 until March 17, 2010.  As always, participation decisions are effective Jan. 1 and binding for the entire year.  For more information, see the Medicare participation options web page on the American Academy of Family Physicians' web site. 

As noted, the reprieve for the 2010 fee schedule is only temporary, and a "Bridge Out!!" sign looms on the horizon as the fee schedule hurtles down the tracks with no brakes.  Will Congress and the President come to the rescue again?  Will the 2010 fee schedule and physicians finally find lasting happiness?  Or will it all come to a crashing 21 percent decline on March 1? 

While we await the answers to these and other exciting questions, you may want to keep your options open as it relates to Medicare in 2010, especially since CMS has given you until March 17 to make a final decision on your Medicare participation status.  Regardless of your current status, your options in the meantime are to either hold your Medicare claims (if your cash flow allows that) until the dust settles or to continue submitting them as you always do. 

If you continue to file Medicare claims and later change your participation status, please be aware that there may be some consequences to the status change since it will be retroactive to Jan. 1, 2010.  Thus, if you are currently "participating" and change to "non-participating," you will likely have to make a refund to Medicare, since participating physicians have a higher Medicare allowance than non-participating physicians.  On the other hand, you will then be able to bill Medicare beneficiaries up to the Medicare limiting charge for unassigned claims, which will theoretically allow you to collect more for your services than you could have as a participating physician. 

On the flip-side, if you are currently non-participating and choose to become participating, you may be able resubmit your claims and get paid at the higher participating rate.  However, you will also likely have to refund to beneficiaries any amounts previously collected for 2010 services that exceed the participating physicians' allowed amounts. 

Thus ends this chapter in our story.  Stay tuned for the next exciting installment of "The Perils of the 2010 Medicare Physician Fee Schedule!" 

Tuesday, January 5, 2010

A Happy New Year's greeting from CMS

As if you are not busy enough at this time of year with higher flu season demand to meet, CPT code changes to accommodate, and the holiday aftermath, the Centers for Medicare & Medicaid Services (CMS) is delivering a special Medicare present this year in the form of new modifier AI and new rules related to the deletion of the consultation codes from the Medicare Physician Fee Schedule. The first instructions regarding these changes were described in Change Request 6740. More recent guidance was published in the form of an MLN Matters article on the CMS web site. Here are some highlights:

Add modifier AI to your list of commonly used modifiers if you admit patients to hospital or nursing facilities.

The modifier must now be reported by the admitting physician of record in addition to the code for initial care services in the hospital (99221-99223) or nursing facility (99304-99306) according to the level of care provided. Modifier "-AI," defined by CMS as "Principal Physician of Record," shall be used by the admitting or attending physician who oversees the patient’s care, as distinct from other physicians who may be furnishing specialty care. All other physicians who perform an initial evaluation on this patient shall bill only the code for initial hospital or nursing facility care that represents the level of service provided as indicated in the E/M documentation guidelines.

Physicians other than the physician who ordered observation care services must report office and other outpatient care evaluation and management codes (99201-99215) for their services.

Initial charges for patients admitted to observation status (99218-99200 or 99234-99236) will continue to be reported only by the physician who ordered the observation stay with no requirement to add the AI modifier. All other physicians who furnish consultations or additional evaluations or services while the patient is receiving hospital outpatient observation services must bill the appropriate outpatient service codes.

For example, if a cardiologist orders observation services and asks a family physician to additionally evaluate the patient, only the cardiologist may bill the initial observation care code. The family physician who evaluates the patient must bill the new or established office or other outpatient visit codes (99201-99215) as appropriate. The same guidance for determining whether a patient is new or established applies to these services as to any other office or outpatient encounter. The patient is established if any physician of the same specialty in the same group practice has provided a face-to-face service within the last three years.

Services in the outpatient setting that were previously reported with consultation codes must now be reported with office or other outpatient evaluation and management codes (99201-99215). 

These rules apply to all Medicare claims whether Medicare is the primary or secondary payer.

We will be watching for more guidance on filing secondary claims where the codes on the claim may not match the codes on the explanation of benefits from the primary payer (e.g., private payer paid consultation code leaving co-insurance due from Medicare).

It will also be necessary to recognize Medicare Advantage plans that will no longer maintain the consultation codes in their fee schedules in 2010 and may require the AI modifier on initial care charges from the admitting physician for services in a hospital or nursing facility.

There you have it. Stay tuned. We'll share what we learn as we receive and read more; and hopefully buy you a little New Year's respite.

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The views expressed here do not necessarily reflect the opinion of FPM or the AAFP. Some payers may not agree with the advice given. This is not a substitute for current CPT and ICD-9 manuals and payer policies. See Terms of Use.

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