American Academy of Family Physicians
Tuesday Dec 18, 2012

New rule would let more family physicians treat veterans

While many family physicians want to treat the military veterans in their communities, the Department of Veterans Affairs (VA) hasn't always made that easy. Thankfully, the VA recently began taking steps to loosen its regulations in such a way that family physicians could have greater ability to serve veterans and get paid by the VA for doing so.

Under current law, private physicians can provide certain hospital care and medical services to eligible veterans when VA facilities either are not accessible or aren't able to provide the necessary care. These services are provided under the Non-VA Care program. However, the program allows that non-VA care only if the veteran initially received treatment during a period of hospitalization.

Last month, the VA published a proposed revision to this regulation in the Federal Register. The change would enlarge the list of eligible providers where the veteran initially received care to include nursing homes, domiciliary care, or other medical services. The VA could authorize non-VA treatment under the program for up to 12 months, with the option of additional reauthorizations as needed.

The American Academy of Family Physicians (AAFP) enthusiastically supports this step since it improves health care access for veterans and will allow the VA to better utilize community resources. Separate from this proposed regulation, the AAFP is encouraging the VA to identify and remove additional barriers that inhibit the way community-based family physicians are able treat their patients who also happen to be veterans. Specifically, the AAFP is urging the VA to reexamine a burdensome regulatory requirement that in order for a veteran to obtain a prescription at the VA's discounted price it has to be written by a VA-affiliated provider. Instead, AAFP believes the VA should recognize the validity of a community-based physician's prescription.

The VA’s recent proposal won’t eliminate all of the barriers that community family physicians face in trying to serve veterans. However, it appears to be a step in the right direction for both veterans and their family physicians.

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

Friday Jun 24, 2011

Medicare RVU proposals: Two out of three ain't bad

On June 6, the Centers for Medicare & Medicaid Services (CMS) published a proposed notice in the Federal Register, in which it laid out its initial decisions related to the Five-Year Review of work relative value units (RVUs) under the Medicare physician fee schedule. Family physicians looking for good news in the proposed notice should find some, except when it comes the valuation of observation care in a hospital.

First, the good news.  CMS stated that it intends to increase the work RVUs for nursing facility discharge services, represented by codes 99315 and 99316. The proposed new values will put these codes on par with the corresponding codes for hospital discharge day services (99238 and 99239).

CMS also proposed to publish increased values for preventive medicine services codes (99381-99397). Although Medicare does not cover these services, many other payers do. The proposed RVUs represent an increase over the current RVUs in each case, reflecting a more appropriate recognition of the value of preventive medicine services. Publication of the new values will provide a basis for other payers to use those values in setting their own fee schedules.

Now for the bad news. In the proposed notice, CMS indicated its intent to maintain the current work RVUs for initial observation care (codes 99218-99220) and to decrease the work RVUs for codes 99234-99236, which include observation admission and discharge on the same date.

CMS’s rationale, as stated in the proposed notice is that “we [CMS] do not believe the work RVUs of the initial observation care codes (99218, 99219, and 99220) should be equivalent (or close) to the initial hospital care codes (99221, 99222, and 99223).” Instead, CMS believes that “the acuity level of the typical patient receiving outpatient observation services would generally be lower than that of the inpatient level" and that "if the patient’s acuity level is determined to be at the level of the inpatient, the patient should be admitted to the hospital as an inpatient.” The CMS recommended values for 99234-99236 are subsequently affected by CMS’s recommendations for 99218-99220.

CMS’s belief that the acuity level of the typical patient receiving outpatient observation services would generally be lower than that of the inpatient level is an assumption, not a documented statement of fact. In reality, hospital inpatient and outpatient status is often as much a function of payment policy as it is patient acuity. That is, hospitals not infrequently declare a patient’s status as “inpatient” or “outpatient” based on what they calculate will be most financially advantageous (e.g., based on a comparison of what Medicare will pay under the outpatient versus inpatient prospective payment systems), which does not necessarily equate to patient acuity.

CMS will not finalize its proposals until this fall, when it publishes the final rule on the 2012 Medicare physician fee schedule, so CMS may yet change its mind with respect to any or all of the above. Whatever CMS finally decides will be reflected in Medicare's payment for the services in 2012.

Friday Nov 05, 2010

The 2011 Medicare physician fee schedule is here

This week, the Centers for Medicare and Medicaid Services (CMS) unveiled its final rule on the 2011 Medicare physician fee schedule

An initial review shows positive news with respect to the primary care bonus that is effective in 2011. CMS apparently responded positively to comments from the American Academy of Family Physicians and others to change the primary care incentive payment implementation rules to make it more inclusive. As a result, CMS estimates that, under the new, less restrictive rules, about 80 percent of family physicians will qualify for the bonus. 

On the downside, the final rule with comment period announces a reduction to payment rates for physicians' services in 2011 under the sustainable growth rate (SGR) formula. The Medicare physician fee schedule rates are currently scheduled to be reduced under the SGR system on Dec. 1, 2010, and then again on Jan. 1, 2011 under current law. The total reduction in rates between November and January under the SGR system will be 24.9 percent. That means the conversion factor will drop from its current $36.8729 to $25.5217 in January, unless Congress and the President intervene. Of course, this week's Congressional election results may impact what happens in this regard, so stay tuned. 

The final rule will appear in the Federal Register on Nov. 29, 2010, and CMS will accept comments on certain aspects of it until Jan. 2, 2011.

Friday Jul 16, 2010

Looking ahead to the 2011 Medicare physician fee schedule

While the fate of the 2010 Medicare physician fee schedule is temporarily settled, it is time to look ahead to 2011. 

On July 13, the Centers for Medicare and Medicaid Services (CMS) published its proposed rule on the 2011 Medicare physician fee schedule in the Federal Register. The proposed rule covers a wide array of topics, including changes in Medicare fees, updates to existing Medicare programs (like the Physician Quality Reporting Initiative and e-prescribing incentive payments), and implementation of some provisions of the Patient Protection and Affordable Care Act

The bottom-line, good news in the proposed rule is that CMS estimates family physicians will see a 1 percent increase in their Medicare allowed charges in 2011 as a result of changes proposed in the rule, all other things being equal. That is not much, but it is better than the decreases estimated for many other specialties. Of course, any gains could be washed away if Congress and the President do not act to avert the scheduled cut of 21 percent in the Medicare payment rate that will be effective Dec. 1, 2010, under current law.

As in any proposed federal regulation, "the devil is in the details," and I and other AAFP staff are poring over those details in preparing an AAFP response to the proposed rule.  I'll share more on those details in a future post. 

In the meantime, feel free to peruse the proposed rule yourself and share your comments here.

Thursday Nov 05, 2009

Sunny with a chance of gloom

There is potential good news on the Medicare horizon as far as family physicians are concerned.  However, the silver lining is attached to a big, black cloud that could rain on everyone's parade unless Congress intervenes by the end of the year.

On Friday, Oct. 30, the Centers for Medicare and Medicaid Services (CMS) put the final rule on the 2010 Medicare physician fee schedule on display for review and comment by all interested stakeholders.  CMS plans to publish the final rule in the Federal Register on Nov. 25, 2009.  CMS will accept comments until Dec. 29, 2009.

In the final rule, CMS finalized many of the proposals that it made in its proposed rule earlier this year.  For those of you keeping score at home, that's good news for family physicians.  In fact, in the final rule, CMS estimates that family physicians will experience a 4 percent increase in their Medicare allowed charges in 2010 as a result of the rule, all other things being equal.  That is second only to ophthalmologists and optometrists, who are projected to reap a 5 percent increase, and much better than physicians in many other specialties, who are expected to see a decrease in their 2010 Medicare allowed charges as a result of the rule.

Of course, with Medicare, there's always a catch, and the final rule on the 2010 physician fee schedule is no exception.  Under current law, the Medicare conversion factor, which translates Medicare's relative value units into payment allowances, is scheduled to decrease 21.2 percent on Jan. 1, 2010, which would more than wipe out the potential gains for family medicine noted above.  That means Congress has until Dec. 31, 2009, to intervene, as it has the last several years, to avoid this cut.  Forecasters inside the Beltway are optimistic, but as they say on Wall Street, past performance is no indication of future returns.

So, as we approach the new year, the outlook is sunny, but you might want to keep your umbrella handy, just in case.

Thursday Oct 22, 2009

You might be a coding and payment geek if . . .

The arrival of the new ICD-9 manual recently reminded me that there are certain things that distinguish coding and payment geeks from otherwise "normal" people.  So, for your consideration, I offer you the top 10 signs that you might be a coding and payment geek:

10.  The first thing you associate with December is the arrival of the new CPT book.

9.  You actually get excited when your new coding books arrive.

8.  You wonder why the toy doctors bag you bought your kid doesn't include a claim form.

7.  You worry your family physician is undercoding your visit.

6.  You consider the Federal Register light reading.

5.  You write to CMS more than to your own mom.

4.  You actually understand Medicare's Sustainable Growth Rate formula.

3.  You collect past issues of CPT Assistant on eBay.

2.  When your family physician tells you that you have conjunctivitis, you wonder what the ICD-9 code for that is.

 And the number one sign that you might be a coding and payment geek:

1.  You actually understood the humor in this blog post!

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