Changes coming to Medicare payments for durable medical equipment

If you prescribe durable medical equipment (DME) for your Medicare patients, you should be aware that, effective July 1, Medicare will expand its competitive bidding program for DME, prosthetics, orthotics, and other supplies. The expansion may affect where your patients can fill their prescriptions and how much they and Medicare end up paying for the DME.

The Centers for Medicare & Medicaid Services (CMS) introduced its competitive bidding program in nine areas of the country in 2011. Based on the program's success in those areas, CMS is extending it to 91 new areas across the country. CMS will also implement a national mail-order program for diabetic testing supplies on July 1.

The program affects Medicare payments for wheelchairs, oxygen, mail-order diabetic supplies, and more. Historically, Medicare based its payment for most of these items on historical charges, adjusted for inflation over time. However, many studies have shown that the prices Medicare has paid for certain medical equipment and supplies are excessive – sometimes three or four times retail prices and the amounts paid by commercial insurers.

Under the competitive bidding program, suppliers submit bids for certain medical equipment and supplies that must be lower than what Medicare pays for these items currently. Medicare then uses the bids to set the amount it will pay for those items and chooses the qualified, accredited companies with winning bids as Medicare contract suppliers. The lower Medicare payment amounts also lower a Medicare beneficiary’s co-payment.

The competitive bidding is part of CMS's efforts to fight fraud and waste in the Medicare program. Media reports have noted that, from 2009 to 2012, Medicare paid $43 billion for DME, more than 60 percent of which may have been improper. Similarly, CMS has introduced a pilot program that requires approval before Medicare will pay for power wheelchairs and scooters for beneficiaries in seven states with high rates of fraud and errors: California, Illinois, Michigan, New York, North Carolina, Florida, and Texas.

You and your patients can find a list of Medicare contract suppliers in your area by visiting Medicare's supplier directory tool or by calling 1-800-MEDICARE. For additional information, visit the Medicare DME Competitive Bidding Program's website, which includes all of the products and items that are covered under the program.

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

Posted at 04:49PM May 14, 2013 by David Twiddy, Associate Editor  |  Comments[0]

Medicare delays penalties for claims with invalid or missing NPIs

In a recent post, I referenced that the day of reckoning was finally coming for those who order or refer items or services for their Medicare patients but who lack the proper identification. As it turns out, that day has been pushed back.

The Centers for Medicare & Medicaid Services (CMS) announced late last week that, due to technical issues, implementation of phase 2 of the ordering and referring denial edits is being delayed from May 1 to an unspecified future date. As a reminder, these edits would have denied certain claims from physicians and other eligible professionals who lacked a valid individual National Provider Identifier. Those claims include Medicare Part-B claims involving laboratories, imaging centers, durable medical equipment, orthotics, and supplies that have an ordering or referring physician/nonphysician provider as well as Part-A home health agency claims that require an attending physician. 

CMS will advise physicians and other qualified health professionals of the new implementation date in the near future. In the interim, the agency will continue to attach warnings to those claims that would have been denied had the edits been in place.

All of this means that if you order or refer items or services for Medicare beneficiaries and you do not have a Medicare enrollment record, you have a little more time to submit an enrollment application to Medicare using the Internet-based Provider Enrollment, Chain, and Ownership System. As noted previously, physicians who have a valid opt-out affidavit on file are not required to enroll in Medicare for this purpose; CMS has a special, shorter enrollment form, known as the CMS-855O, for use by physicians and other health professionals who just refer and order services but do not bill Medicare directly.

More information on the new edits can be found here.

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

Posted at 03:15PM Apr 30, 2013 by David Twiddy, Associate Editor  |  Comments[0]

Update on Medicaid payment parity with Medicare

Medicaid payments were supposed to rise to the level of Medicare this year, but chances are that you haven't seen it yet. Here's an update.

Section 1202 of the Affordable Care Act increases Medicaid payments for specified primary care services to Medicare levels for certain primary care physicians in 2013 and 2014. The provision was nominally effective Jan. 1, 2013.

However, the Centers for Medicare & Medicaid Services (CMS) gave states until March 31, 2013, to file the necessary state plan amendments. CMS then gave itself up to 90 days to review and approve those amendments.

Last week, I participated in a conference call with staff from CMS to discuss implementation of this provision. The good news is that CMS staff reported that all of the states submitted the necessary state plan amendments by the March 31 deadline, and CMS expects that most will be approved in the 90-day timeframe allowed to CMS. The bad news is that, so far, CMS has approved only three.

CMS has been clear that the provision is retroactive to Jan. 1, 2013, and states are required to give physicians two to three months to attest that they qualify to receive the enhanced payment once a) the state’s attestation process is operational AND b) the state has provided notice to physicians. Unfortunately, CMS is not tracking state efforts and deadlines in this regard, and CMS itself will not conduct any physician outreach on attestation. Instead, CMS will leave it to the states. 

So, what do you need to do? First, if you accept Medicaid, contact your state Medicaid agency and the state chapter of your specialty society regarding the status of your state’s implementation of this provision. You want to be aware of when the attestation process begins and the deadline for attestation. Second, when that process is operational in your state, follow the procedures mandated by your state in the timeframe given.

The American Academy of Family Physicians' website contains additional information on the program, if necessary.

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

Posted at 10:10AM Apr 26, 2013 by David Twiddy, Associate Editor  |  Comments[0]

A limited time opportunity on eRx penalties

Time is running out for physicians to avoid having their Medicare Part B fees cut next year under a federal initiative that encourages electronic prescribing.

The Centers for Medicare & Medicaid Services (CMS) has given practices until June 30, 2013, to show that they have met e-prescribing (eRx) requirements during the first six months of this year (or during the 12-month eRx reporting period of Jan. 1, 2012-Dec. 31, 2012) or to request a hardship exemption from the requirements to avoid the 2014 penalty. (CMS calls it a "payment adjustment.")

Practices can also avoid the 2014 penalty if they do one of the following by June 30, 2013:

•    Register to participate in the Medicare or Medicaid Electronic Health Record (EHR) Incentive Program and adopt certified EHR technology; or

•    Attest achievement of meaningful use under the EHR Incentive Program during either the 12-month eRx reporting period (Jan. 1, 2012-Dec. 31, 2012) or the six-month eRx reporting period (Jan. 1, 2013-June 30, 2013).

If you are currently subject to the eRx payment adjustment or have been in the past, you are not alone. CMS reports that 135,931 eligible professionals were subject to the 2012 eRx payment adjustment because they did not qualify for an exemption, meet exclusion criteria for the adjustment, or comply with eRx reporting requirements in the first half of 2011.

The payment adjustment in 2014 will be 2 percent, which means if you are subject to the adjustment, you will only receive 98 percent of your Medicare Part B physician fee schedule amount for covered professional services, assuming you are not subject to any other payment adjustments under Medicare.

On March 1, CMS re-opened the Quality Reporting Communication Support Page to allow individual eligible professionals and group practices the opportunity to request a significant hardship exemption for the 2014 eRx payment adjustment. As noted, hardship exemption requests will be accepted through June 30, 2013. After that, you're out of luck. Also, please note this applies only to hardship exemption requests for the 2014 eRx payment adjustment. The reporting period to avoid the 2013 eRx payment adjustment, or to submit hardship exemption requests, has ended.

The following resources are available to assist individual eligible professionals and group practices in submitting their request for a hardship exemption:

• Quality Reporting Communication Support Page User Guide

• Tips for Using the Quality Reporting Communication Support Page

For additional information on the 2014 eRx payment adjustment, including who is subject to the payment adjustment and how to avoid it, please review the 2014 eRx Payment Adjustment Fact Sheet.

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

Posted at 11:50AM Apr 23, 2013 by David Twiddy, Associate Editor  |  Comments[0]

Medicare to deny claims with no NPI

The day of reckoning is finally coming for those who order or refer items or services for their Medicare patients but who lack the proper identification.

On May 1, the Centers for Medicare & Medicaid Services (CMS) will begin instructing its contractors to deny Medicare claims from individuals who don't include a valid National Provider Identifier (NPI).

Section 6405 of the Affordable Care Act requires physicians or other eligible professionals to be enrolled in the Medicare program to order or refer items or services for Medicare beneficiaries. Also, Medicare requires that a physician or supplier that bills Medicare for a service or item show the name and unique identifier (i.e., the NPI) of the attending physician on the claim if that service or item was the result of an order or referral.

Beginning in October 2009, Medicare contractors began alerting billing providers if the identification of the ordering/referring provider was missing, incomplete, or invalid, or if the ordering/referring provider was not eligible to order or refer. The alerts were merely warnings, however, that the claims lacked the required information, and the claims were paid anyway. Beginning next month, however, CMS will deny Part B, durable medical equipment, and Part A home health agency claims that fail the ordering/referring provider edits.

Physicians and others who want to continue ordering and referring items and services need to establish their Medicare enrollment record and make sure they're of a specialty that is eligible to order and refer. You can enroll in the Medicare program here: Internet-Based Provider Enrollment, Chain, and Ownership System (PECOS). Physicians who have a valid opt-out affidavit on file are not required to enroll in Medicare. CMS also has a shorter enrollment form, known as the CMS-855-0, for use by physicians and other health professionals who refer and order services but do not bill Medicare directly.

More information on the new edits can be found in this Medicare bulletin.

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

Posted at 01:18PM Apr 10, 2013 by David Twiddy, Associate Editor  |  Comments[0]

Sequestration takes effect, but how will it affect you?

Like a cruel April Fool's joke (without the joke), sequestration began Monday with big implications for you and your practice.

Under the current sequester, Medicare payments to doctors, hospitals, and other health care providers, as well as to health plans and drug plans, are to be reduced by 2 percent for services provided on or after April 1. This also covers physician-administered drugs included on your claims.

Medicare contractors will apply the cut to the payment itself, not the underlying "allowed charge" in the Medicare fee schedule. As a result, beneficiary copayments and deductibles will not change. In other words, Medicare imposes the 2 percent cut only on the 80 percent of the allowed charge that a participating physician would receive directly from Medicare. The 20 percent copayment amount (and any applicable deductible) that the physician collects from the patient will be based on the full allowed charge amount.

With respect to unassigned claims for services provided by nonparticipating physicians, the 2 percent cut will be applied to the Medicare payment made to the beneficiary (but not to the limiting charge amount). If you are a nonparticipating physician, reducing your charges on unassigned claims will not insulate your Medicare patients from the cut; it will only take money out of your own pocket.

The Budget Control Act requires that $1.2 trillion in federal spending cuts be achieved over the course of nine years. This means federal spending will be subject to sequestration until 2022 unless Congress takes action to change the law or reaches a new budget agreement to address deficit and spending concerns. (The Medicare cut will never be higher than 2 percent, however, and the Medicare cuts each year are not cumulative.)

With all the fiscal deadlines facing Congress this year, the sequester will remain a subject for debate. However, it is not expected that the sequester cuts will be lifted before Sept. 30, which is the end of the current federal fiscal year.

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

Posted at 12:37PM Apr 03, 2013 by David Twiddy, Associate Editor  |  Comments[0]

Sequestration and you

With sequestration now, apparently, a fact of life, what are the implications for your practice?

Absent further action by Congress, the current slate of required federal budget cuts is expected to reduce Medicare payments to doctors, hospitals, and other health care providers, as well as health plans and drug plans, by 2 percent for services provided on or after April 1.

That will result in $11 billion in lost revenues this year for providers, who will receive only 98 cents on the dollar for their services to Medicare beneficiaries.

The American Academy of Family Physicians, among other medical associations, is decrying the impending cuts.

However, as bad as sequestration sounds, things could be worse if President Obama and congressional Republicans actually did reach an agreement to reduce federal deficits. As the Washington Post noted last week, the sequester would reduce Medicare spending by about $100 billion over a decade. But President Obama had suggested $400 billion in health care cuts, mainly from Medicare, and Republicans reportedly wanted more.

So, unless federal leaders intervene in the interim, expect your Medicare payments to drop by 2 percent beginning next month – and be thankful it isn’t any worse than that.

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

Posted at 04:46PM Mar 06, 2013 by David Twiddy, Associate Editor  |  Comments[0]

Pay attention, or don't get paid for E/M services performed with vaccinations (UPDATED)

Getting fully reimbursed for vaccinations is now requiring a little extra effort.

The latest round of edits for the Correct Coding Initiative (CCI) went into effect Jan. 1 and included around 300 changes that affect evaluation and management (E/M) services and immunization administration, specifically codes between 90460 and 90474.

In each edit, the administration code trumps the E/M code. That means if you bill a vaccine administration code and an E/M code for the same patient on the same date and do not append a modifier to the E/M code, Medicare and other payers who follow the CCI edits will only pay for the vaccine administration.

The idea behind the edits is that an E/M service provided at the same encounter as a vaccine administration should be a significant and separately identifiable service. Vaccine administration by itself does not merit both the administration code and an E/M code.

If, however, the situation merits separate reporting and you have supporting documentation, you can attach a modifier (such as modifier 25) to the E/M code and report both services. The one exception is E/M code 99211 (office or other outpatient visit for the evaluation and management of an established patient that may not require the presence of a physician). CCI will not allow the addition of a modifier to report both 99211 and a vaccine administration. That edit is not new.

Both the American Academy of Family Physicians and American Academy of Pediatrics are protesting the new edits, saying they needlessly complicate physician billing practices and don't appear necessary under current CPT language.

They also worry that placing additional barriers to practices seeking proper payment for immunizations will lead to fewer people getting vaccinated. That's obviously a problem for both public and individual health and comes at a time when the Centers for Disease Control and Prevention has lamented the unacceptably low adult immunization rates in the United States.

Considering that the CCI is overseen by the Centers for Medicare & Medicaid Services, it appears once again that Uncle Sam’s right and left hands don’t know what each other are doing or that, even if they do, the consequences are just as disastrous.

2/14/13 UPDATE: CMS gives state Medicaid programs some leeway in following new vaccination E/M coding changes.

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

Posted at 05:06PM Feb 07, 2013 by David Twiddy, Associate Editor  |  Comments[2]

Time running out for PQRS and eRx incentives

It's not too late to participate in a pair of federal incentive programs targeting clinical quality and computerized prescriptions. But you need to move fast.

The Centers for Medicare and Medicaid Services (CMS) this week hosted a national call to discuss how physicians and other eligible health care professionals can submit 2012 program year data for the Physician Quality Reporting System (PQRS) and the Electronic Prescribing (eRx) Incentive Program.

In case you missed it, below are some of the highlights.

For individual eligible professionals, you still have time to participate in the 2012 PQRS if you report your information either through a qualified registry or through a qualified electronic health record (EHR). The EHR option can communicate either directly or through a data submission vendor.

Registry vendors can submit data between Feb. 1 and March 31. EHR users can already submit their data, but they only have until Feb. 28. No submissions after the end dates will be allowed.

You may potentially qualify to receive a full-year incentive payment. But even if you don't, it's good experience in reporting PQRS measures before tackling 2013, which is the reporting period CMS will use in determining PQRS penalties in 2015.

The same options and dates apply with respect to the eRx Incentive Program. As with the PQRS, you may potentially qualify to receive a full-year incentive payment, and you may potentially qualify to avoid the 2014 eRx penalty. However, to avoid a penalty this year, you had to have complied with the program by June 30, 2012.

For more information on the programs, you can find the presentation from the national call online.

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

Posted at 11:09AM Jan 23, 2013 by David Twiddy, Associate Editor  |  Comments[0]

Avoiding Medicare cliff still has initial consequences for payment

With the Medicare payment cliff averted for now, Medicare and its contractors are beginning to implement payments for 2013 services. Here is what you can expect, based on information provided by the Centers for Medicare and Medicaid Services (CMS).

First, CMS is revising the 2013 Medicare Physician Fee Schedule (MPFS) to reflect the new law's requirements as well as technical corrections identified since publication of the final rule on the 2013 MPFS in November 2012. Officially, the 2013 conversion factor is $34.0230.

Second, to allow sufficient time to develop, test, and implement the revised MPFS, Medicare contractors were able to hold MPFS claims with January 2013 dates of service for up to 10 business days (i.e., through Jan. 15). CMS expected those claims to be released into processing no later than Jan. 16. The claim hold should have minimal impact on your cash flow, however, because, under current law, clean electronic claims are not paid sooner than 14 calendar days (29 for paper claims) after the date of receipt anyway. Claims with dates of service prior to Jan. 1, 2013, are unaffected.

Medicare contractors will be posting the correct MPFS payment rates on their websites no later than Jan. 23. If you have downloaded or will be downloading the fee schedule from your local Medicare contractor's web site, double-check to ensure that it reflects the correct rates, based on the recent change in the law.

Finally, the 2013 Annual Participation Enrollment Program allowed eligible physicians, practitioners, and suppliers an opportunity to change their Medicare participation status by Dec. 31, 2012. Given the new legislation, CMS is extending the 2013 annual participation enrollment period through Feb. 15, 2013. Therefore, you have until Feb. 15, 2013, to postmark any participation changes (both elections and withdrawals) that you want to make. The effective date for any participation status changes during the extension remains Jan. 1, 2013, and will be binding for the rest of the year.

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

Posted at 01:35PM Jan 17, 2013 by David Twiddy, Associate Editor  |  Comments[0]

Webinar to discuss what's new in Medicare and Medicaid payment in 2013

With the Medicare payment cliff averted for now, Medicare payments should be fairly stable for a while. However, that does not mean there are no changes in store for Medicare and Medicaid this year.

From Medicare adding two new codes for transitional care management to Medicaid payments for some primary care services rising to the level of Medicare to the continuing use of Physician Quality Reporting System (PQRS) bonuses, it's going to be a busy year for family physicians understanding and taking advantage of the new payment rules.

My colleague Debra Seyfried and I will be covering these and other aspects of Medicare payment in 2013 during a live webinar at 1:00 p.m. (Central Standard Time) on Jan. 23, 2013. I would invite you to join us by registering online. It could make a difference to your bottom line this year and in years to come.

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

Posted at 03:42PM Jan 07, 2013 by David Twiddy, Associate Editor  |  Comments[0]

Medicare's fiscal cliff averted ... for now

They waited until the very last second, but members of Congress on Tuesday approved legislation that preserves Medicare physician payment rates for another year and delays planned budget cuts until March.

In the waning hours of New Year's Day, the U.S. House of Representatives passed House Resolution 8, the American Taxpayer Relief Act, which had previously been approved by the Senate. Under the act, current Medicare physician payment rates (i.e., the conversion factor) are extended through Dec. 31, 2013, thus avoiding the 26.5 percent cut required by the sustainable growth rate (SGR) formula. The act also delays, for two months, implementation of the Budget Control Act's sequestration provision, which could reduce payments by an additional 2 percent.

The $25 billion cost for the SGR patch was offset by an array of provisions. One of those included extending the statute of limitations from three to five years for recoupment of Medicare overpayments.

So, what does this mean for your Medicare payments in 2013? Well, for the next two months at least, you should not see any substantial changes. The actual payment allowance for some services may vary slightly, based on changes in relative value units assigned to those services and other elements of the Medicare physician fee schedule. If Congress fails to further address the sequestration cut, you may see a 2 percent drop in your Medicare allowances in early March. Otherwise, things should be stable through the end of the year. 

The American Academy of Family Physicians and the rest of organized medicine continue to push for a permanent solution to the SGR problem. In the meantime, Congress has provided another of its annual patches to this perennial issue.

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

Posted at 05:29PM Jan 02, 2013 by David Twiddy, Associate Editor  |  Comments[0]

Medicare's impending fiscal cliff for physicians

If the federal government does go over the "fiscal cliff" in a little more than a week, don't expect those overseeing physician reimbursements to pad the fall.

The Centers for Medicare and Medicaid Services (CMS) on Dec. 19 announced in an email and conference call with physicians that Medicare claims filed after the first of the year will be processed as normal, which means likely including a planned 26.5 percent reduction in the Medicare physician services conversion factor.

Physicians are also facing an additional 2 percent cut in the Medicare physician payment rate because of the Budget Control Act's sequestration provision.

Under current law, clean electronic claims are not paid sooner than 14 calendar days (29 days for paper claims) after the date of receipt. In similar past situations, CMS has taken advantage of that provision to have its contractors hold claims for up to 10 business days before processing them, in order to give Congress more time to act and to avoid processing claims twice when the conversion factor is in flux.

“The negative update of 27 percent under current law for the 2013 Medicare Physician Fee Schedule is scheduled to take effect on January 1, 2013,” CMS wrote in the email. “Given the current progress with the legislation, CMS must take steps to implement the negative update.”

CMS did say that it would notify physicians on or before Jan. 11, 2013, about the status of Congressional action to avert the negative update and next steps. Claims with dates of service on or before Dec. 31, 2012, will be unaffected in any case.

Ongoing efforts to avoid the cliff and override the planned rate reduction have so far failed and won't resume until after Christmas at the earliest.

In the meantime, you are advised to start taking steps to mitigate the disruption and meet your own financial obligations in January, in case the cuts actually take effect. This includes re-assessing your Medicare participation options and the extent to which you can continue to afford to care for Medicare beneficiaries. If you decide to limit your involvement with the Medicare program, notify your Medicare patients promptly, so that they, too, can explore other options to seek health care and medical treatment. Finally, you are encouraged to contact your Congressional representatives about this matter, and the American Academy of Family Physicians has provided a convenient means to do so.

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

Posted at 04:10PM Dec 21, 2012 by David Twiddy, Associate Editor  |  Comments[0]

Rethinking your Medicare participation options?

With just a little more than three weeks left before the wheels could fall off Medicare payments, you may be rethinking your level of involvement with the program.

Congress may step in again this year to avoid the scheduled 26.5 percent cut tied to the Sustainable Growth Rate formula. But if not, here is a brief look at the options open to you and ways to reduce your Medicare exposure, even if you remain a participating physician.

You have three Medicare contractual options. You can sign a participating (PAR) agreement, accepting Medicare's allowed charge as payment in full; elect to be a non-PAR physician, which allows you to take Medicare patients on a case-by-case basis and bill patients for more than the Medicare allowance for unassigned claims; or opt out and become a private contracting physician who bills Medicare-eligible patients directly for your services.

You have until Dec. 31 to change your Medicare participation or non-participation status for 2013. Before making a change in status, you should first determine that you are not bound by any contractual arrangements with hospitals, health plans, or other entities that require you to be a PAR physician.

Even if you choose to continue being a PAR physician, there are ways that you can limit your Medicare exposure. For instance, you can refuse to treat Medicare patients except on an emergency basis. Medicare is a voluntary program, and nothing requires you to treat Medicare patients in your practice if you do not wish to do so. You can also limit your practice to existing Medicare patients only and accept no new Medicare patients. Lastly, you can reduce the number of Medicare patients in your practice.

For more information, see Family Practice Management's previously published articles on opting out of Medicare and preparing for a Medicare fee cut.  

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

Posted at 03:38PM Dec 06, 2012 by David Twiddy, Associate Editor  |  Comments[0]

Medicare releases its final rule on the 2013 physician fee schedule

On November 16, the Centers for Medicare and Medicaid Services (CMS) published the final rule on the 2013 Medicare Physician Fee Schedule, changing the physician fee schedule and other Medicare Part B payment policies and implementing certain provisions of the Affordable Care Act.

The regulation also discusses:

• 2013 Physician Quality Reporting System


• Electronic Prescribing Incentive Program


• Implementation of the Physician Value-Based Payment Modifier

Among the highlights in the final rule:

• In 2013, CMS will pay for new Current Procedural Terminology transitional care management codes, 99495 and 99496, with some small modifications. Based on the relative value units that CMS finalized and assuming that Congress averts the pending 26.5-percent reduction discussed below, code 99495 performed in a facility will pay approximately $135; in a non-facility setting, 99495 will pay approximately $164. Code 99496 performed in a non-facility will pay approximately $231.12, and when performed in a facility setting, it will pay approximately $197.76.


• CMS delayed to July 1, 2013, the effective date of its requirement that a face-to-face visit be a condition of payment for certain high-cost durable medical equipment (DME) covered items. The list included many items that have historically been targets of Medicare fraud as identified by various program integrity experts. The encounter must occur within six months before the written order for the DME. CMS is not mandating additional documentation beyond what the physician or other qualified health professional would normally document during the actual face-to-face encounter.


• CMS is limiting the applicability of the value-based payment modifier to groups of 100 or more eligible professionals during 2015, the first year it will be effective. This means that most family physicians will not have to worry about it for now.

CMS estimates that, all things being equal, family physicians will experience a 7-percent increase in their Medicare allowed charges in 2013 as a result of what is in the final rule.

Unfortunately, that assumes no change in the Medicare conversion factor from 2012. However, as noted in the final rule, the conversion factor under current law will decrease 26.5 percent to approximately $25 (from the current $34.04), effective with dates of service on or after Jan. 1, 2013. That means, unless Congress intervenes in the interim, the drop in the conversion factor will more than wipe out the projected 7-percent increase.

So, there is good news and bad news in the final rule this year. Only time will tell which will prevail, so stay tuned. In the meantime, for more information on the final rule, please visit the American Academy of Family Physicians' web site.

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

Posted at 11:24AM Nov 30, 2012 by David Twiddy, Associate Editor  |  Comments[0]