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American Academy of Family Physicians
Wednesday Aug 17, 2011

Your Medicare participation options

A couple of recent news items have me asking again a question previously asked on this blog in October of 2010. "Why would any physician in his [or her] right mind want to participate in a system such as this [Medicare]?"

First, the ever-voluminous proposed rule for the Medicare Physician Fee Schedule has been published and is now open to comment. Looming above all the program changes and some potential additional work that is proposed is the ever-constant threat of a pay cut due to the sustainable growth rate (SGR). If Congress, also charged with reducing a massive budget deficit, does not act to either fix the SGR or again delay the related decrease in payments, the Medicare Physician Fee Schedule will be reduced by 29.5 percent. Doesn't sound like a reasonable business proposition to me.

Second, CMS announced this week that all physicians and providers who completed the enrollment process before March 25, 2011 will once again have to re-validate their enrollment in PECOS. (PECOS may stand for Particularly Exacerbating CMS Online System.) CMS notes that this is to comply with Section 6401(a) of the Affordable Care Act, which increases screening of physicians and providers enrolling in Medicare and Medicaid. (Note: You must complete this work when your Medicare contractor notifies you to do so and not before then, but then you must not be late either. "Upon receipt of the revalidation request, providers and suppliers have 60 days from the date of the letter to submit complete enrollment forms. Failure to submit the enrollment forms as requested may result in the deactivation of your Medicare billing privileges. ")

So what is the alternative? There are three Medicare participation options. The first is to participate, which means enrolling, accepting the Medicare fee schedule for all Medicare patients and being paid directly from Medicare. The second is to enroll but not participate, which allows you to charge the patient a fee up to the Medicare limiting charge and submit a claim for the patient to receive the reduced payment from Medicare. The third is to opt-out of Medicare for periods of two years and privately contract with your Medicare patients. To opt out, a physician must file an affidavit that meets the necessary criteria and is received by the carrier at least 30 days before the first day of the next calendar quarter.

Acknowledging that physicians in hospital-owned or large group practices may not have the luxury of opting out of Medicare, a good business case might be made for individual practices. There is some administrative burden in completing the opt-out affidavit and being sure that the Medicare contractor has validated it and then having each Medicare or Medicare Advantage patient sign a private contract every two years. But that effort should be more than offset by a reduction in many other administrative areas and an improvement to cash flow if a reasonable fee is set based upon actual costs per visit and perhaps a sliding scale for those patients with limited resources. If interested, you can try it out for 90 days and see if it works for your practice. There is a 90-day period after the effective date of the first opt-out affidavit during which physicians may revoke the opt-out and return to their prior status.

What do you think? If you are one of the few physicians who have opted out and still care for Medicare patients, how is it going? Are your patients able to receive equal or better access and quality of care? Do you miss dealing with CMS and their contractors?

Wednesday Mar 09, 2011

Drug screening codes have changed

There are now two drug screening codes for reporting use of a multiplexed screening kit that tests for multiple drugs or drug classes. The Centers for Medicare & Medicaid Service published new HCPCS code G0434 for the multiplexed drug screening to differentiate these tests from those that are more complex. CPT followed with new code 80104 for the same purpose. The descriptors for these new codes follow:

• G0434, "Drug screen, other than chromatographic; any number of drug classes, by CLIA waived test or moderate complexity test, per patient encounter (add modifier QW if you have CLIA certificate of waiver)"

• 80104, "Drug screen, qualitative; multiple drug classes other than chromatographic method, each procedure"

Use the G code for Medicare claims, and use the CPT code for other claims. The Medicare Clinical Laboratory Fee Schedule shows an average fee of $20.67.

CMS explained in MLN Matters publication SE1105 (PDF download) that refining the drug screen testing codes and revising the descriptors was done to avoid unnecessary or excessive utilization of code G0431 for relatively simple point-of-care tests that screen for multiple substances. In addition to introducing code G0434, code G0431 was changed from “Drug screen, qualitative; single drug class method (e.g., immunoassay, enzyme assay), each drug class” to “Drug screen, qualitative; multiple drug classes by high complexity test method (e.g., immunoassay, enzyme assay), per patient encounter.” If your practice has received denials for claims with dates of service on or after Jan. 1, 2011, that use code G0431QW for tests conducted with the kits listed in MLN Matters publication MM7266 (PDF download), corrected claims should be submitted with code G0434QW. For dates of service on or after April 1, 2011, claims that use code G0431QW will be denied. 

Also effective Jan. 1, 2011, code G0430 has been deleted and replaced with code G0434. Therefore, the code G0434QW replaces G0430QW. 

G0434 should be used to report very simple testing methods, such as dipsticks, cups, cassettes and cards, that are interpreted visually or with the assistance of a scanner, or that are read utilizing a moderately complex reader device outside the instrumented laboratory setting (i.e., non-instrumented devices). This code should also be used to report any other type of drug screen testing using test(s) that are classified as Clinical Laboratory Improvement Amendments (CLIA) moderate complexity test(s), keeping the following points in mind:

• G0434 includes qualitative drug screen tests that are waived under CLIA as well as dipsticks, cups, cards, cassettes, etc., that are not CLIA-waived.

• Laboratories with a CLIA certificate of waiver may perform only those tests cleared by the Food and Drug Administration (FDA) as waived tests. Laboratories with a CLIA certificate of waiver should bill using the QW modifier.

• Laboratories with a CLIA certificate of compliance or accreditation may perform non-waived tests. Laboratories with a CLIA certificate of compliance or accreditation should not append the QW modifier to claim lines.

• Only one unit of service for code G0434 can be billed per patient encounter regardless of the number of drug classes tested and irrespective of the use or presence of the QW modifier on claim lines.

Note that the "per encounter" reporting for G0434 doesn't prevent reporting when a patient is tested in two different settings, such as when a patient tested in the physician's office in the morning later reports to the emergency department and receives a second test.

The MLN Matters publication mentioned earlier (MM7266) also provides a listing of the drug kits that should be reported using the new code G0434 with the QW modifier to signify the test's waived status. Each quarter CMS publishes a list of all test products with CLIA-waived status. Providers may use this list to determine if a particular test product can be appropriately performed by a laboratory with a CLIA waiver and is eligible to be billed using the QW modifier. However, the currently displayed list is from Jan. 5, 2010. You can view the most recent list as provided to the Medicare contractors in Medicare CR7266 (PDF download).

If you are unsure about Medicare coverage of drug screening tests, this information is available from the Medicare Coverage Database and the Medicare National Coverage Determinations (NCD) Coding Policy Manual and Change Report dated January 2011. I found local coverage determinations for qualitative drug screens posted by National Governments Services Inc., First Coast Service Options Inc., and Palmetto GBA by searching the term "drug screen" in the Medicare coverage database. 

I may have just set the record for the most links in a Getting Paid blog, but I'm sure my drug screen would come out clean. I just like to provide the sources for further information and to help you and your staff keep up with these ever-changing codes and coverage decisions.

Friday Dec 17, 2010

A happy new year, indeed!

In my last post ("Good news from Medicare, over time," Dec. 2, 2010), I mentioned that, assuming Congress intervenes again by the end of the year and the conversion factor for 2011 is no less than it is now, there would be good news for family physicians in the 2011 Medicare physician fee schedule. Well, I am happy to report that Congress and the President did intervene last week and approved legislation that extends the current Medicare physician payment rate through the end of 2011. 

Admittedly, no increase in the Medicare conversion factor does not sound like good news; after all, it's not like your expenses are going to remain flat for the next year. However, no increase is better than the 25 percent decrease that would have occurred in the absence of an extension. Further, as I noted in my last post, because of relative value unit changes, family physicians should experience an increase in the Medicare payment allowance for some of the services that they provide most often, not to mention the primary care bonus that Medicare will begin to pay in 2011. 

Congress also voted last week to exempt physicians from the Federal Trade Commission's Red Flags Rule. The rule, which applies to creditors and is in intended to stop identity theft, would have been onerous for the typical medical practice. That burden will now be avoided. 

So, as you prepare to ring in the new year, you may do so with the knowledge that you will not be paid any less by Medicare in 2011 and, in fact, as a family physician, you will probably be paid more. Happy new year!

Monday Dec 06, 2010

Not e-prescribing in 2011 may cost you in 2012

By law, Medicare must apply a 1-percent reduction to Medicare Physician Fee Schedule (MPFS) payments in 2012 for those physicians who do not successfully participate in the Medicare e-prescribing (eRx) incentive program in 2011. This applies to all physicians who provide at least 100 evaluation and management (E/M) and/or other services designated by the Centers for Medicare & Medicaid Services (CMS) as eRx denominator codes and receive at least 10 percent of their MPFS income from these. To avoid the fee reduction, covered physicians must adopt a "qualified" eRx system and report its use during at least 10 distinct encounters for services represented by a denominator code in the first six months of 2011 to avoid a 1-percent decrease in MPFS payments in 2012. The code to report is G8553, "At least one prescription created during the encounter was generated and transmitted electronically using a qualified eRx system," and it must be reported on the same claim as the associated denominator code.

The denominator codes are 90801, 90802, 90804-90806, 90807-90809, 90862, 92002, 92004, 92012, 92014, 96150-96152, 99201-99205, 99211-99215, 99304-99310, 99315, 99316, 99324-99328, 99334-99337, 99341-99343, 99345, 99347-99350, G0101, G0108, G0109.

CMS does allow for two hardship exceptions. These require reporting one of the following codes once during the period from Jan. 1, 2011, to June 30, 2011. The exceptions and codes are as follows:

• G8642 - The eligible professional practices in a rural area without sufficient high speed Internet access and requests a hardship exemption from the application of the payment adjustment under section 1848(a)(5)(A) of the Social Security Act,

• G8643 - The eligible professional practices in an area without sufficient available pharmacies for electronic prescribing and requests a hardship exemption from the application of the payment adjustment under section 1848(a)(5)(A) of the Social Security Act.

For a physician or nonphysician provider who would otherwise be required to participate in the eRx program but does not have prescribing privileges, a one-time reporting of code G8644, "Eligible provider does not have prescribing privileges," is required to be granted an exception.

On the up-side of this, successful eRx for the entire year in 2011 (reporting 25 encounters) will earn a bonus of 1 percent of all MPFS allowed charges for 2011. Also, it is not too late to claim a bonus of 2 percent for 2010 if you have been using an eRx system that qualifies for the incentive. Here's how:

1. Determine if you are using a qualified eRx system. There are two types of systems. You may use either a stand-alone eRx system or an electronic health record (EHR) system with eRx functionality. Your system must be able to perform the following tasks:

• Generate a complete active medication list incorporating electronic data received from applicable pharmacies and pharmacy benefit managers (PBMs), if available.

• Select medications, print prescriptions, electronically transmit prescriptions, and provide all alerts.

• Provide information related to lower cost, therapeutically appropriate alternatives, if any. (The availability of an eRx system to receive tiered-formulary information, if available, would meet this requirement for 2010.)

• Provide information on formulary or tiered-formulary medications, patient eligibility, and authorization requirements received electronically from the patient's drug plan, if available.

2. Submit code G8553 on at least 25 of your claims for E/M services with dates of service in 2010. Alternatively, you may choose to report a minimum of 25 patient encounters through a qualified registry or qualified EHR. CMS also offers a group reporting option for practices that also participate as a group in the Physician Quality Reporting System (PQRS, formerly PQRI).

The opportunity for a bonus will continue through 2013 but is reduced by .5 percent each year. I hope you can take advantage of the opportunities to receive a bonus while they exist and avoid the penalties that are scheduled to increase by .5 percent in each year through 2014.

Thursday Dec 02, 2010

Good news from Medicare, over time

In my last post ("SGR relief:  Let us give thanks, for now," Nov. 19, 2010), I referenced that the U.S. Senate had approved a one-month extension of the current Medicare physician fee schedule conversion factor and that the U.S. House of Representatives was expected to do the same when they returned from their Thanksgiving recess. I am happy to report, as Bob Edsall observed in the "Noteworthy" blog earlier this week, that the U.S. House acted as expected, and the conversion factor will remain at its current level through the end of the year. 

Assuming Congress intervenes again by the end of the year (a big assumption, I grant you) and the conversion factor for 2011 is no less than it is now, there is even more good news for family physicians in the 2011 Medicare physician fee schedule. At the current conversion factor and using the relative value units (RVUs) published in the final rule on the 2011 fee schedule, codes 99213 and 99214 (two of the CPT codes most commonly used by family physicians) will have Medicare allowances in 2011 that are 42 and 35 percent higher, respectively, than they were in 2006. The increase will be even larger for those family physicians that qualify for the Medicare primary care bonus that goes into effect next year. 

How is that possible, especially when the current conversion factor is less than it was in 2006? As you can see in this chart, which details the changes over time, the answer lies in the relative value units (RVUs) that are assigned to these codes. Physician work RVUs for these codes got a significant boost in 2007, as a result of the five-year review of the Medicare physician fee schedule, and they got another boost in 2010, when the Centers for Medicare & Medicaid Services (CMS) decided to quit paying for consultation codes and redistributed the RVUs to other evaluation and management (E/M) codes, like 99213 and 99214. The practice expense RVUs and professional liability insurance RVUs have also gone up, thanks to methodology changes at CMS and the use of more current data.  

Given the trials and tribulations to which the conversion factor has been subjected, it is easy to get discouraged about the state of Medicare payments, but it turns out that the reality is a little better than the perception for some of the codes family physicians use most often.  Admittedly, the gains did not occur overnight, which is why it's easy to overlook them, but they are there.  Or at least they will be, if Congress can continue to spare the conversion factor, like it did this week.   

Friday Nov 19, 2010

SGR relief: Let us give thanks, for now

In my last post ("The 2011 Medicare physician fee schedule is here," Nov. 5, 2010), I noted that the fee schedule conversion factor would drop from its current $36.8729 to $25.5217 in January, unless Congress and the President intervened. Thankfully, the U.S. Senate began the intervention process yesterday.

Specifically, yesterday evening, the Senate approved a one-month extension of the current conversion factor. Unfortunately, they did so after the House had recessed for the Thanksgiving holidays, so the House cannot act on the measure until legislators return. However, the House Majority Leader's Office issued this statement:  "Tonight, the Senate passed a one month extension of the current Medicare physician payment rates. It is my intention to schedule this bill for consideration when the House reconvenes on Nov. 29, so we can send it to the President's desk prior to the Nov. 30 expiration date of current SGR relief."

Thus, it appears the fee schedule conversion factor will not drop before the end of the year. Beyond that, who knows? The cost of a 12-month extension that will include some other Medicare provisions is roughly $19 billion. Where that money might be found in the federal budget is unknown, and Senate Democratic leaders have indicated that none of it should come from repealing portions of the health reform legislation. Even if (and this is a big IF) there are sufficient funds for a 12-month extension, the next issue is the legislative vehicle to make that happen. Should Congress use the Continuing Resolution (which is likely to be only two to three months, but will certainly pass to keep the government operating) or the tax bill (which is likely to be an extension for a year or two of the current tax structure, but which will be the most politically volatile bill)? Absent sufficient funds for a 12-month extension, the question will be how long should the extension be (i.e., how long an extension can be funded)? Ultimately, this may be mostly a political question about whether it is better to force a showdown on health reform sooner or later. 

In the meantime, as you prepare to enjoy your turkey (or other holiday meal of choice) next week, say a little word of thanks for the folks in Washington who have spared the Medicare physician fee schedule for another month. And if you're so inclined, say a little prayer that they will find the money (and the fortitude) to implement a longer-term fix before the end of the year. 

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.

Monday Oct 25, 2010

Medicare participation: Why, indeed?

As I write this entry, the "SGR Countdown" on the Family Practice Management (FPM) home page has dropped to less than 40 days. And it reminds me of a question that a family physician asked awhile back: "Why would any physician in his [or her] right mind want to participate in a system such as this [Medicare]?"

Why, indeed? I doubt it's for the money. I understand that Medicare is the best payer in some parts of the country (a scary thought as we head into Halloween!).  However, the fact is that the current Medicare physician fee schedule conversion factor ($36.8729) is less than it was in 2004. 

I also doubt that it's because of the simplicity and ease of interaction with Medicare. As documented in this blog and elsewhere, just getting enrolled in Medicare can be a nightmare, and once you're in, there are the myriad of other rules and regulations with which physicians must comply.

So, why do family physicians participate in Medicare? The most common answer that I've heard is that they do it for their Medicare patients. There is a relationship and obligation there that family physicians are reluctant to break. 

What confuses me about this answer is that the law allows physicians to privately contract with those patients and continue to treat them without being bound by Medicare's rules or low payments. Both FPM and the AAFP web site explain what this option involves and provide sample forms for pursuing the option. It does not seem difficult, and yet, the last that I heard, only about 10,000 of the more than 850,000 physicians in the U.S. had elected to pursue this option. 

In the end, I do not have a good answer to the question, although I still think it's a good question. What do you think?

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.

Friday Jun 18, 2010

And so it begins ... Medicare claims pay out today, fees cut 21 percent

With half of the year behind us, the Medicare Physician Fee Schedule for 2010 still hangs in limbo. This afternoon, the Senate voted to delay the cut another six months, but the cut is still in place until the U.S. House of Representatives acts.

In response to Congressional inertia, CMS had issued guidance to the Medicare contractors on June 14 to continue holding claims with dates of service June 1 or later until Friday, June 18. So starting today, your claims for dates of service June 1 or later will be paid at the 21-percent reduced rate – and likely reprocessed later if Congress makes an updated fee schedule retroactive to June 1.

Hopefully the Congressional action will take place next week but in the meantime, your practice must determine if and how this affects your day-to-day operations. If you have a significant Medicare and Tricare patient population, you may need to assess your options for maintaining a workable cash flow and perhaps making some temporary cut backs in expenses:

  • Are there any planned purchases that can be delayed?
  • Can you schedule more procedures and ancillary services to offset the lost revenue?
  • Would a push to clean-up outstanding accounts receivables make a difference?
  • Can you limit the number of non-urgent Medicare and Tricare patients seen in the next few weeks to bring in more patients whose plans pay higher fees?

These disruptive and disheartening delays take away from your practice's ability to focus on quality care and waste tax dollars to pay for the reprocessing of claims due to untimely legislation and the unwillingness of our Congress to develop a long-term solution to this broken payment methodology. Help keep this issue in front of the Congressional representatives through AAFP Speak Out. Download and share this patient information piece about the broken Medicare physician payment system by placing copies in your waiting and exam rooms. 

Stay tuned. Good, bad, or more of the same, we'll keep the reports coming. In the meantime, keep in mind this quote often attributed to Mark Twain: "No man's life, liberty, or property is safe while the legislature is in session." Things haven't changed much in 150 years, have they?

Thursday Jun 03, 2010

2010 Medicare physician fee schedule: Here we go again!

I feel like a broken record. 

On April 1 (see "2010 Medicare physician fee schedule:  Stop me if you've heard this one before"), I shared with you how the Senate had again failed to pass legislation avoiding a 21 percent cut in the Medicare payment rate to physicians. As a result, the cut was technically effective with dates of service on or after April 1, 2010, but the Centers for Medicare & Medicaid Services (CMS) again instructed its contractors to hold claims for services paid under the fee schedule for the first 10 business days of April to give Congress time to rescind the cut. 

It actually took 15 days. On April 15, Congress passed and the President signed legislation that extended the 2009 Medicare physicians payment rate until May 31, 2010. 

Now May 31 has come and gone, and I know that you will be shocked to learn that Congress again failed to act. Actually, to be fair to the House of Representatives, it was the Senate that again failed to act. The House passed a bill on May 28 that would have increased the payment rate by 2.2 percent for the rest of 2010 plus an additional 1 percent in 2011. The Senate, however, determined that there was insufficient time to consider the bill before their Memorial Day recess and left Washington without action on the bill.

Consequently, the 21 percent cut is technically in effect again for dates of service on or after June 1. And once again, CMS has instructed its Medicare contractors to hold claims for services paid under the fee schedule for the first 10 business days of the month to give Congress time to rescind the cut. 

Congress returns from its recess on June 7. What will happen then is anyone's guess. In the meantime, it's the same tune and a different verse, and it's beginning to sound like the blues to most physicians. 

Thursday Apr 01, 2010

2010 Medicare physician fee schedule: Stop me if you've heard this one before

I know that it's April 1, but this is not a joke.  The U.S. Senate dropped the ball again, and Medicare payment allowances for physicians dropped 21 percent today. 

As you will recall from my last post (see "2010 Medicare physician fee schedule: What next?"), on March 2, Congress and the President enacted legislation that extended the 2009 Medicare payment rate through the end of March. This reversed a one-day drop in the fee schedule which occurred after the U.S. Senate failed to pass an extension by the previous deadline of Feb. 28, 2010. 

Like deja vu all over again (to quote Yogi Berra), the Senate again failed to pass a bill that would have extended the 2009 payment rate for physicians until April 30. The bill was ready for passage under standard unanimous consent procedures, but Sen. Tom Coburn (R-OK), playing the role previously played by Sen. Jim Bunning (R-KY), objected because the bill was not completely paid for. Then the Senate left for a two-week recess. As a result, the 21-percent reduction in physician payments took effect today.

Once again, the Centers for Medicare and Medicaid Services (CMS) is trying to play the good guy in this farce. CMS has instructed its contractors to hold claims containing services paid under the fee schedule for the first 10 business days of April, which, according to my calendar, would be through April 14. This hold will only affect claims with dates of service April 1, 2010, and forward. CMS expects the hold will have minimal impact on cash flow because, under the current law, clean electronic claims are not paid any sooner than 14 calendar days (29 days for paper claims) after the date of receipt anyway. 

The Senate will return on April 12. Senate Majority Leader Harry Reid (D-NV) has filed a motion to close debate and proceed to consideration of the temporary extenders legislation if there is no unanimous consent at that time. Expectations inside the Beltway are that negotiations between both sides will continue during the recess, and it is likely that the bill will proceed quickly through the Senate when they return. 

In the meantime, physicians are left to play the waiting game again and ponder what the punchline is. The situation might actually be funny if it weren't so sad and pathetic at the same time.

Wednesday Mar 03, 2010

2010 Medicare physician fee schedule: What next?

When we last left the 2010 Medicare physician fee schedule (see "2010 Medicare physician fee schedule: the saga continues," Jan. 27, 2010), it was headed down the tracks towards a "Bridge Out!!" sign after Feb. 28. For those of you who don't follow this story on a day-to-day basis, here is what's happened in the interim. 

As typically happens in this story, Congress tried to avert calamity by passing a stop-gap bill just before Feb. 28, 2010. Unfortunately, Sen. Jim Bunning (R-KY) decided to play Snidely Whiplash in this particular installment and used Senate procedures to prevent Congressional action in advance of the deadline. Consequently, Feb. 28 came and went without Congressional intervention, and the fee schedule dropped on March 1. 

Seeking to play Dudley Do-Right in our story, the Centers for Medicare and Medicaid Services (CMS) bravely threw the fee schedule a lifeline and instructed its contractors to hold all Medicare claims with dates of services on or after March 1 for 10 business days to give Congress one more chance. On March 2, Congress and the President took advantage of that lifeline and enacted legislation (H.R. 4691) that extends the 2009 Medicare payment rate through the end of March. This effectively postpones any cut in the 2010 Medicare physician fee schedule until Apr. 1, 2010 – April Fools' Day.  (Coincidence or cruel irony? You decide.)

So now, the 2010 Medicare physician fee schedule will float along at the 2009 rate through at least the end of March, at which point it is scheduled to plunge over the falls to a precipitous 21 percent decline. Will CMS once again be called upon to throw the fee schedule a lifeline? Will Congress be able once again to rescue the fee schedule before total disaster strikes? And how many physicians will stick it out (instead of opting out) to see what happens? Stay tuned! 

Tuesday Feb 02, 2010

No crosswalking!

As the dust settles following the removal of the consultation codes from the 2010 Medicare fee schedule, a lot of questions remain. Unfortunately, some of the people trying to answer those questions are not providing sound coding advice. Most concerning is the idea that the outpatient consultation codes crosswalk directly to the office or other outpatient service codes.

The very first cross in this walk should raise questions. Could a 99241 service with key components of a problem focused history and exam and straightforward medical decision making realistically cross to a 99211 nursing visit? No. This service is much more likely going to meet the key components of a 99212 service. The difference is significant. The national average Medicare fee schedule amount for a 99211 is $19.12 while the national average amount for a 99212 is $38.97. By using someone's idea of a time-saving crosswalk rather than selecting the code that your documentation support, you could lose half the revenue your practice earned for this service.

Physicians should also be aware that hospital or nursing facility consultations that meet the key components of 99251 or 99252 do not satisfy the key components for 99221 or 99304, which require higher levels of history and examination.

The bottom line is that services should be assigned the code that the documentation supports. You should not cut corners by crosswalking the codes. This may be especially important to consider if you are billing a patient's private payer plan first and Medicare second. You may be able to bill the private plan for a 99251 service but you cannot bill that same code to Medicare for the secondary payment. In this case, you must determine whether your Medicare contractor will accept a subsequent hospital care code even though this was the physician's first inpatient encounter with the patient. They may require you to submit code 99499 for an unlisted E/M service instead, leaving them decide what level of service was rendered.

This move by Medicare to eliminate consultation codes from the fee schedule has shown just how complex E/M coding has become.Let's hope we can move toward a simpler system where physician work (i.e. level of history, exam, medical decision making, counseling and coordination of care) is fully valued with or without a request for advice or opinion. Now if there could be a closer look at all those E/M services valued into the global fees for surgery...

Wednesday Jan 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!

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