SGR, ICD-10 not the only targets of adopted legislation
Last week's SGR legislation didn't just push back Medicare cuts and delay ICD-10 implementation.
A new blog post by Betsy Nicoletti notes that the 123-page bill passed by Congress and signed into law by President Obama also requires additional reporting for lab test reimbursements and creates greater scrutiny of CT scans.
Another patch and more time to prepare for ICD-10
Following up last week's post, the Senate approved and the president signed a House bill that prevents steep cuts to Medicare physician payments from going into effect for one year. The bill (now law) also delays the conversion to ICD-10 diagnostic and procedure codes for at least one year.
The measure calls for a 0.5 percent increase in physician payments through Dec. 31, 2014, and no change from Jan. 1 through March 31, 2015. That means is that it will be another year before you have to worry about a potential cut in the Medicare physician payment rate. It also means that Congress has additional time to pass a permanent repeal of the Sustainable Growth Rate that has led to the current predicament. Such action in advance of the mid-term elections seems unlikely, however, given the current lack of agreement on how to pay for repeal.
On the plus side, the delay in ICD-10 does give physicians more time to prepare for that change, which will now occur on Oct. 1, 2015 (or later). Until then, everyone will continue to use ICD-9 codes. That said, you shouldn't use the delay in implementation as an excuse to delay preparation. Physicians, payers, and other users of ICD-10 should continue to move forward with preparation wherever they are in the process, and AAFP has resources to help its members do just that.
– Kent Moore, Senior Strategist for Physician Payment for the American Academy of Family Physicians
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
Another patch and another cliff
Last week, a U.S. House-Senate Conference Committee reached a 10-month deal that would maintain current physician payment rates through the end of the year. The measure, H.R. 3630 (at the THOMAS website, type "H.R. 3630" into the search field after selecting "Bill Number"), was subsequently approved by both the House and Senate. Yesterday, the President signed the bill into law.
This latest patch to the Medicare physician fee schedule avoids the 27.4 percent Medicare physician payment cut that was otherwise scheduled to occur on March 1 as a result of the sustainable growth rate (SGR) formula. Because H.R. 3630 postpones but does not eliminate the threat posed by the SGR, physicians will face a 32 percent Medicare payment reduction when the payment patch expires at the end of this year, which makes Jan. 1, 2013, the next "cliff" that physicians will face in terms of Medicare payments.
As noted, the law does not solve the underlying problem. It only postpones its resolution and adds to the cost of a permanent solution. The cost of repealing the SGR will climb from $316 billion today to $335 billion in 2013. In the meantime, physicians are left to cope with the ongoing uncertainty and hope that Congress will find the fortitude and funds for a permanent solution before 2013 rolls around.
What the 2012 Medicare Physician Fee Schedule tells us about the future
The final rule for the 2012 Medicare Physician Fee Schedule went on display this week. Of course it includes the all-too-familiar fee cut (27.4 percent) – the result of the Centers for Medicare & Medicaid Services' (CMS) flawed formula for calculating physician payment that Congress has been patching annually since 2002 but which needs a permanent fix. This year's fee schedule is notable for another reason as well. The PDF file is 1,235 pages long, and that's without the appendices that will be included when the final rule is published in the Federal Register later this month. The fact that it requires so many pages to describe one year's changes to one part of one government program is mind-boggling, but the additional bulk is partly because this year the rule also provides a forecast for how CMS plans to carry out government mandates for the program over the next five to 10 years. It is not a crystal ball, but the rule leaves no doubt that Medicare payment to physicians will be changing and that today's initiatives and incentives are intended as the basis for tomorrow's payment.
Examples of this are especially clear in the portion of the rule that speaks about a value-based payment modifier, which will actually modify payments under the Medicare Physician Fee Schedule based on Medicare's record of the quality of care you provide to patients compared with the cost of that care. Where will Medicare get this data? Primarily from the quality measures reported for programs like the Physician Quality Reporting System and the EHR Incentive Program and from claims data for your patients. Physicians who are found to deliver high quality for the cost of care will be paid more than other physicians. The program is budget neutral, so one physician's gain is another physician's loss.
CMS is still working out the details, such as how to attribute patients to physicians, adjust for risk and complexity, and make the measurements meaningful for all specialties. What is clear from the rule is that the process is underway to put the value-based modifier in place by 2015 for some physicians (based on claims and quality reporting in 2013) and by 2017 for all physicians (probably based on claims and quality reporting in 2015).
CMS has this to say in the final rule:
"We strongly encourage physicians to participate in the Physician Quality Reporting System program and the EHR Incentive Program sooner rather than later and to choose to report quality of care measures that best reflect their practice and patient population. Although we have not yet proposed the value modifier methodology, our primary interest at this point is to increase the quality of care for Medicare beneficiaries. We note that we also plan to propose a value modifier in rule making during 2012, prior to the initial performance period. Thus, we believe it is reasonable to encourage physicians to report appropriate quality measures well in advance and irrespective of the exact value modifier methodology at this time."
The complexity and unknowns of this value based payment system are daunting. However, this could be a good thing if physicians who know their patients and provide comprehensive, coordinated care are rewarded for their work. Sounds like family medicine to me.
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.
The 2011 Medicare physician fee schedule is here
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 (
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.
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?
A familiar tune
The end-of-year holiday season is upon us. I can always tell it is because of the displays in the stores, the songs on my radio, and the phone calls I receive asking about the status of next year's Medicare physician fee schedule.
Each year about this time, I start getting phone calls from anxious physicians and their staff members asking if the Medicare fees really are going down in January or whether Congress will intervene as it has in the past. This year is no different. Under current law, the Medicare conversion factor (which converts relative value units (RVUs) to Medicare payment allowances) is scheduled to decrease by approximately 21 percent for services provided on or after Jan. 1, 2010. That decrease will be partially offset by RVU increases announced for office visits and other evaluation and management services that family physicians frequently perform, but Medicare fees will still decline significantly if the conversion factor goes down.
For the past several years, Congress has intervened at the last minute (or sometimes after the last minute) to either freeze the conversion factor or increase it slightly (although the increase is always less than the rate of inflation, so physicians still lose). The expectation and hope is that Congress will do so again this time around. For instance, as I write this, the U.S. House of Representatives' Rules Committee has produced a Defense appropriations bill that includes, among other things, a provision to extend the current Medicare physician payment rates through the end of February, with the expectation that this extension will give Congress enough time to enact health reform legislation that includes a longer-term fix to Medicare's Sustainable Growth Rate (SGR) and physician fee schedule issue. It's probably appropriate that the extension is attached to a Defense appropriations bill, since physicians would likely be up in arms if Medicare rates actually fell 21 percent.
In the meantime, the fact remains that Medicare fees will drop in January unless Congress intervenes, which it has not completely done yet. So, what's a physician to do? Well, the good folks at the Centers for Medicare and Medicaid Services have given you until Jan. 31, 2010 to decide. That's when the current period for changing your Medicare participation status for 2010 will end. For more information, I would encourage you to visit the Medicare participation options web page on the American Academy of Family Physicians' web site.
And with that, I'll return to listening to the radio, where I can almost hear the Congressional Tabernacle Choir singing:
God rest ye merry gentlefolk; let nothing you dismay.
We plan to patch the SGR, and not to cut your pay.
Then do it all again next year, lest you should go astray.
So our tidings of comfort to the annoyed, to the annoyed.
So our tidings of comfort to the annoyed!
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!