Summary: Proposed CY 2013 Medicare Physician Fee Schedule
On July 6, the Centers for Medicare & Medicaid Services (CMS) posted the proposed rule for the Medicare physician fee schedule (MPFS) for calendar year (CY) 2013. The Academy submitted comments to CMS on the proposed rule, which can be viewed on the Academy’s website at http://www.entnet.org/Practice/Summaries-of-Regulations-and-Comment-Letters.cfm#CL. Some key provisions from the proposed rule included: Medicare Sustainable Growth Rate (SGR) The overall estimated influence of the policy changes within the proposed rule for CY 2013 MPFS on otolaryngology is zero percent. (Note: This amount does not include the possible 27 percent reduction to the conversion factor (CF) that could result if Congress does not take action to prevent the annual cuts from the SGR [if the cuts were to take effect, the CF would go from $34.0376 in 2012 to potentially $24.7124 for CY 2013].) While the 27 percent is due to projected SGR cuts, the reduced CF is partially due to CMS’ proposal to add new G-codes to the Medicare system, which due to budget neutrality requirements, causes a reduction to all other services in the fee schedule in order to pay for the existence of the new code’s expected utilization. Improving Valuation of the Global Surgical Package Since 1992, different methodologies have been used in valuing global surgical services through the American Medical Association Relative Value Scale Update Committee (AMA RUC) process. Studies by the United States Government Accountability Office (GAO) have shown that codes reviewed more recently tend to have fewer evaluation and management (E/M) visits in their global periods while codes reviewed less recently did not appear to have the full work RVUs of each E/M service in the global surgical package. This resulted in inconsistent numbers of E/M visits during the postoperative period across families of procedures. CMS acknowledges that under current policy surgeons are not required to document in the medical record what level of E/M visit they are providing, making it difficult to determine whether the number and type of visits provided in association with a surgical procedure is appropriate. As a result, CMS states it is interested in a “claims-based data collection approach” to track E/M visits provided during the global surgery period, and the Agency requested comments on this and other methods of obtaining data. Validating RVUs of Services Under the ACA, the Secretary of Health and Human Services (HHS) is directed to validate a sampling of RVUs for services. In the proposed rule, CMS states it intends to “enter into a contract to assist them in validating RVUs of potentially misvalued codes that will explore a model for the validation of physician work under the PFS, for both new and existing services.” It states it will discuss this model in future rulemaking. Expanding the Multiple Procedure Payment Reduction Policy (MPPR) CMS proposes to expand the MPPR to the Professional Component (PC) of certain advanced diagnostic imaging services (CT, MRI, and ultrasound) when two or more physicians in the same group practice furnish services to the same patient, in the same session, on the same day. G-Code for Care Coordination CMS proposes the creation of a HCPCS G-code, valued at 1.28 RVUs, to describe the work involved with care management and coordination (including non-face-to-face care management services). Specifically, the transition of a beneficiary from care furnished by a treating physician during a hospital stay (inpatient, outpatient observation services, or outpatient partial hospitalization) and other facilities to care furnished by the beneficiary’s primary care physician within 30 calendar days following the date of discharge. CMS clarifies that the new G-code is not billable by a physician or non-physician billing for a procedure with a 10- or 90-day global period because it considers such management “included in the postoperative portions of the global period.” However, some otolaryngology-head and neck surgeons may be able to use this code, e.g., those who receive patients from a hospital and provide E/M services through referrals, those treating trauma cases, and those treating cancer patients. Physician Quality Reporting System (PQRS) CMS proposes many overarching changes to the PQRS system, with highlights of those potentially affecting otolaryngology following here: Changes to Group Reporting: CMS proposes to change the definition of a “group practice” from 25 or more eligible professionals to two or more eligible professionals. Modification of Reporting Periods: CMS proposes the continuation of a six-month reporting period (July 1-December 31) for reporting measures groups via registry in 2013 and 2014 only. Satisfactorily reporting for the 2015 and 2016 payment adjustment: CMS proposes to allow individuals and group practices to report only one PQRS individual measure or one measure groups to avoid the 2015 and 2016 penalty adjustment. The penalty adjustment will be -1.5 percent in 2015 and -2 percent in 2016 and subsequent years. Adult Sinusitis Measures: CMS proposes the addition of 13 new measures for reporting individual quality measures in 2013 and proposes the addition of 45 new individual measures for 2014. However, the newly approved “Adult Sinusitis” measures were not included in any of their proposals. Physician Compare Website CMS plans to publish additional information to the Physician Compare website, including whether a professional is accepting new Medicare patients, board certification information, whether or not a professional participates in the electronic health record (EHR) Incentive Program, names of professionals satisfactorily participating in PQRS, as well as foreign language and hospital affiliation data. CMS also proposes adding patient experience survey measures such as Clinician and Group Consumer Assessment of Healthcare Providers and Systems (CG-CAHPS) for groups participating in the Physician Quality Reporting System (PQRS) Group Practice Reporting Option (GPRO) and Accountable Care Organization (ACO) programs. Electronic Prescribing (eRx) Incentive Program CMS proposes reducing the minimum group practice size for participation in the eRx incentive program from 25 to two eligible professionals (EPs) for 2013. Groups of two to 24 would have to report the eRx numerator code during a denominator-eligible encounter at least 225 times within the designated reporting periods. CMS also proposes adding two new hardship exemptions to the 2013 and 2014 eRx payment penalties. Finally, CMS proposes extending the PQRS-Medicare EHR Incentive Pilot for 2013. Value-Based Payment Modifier and Physician Feedback Reporting Program Beginning January 1, 2015, the ACA requires the Secretary to establish a value-based payment modifier (incentive or penalty) to specific physicians and groups of physicians. The incentive or penalty is based on measuring quality of care furnished as compared to cost of that care for Medicare beneficiaries with certain chronic conditions. The Agency is proposing to begin a three-year phase-in of the program that would apply the incentive or penalty (up to potential -1 percent) in 2015 based on 2013 performance for groups of 25 or more providers. CMS proposes that incentives or penalties in 2016 will be based on 2014 performance for groups of 25 or more providers. The program is voluntary the first two years, but not later than 2017, the value-based payment modifier will apply to all physicians, regardless of group size. As part of this program, the Secretary is required to provide Physician Feedback reports to providers that measure the resources used in providing care to beneficiaries and the quality of care. To achieve this, CMS has included information reported in the PQRS program in the 2010 Physician Feedback reports that were provided to groups of physicians in 2011 and individual physicians in early 2012, which some otolaryngologists received. For a more detailed summary on the proposed requirements for the programs highlighted above, visit the Academy’s CMS Regulations and Comment letter page at http://www.entnet.org/Practice/Summaries-of-Regulations-and-Comment-Letters.cfm#CL or email Academy staff at HealthPolicy@entnet.org. Evidence-Based Guidelines Affecting Policy, Practice, and Stakeholders (E-GAPPS) ConferenceThe E-GAPPS Conference is a two-day meeting co-sponsored by the Guidelines International Network North America (G-I-N NA) and the Section on Evidence Based Health Care (SEBHC) of the New York Academy of Medicine. The E-GAPPS mission focuses on constructive dialogue and collaboration; best practices in guideline development, dissemination, and implementation; and perspectives, processes, values, and principles that affect healthcare policy. To register or learn more about the confirmed plenary speakers, conference themes, or breakout sessions, visit http://www.nyam.org/events/2012/evidence-based-guidelines-conference.html. 2012 E-GAPPS Conference New York, NY Monday, December 10 to Tuesday, December 11
On July 6, the Centers for Medicare & Medicaid Services (CMS) posted the proposed rule for the Medicare physician fee schedule (MPFS) for calendar year (CY) 2013. The Academy submitted comments to CMS on the proposed rule, which can be viewed on the Academy’s website at http://www.entnet.org/Practice/Summaries-of-Regulations-and-Comment-Letters.cfm#CL. Some key provisions from the proposed rule included:
Medicare Sustainable Growth Rate (SGR)
The overall estimated influence of the policy changes within the proposed rule for CY 2013 MPFS on otolaryngology is zero percent. (Note: This amount does not include the possible 27 percent reduction to the conversion factor (CF) that could result if Congress does not take action to prevent the annual cuts from the SGR [if the cuts were to take effect, the CF would go from $34.0376 in 2012 to potentially $24.7124 for CY 2013].) While the 27 percent is due to projected SGR cuts, the reduced CF is partially due to CMS’ proposal to add new G-codes to the Medicare system, which due to budget neutrality requirements, causes a reduction to all other services in the fee schedule in order to pay for the existence of the new code’s expected utilization.
Improving Valuation of the Global Surgical Package
Since 1992, different methodologies have been used in valuing global surgical services through the American Medical Association Relative Value Scale Update Committee (AMA RUC) process. Studies by the United States Government Accountability Office (GAO) have shown that codes reviewed more recently tend to have fewer evaluation and management (E/M) visits in their global periods while codes reviewed less recently did not appear to have the full work RVUs of each E/M service in the global surgical package. This resulted in inconsistent numbers of E/M visits during the postoperative period across families of procedures. CMS acknowledges that under current policy surgeons are not required to document in the medical record what level of E/M visit they are providing, making it difficult to determine whether the number and type of visits provided in association with a surgical procedure is appropriate. As a result, CMS states it is interested in a “claims-based data collection approach” to track E/M visits provided during the global surgery period, and the Agency requested comments on this and other methods of obtaining data.
Validating RVUs of Services
Under the ACA, the Secretary of Health and Human Services (HHS) is directed to validate a sampling of RVUs for services. In the proposed rule, CMS states it intends to “enter into a contract to assist them in validating RVUs of potentially misvalued codes that will explore a model for the validation of physician work under the PFS, for both new and existing services.” It states it will discuss this model in future rulemaking.
Expanding the Multiple Procedure Payment Reduction Policy (MPPR)
CMS proposes to expand the MPPR to the Professional Component (PC) of certain advanced diagnostic imaging services (CT, MRI, and ultrasound) when two or more physicians in the same group practice furnish services to the same patient, in the same session, on the same day.
G-Code for Care Coordination
CMS proposes the creation of a HCPCS G-code, valued at 1.28 RVUs, to describe the work involved with care management and coordination (including non-face-to-face care management services). Specifically, the transition of a beneficiary from care furnished by a treating physician during a hospital stay (inpatient, outpatient observation services, or outpatient partial hospitalization) and other facilities to care furnished by the beneficiary’s primary care physician within 30 calendar days following the date of discharge.
CMS clarifies that the new G-code is not billable by a physician or non-physician billing for a procedure with a 10- or 90-day global period because it considers such management “included in the postoperative portions of the global period.” However, some otolaryngology-head and neck surgeons may be able to use this code, e.g., those who receive patients from a hospital and provide E/M services through referrals, those treating trauma cases, and those treating cancer patients.
Physician Quality Reporting System (PQRS)
CMS proposes many overarching changes to the PQRS system, with highlights of those potentially affecting otolaryngology following here:
Changes to Group Reporting: CMS proposes to change the definition of a “group practice” from 25 or more eligible professionals to two or more eligible professionals.
Modification of Reporting Periods: CMS proposes the continuation of a six-month reporting period (July 1-December 31) for reporting measures groups via registry in 2013 and 2014 only.
Satisfactorily reporting for the 2015 and 2016 payment adjustment: CMS proposes to allow individuals and group practices to report only one PQRS individual measure or one measure groups to avoid the 2015 and 2016 penalty adjustment. The penalty adjustment will be -1.5 percent in 2015 and -2 percent in 2016 and subsequent years.
Adult Sinusitis Measures: CMS proposes the addition of 13 new measures for reporting individual quality measures in 2013 and proposes the addition of 45 new individual measures for 2014. However, the newly approved “Adult Sinusitis” measures were not included in any of their proposals.
Physician Compare Website
CMS plans to publish additional information to the Physician Compare website, including whether a professional is accepting new Medicare patients, board certification information, whether or not a professional participates in the electronic health record (EHR) Incentive Program, names of professionals satisfactorily participating in PQRS, as well as foreign language and hospital affiliation data. CMS also proposes adding patient experience survey measures such as Clinician and Group Consumer Assessment of Healthcare Providers and Systems (CG-CAHPS) for groups participating in the Physician Quality Reporting System (PQRS) Group Practice Reporting Option (GPRO) and Accountable Care Organization (ACO) programs.
Electronic Prescribing (eRx) Incentive Program
CMS proposes reducing the minimum group practice size for participation in the eRx incentive program from 25 to two eligible professionals (EPs) for 2013. Groups of two to 24 would have to report the eRx numerator code during a denominator-eligible encounter at least 225 times within the designated reporting periods. CMS also proposes adding two new hardship exemptions to the 2013 and 2014 eRx payment penalties. Finally, CMS proposes extending the PQRS-Medicare EHR Incentive Pilot for 2013.
Value-Based Payment Modifier and Physician Feedback Reporting Program
Beginning January 1, 2015, the ACA requires the Secretary to establish a value-based payment modifier (incentive or penalty) to specific physicians and groups of physicians. The incentive or penalty is based on measuring quality of care furnished as compared to cost of that care for Medicare beneficiaries with certain chronic conditions. The Agency is proposing to begin a three-year phase-in of the program that would apply the incentive or penalty (up to potential -1 percent) in 2015 based on 2013 performance for groups of 25 or more providers. CMS proposes that incentives or penalties in 2016 will be based on 2014 performance for groups of 25 or more providers. The program is voluntary the first two years, but not later than 2017, the value-based payment modifier will apply to all physicians, regardless of group size.
As part of this program, the Secretary is required to provide Physician Feedback reports to providers that measure the resources used in providing care to beneficiaries and the quality of care. To achieve this, CMS has included information reported in the PQRS program in the 2010 Physician Feedback reports that were provided to groups of physicians in 2011 and individual physicians in early 2012, which some otolaryngologists received.
For a more detailed summary on the proposed requirements for the programs highlighted above, visit the Academy’s CMS Regulations and Comment letter page at http://www.entnet.org/Practice/Summaries-of-Regulations-and-Comment-Letters.cfm#CL or email Academy staff at HealthPolicy@entnet.org.
To register or learn more about the confirmed plenary speakers, conference themes, or breakout sessions, visit http://www.nyam.org/events/2012/evidence-based-guidelines-conference.html.
2012 E-GAPPS Conference New York, NY
Monday, December 10 to Tuesday, December 11