Update on Reimbursement by ABC Advocacy

On June 25, 2010, the Centers for Medicare & Medicaid Services (CMS) issued the proposed rule on the 2011 Medicare Physician Fee Schedule (MPFS). The rule contains improved payment for primary care services and eliminates beneficiary out of pocket costs for preventive services provided under the Medicare program. In addition, CMS states that elimination of health care disparities is a consideration in the selection of new PQRI measures for 2011 and beyond.

Unfortunately, a preliminary review of the proposed rule shows that physicians can expect deep reductions in Medicare reimbursement in 2011 and beyond. For 2011, CMS projects a -6.1 percent fee cut, in addition to the 23.5 percent cut slated to take effect December 1, 2010. These large cuts are due to the flawed Sustainable Growth Rate (SGR) Medicare payment formula. Until Congress addresses Medicare payment reform, providers will continue to see deep reductions in Medicare payment.

ABC will post more details on the proposed rule next week. However, several provisions stand out upon initial review:

  • Effective 2011, CMS will assume that advanced diagnostic imaging equipment priced over $1 million is in use 75 percent of the time a practice is open for business. This percentage was specified in the new health care reform law. This will have the effect of reducing practice expense relative value units (RVUs) and ultimately reducing reimbursement for advanced imaging services
  • CMS proposes a framework for implementation of provisions of health care reform to require physicians referring CT, MRI and positron emission tomography (PET) services under the in-office ancillary services exception, to notify patients in writing that the services are available from other suppliers and to provide a list of alternate suppliers
  • CMS proposes to expand on the current policy of multiple procedure payment reduction for diagnostic imaging services performed on contiguous body parts. Under this policy, CMS reduces the technical component payment by 25 percent for the second and subsequent procedures. Effective July 1, 2010, this reduction will increase from 25 percent to 50 percent. In addition, CMS proposes to broaden this policy to imaging performed on the same day regardless of body area CMS proposes numerous changes to holter monitoring codes.

CMS will accept comments on the proposed rule until August 24, 2010. The final rule will be issued on or about November 1, 2010. Please Check this article for updated analysis of this proposed rule.

Update on Reimbursement by ABC Advocacy

June 14, 2010

On May 27th, the Centers for Medicare and Medicaid Services (CMS) had instructed its contractors to hold claims for services paid under the Medicare Physicians Fee Schedule (MPFS) for the first 10 business days of June (i.e., through June 14, 2010). This hold only affects MPFS claims with dates of service of June 1, 2010, and later.

Given the possibility of Congressional action in the very near future, CMS is now directing its contractors to continue holding June 1 and later claims through Thursday, June 17, lifting the hold on Friday, June 18.

This means that unless Congress sends legislation averting the cut to President Obama for signature within the next few days, carriers will begin processing claims with the 21.2% cut on Friday, June 18th.

Important Reimbursement Alert from Dr. Roquell Wyche, ABC Advocacy Chair

May 28, 2010

Congress has once again failed to stop the 21.2 percent Medicare physician fee cut scheduled to take effect June 1, 2010, as mandated under the flawed Sustainable Growth Rate (SGR) formula. It is anticipated that lawmakers will reconsider the issue the week of June 7, 2010. The Centers for Medicare and Medicaid Services has indicated it will hold Medicare provider claims for 10 days in order to allow time for legislative action.

At this point it is uncertain if there is enough support in Congress to address Medicare physician payment for more than a year, largely due to the costs associated with correcting the flawed SGR formula. Updates will be posted as they become available.

ABC encourages all members to contact their two U.S. Senators and their Congressional Representative to express disappointment in the failure of Congress to responsibly address issues with Medicare that require prompt attention, such as fixing the flawed SGR formula. Such inaction only serves to undermine patient and provider confidence in the program.

Important Reimbursement Update from Dr. Roquell Wyche, ABC Advocacy Chair

May 11, 2010

I am pleased to announce that on May 11, 2010, the Centers for Medicare and Medicaid Services (CMS) published in the Federal Register a technical corrections notice which will result in payment increases for some cardiology procedures paid under the 2010 Medicare Physician Fee Schedule. The increases are retroactive to January 1, 2010.

Of note:

  • Myocardial perfusion imaging codes (CPT 78451-78454) will see payment increases to reflect adjustments in practice expense as well as corrections of other calculation errors;
  • Some cardiac catheterization codes will see an increase due to positive adjustments in malpractice risk relative values;
  • Increased practice expense values were also included for cardiac computed tomography codes (CPT 75571 – 75574). These increases are a positive step in recognition of the actual costs of providing cardiac CT services and serve as an important placeholder. However, actual reimbursement for the CCT codes will not increase due to provisions of the Deficit Reduction Act which cap the technical component payment rate at the lesser of the Medicare physician fee schedule or the hospital outpatient prospective payment system rate.

CMS will soon issue instructions for its local Medicare carriers and contractors to implement the changes established in the technical corrections notice. Claims cannot be correctly processed until carriers receive these instructions. As of right now, there is no timetable for providing these instructions or rectifying previously processed claims.

ABC recommends that members NOT re-file claims until CMS provides these additional instructions. Stay tuned to for updates as they become available.

Finally, I want to thank ABC members for their interest and involvement in helping to achieve improved reimbursement, and I extend special thanks to Drs. Carlos Ince, G. Mark Jenkins, Chris Leggett, Kevin Thomas, and Kim A. Williams, for their efforts to communicate with policymakers. All of us working together can make a difference!

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