In addition to including a conversion factor of only $26.6574, the recently released proposed rule for the 2011 Medicare physician fee schedule (MPFS) contains a number of other proposals that could take a significant bite out of your reimbursement. The size of the bite may depend on your specialty.
Affordable Care Act Provisions
The proposed rule provides details about how the Centers for Medicare and Medicaid Services will implement certain provisions of the Affordable Care Act (ACA) of 2010, particularly those provisions that expand preventive services and improve payments for primary care services.
Annual Wellness Examination
The ACA expands Medicare Part B coverage by supplementing the initial preventive physical examination (IPPE) with an annual wellness visit that provides personalized prevention plan services. The personalized approach is an opportunity for both the physician and patient to concentrate their efforts on maintaining or improving the patient’s health as well as reducing the risk of chronic disease. This additional benefit will be effective on January 1, 2011, for patients who have exceeded 12 months since their last annual wellness visit or welcome to Medicare physical. The act requires documentation of a personalized prevention plan and specifies the elements, including establishment of, or update to, the patient’s:
- Medical and family history, including a:
- list of other providers and suppliers the patient may see
- current medications list
- Recording of vital signs including the measurement of :
- height
- weight
- body-mass index (BMI) or waist circumference
- blood pressure
- other routine measurements, as applicable
- Detection of any cognitive impairment
- Review of potential risk factors for depression by using an appropriate screening instrument for individuals without a current depression diagnosis
- Review of functional abilities and level of safety through use of appropriate screening questions or a questionnaire
- Establishment of, or update to, an appropriate screening schedule for the next five to 10 years
- Establishment of, or update to, a list of risk factors and conditions (including any mental health conditions) for which interventions are recommended or underway
- Furnishing of personalized health advice and referral, as appropriate, to health education or preventive counseling services or programs
Other elements may also be added as deemed appropriate by the Department of Health and Human Services secretary through a national coverage determination process. Lastly, the rule outlines likely definitions to many of these elements and also indicates that CMS is proposing the creation of two HCPCS Level II G codes for reporting this service.
Elimination of Patient Deductible and Copayments
The ACA further mandates the elimination of out-of-pocket expenses beneficiaries are required to pay for preventive medicine services that meet a United States Preventive Services Task Force (USPSTF) grade of A or B. Services that DO NOT meet this requirement and therefore are NOT subject to the waiver of the deductible and coinsurance are:
- Digital rectal examination as part of prostate screening (G0102)
- Glaucoma screening (G0117 or G0118)
- Diabetes self-management training (DSMT) (G0108 or G0109)
- Barium colon enemas for cancer screening (G0106 or G0120)
The Bad News
In addition to the 6.1 percent reduction of payments due to the sustainable growth rate (SGR) for all physicians across the board, other proposals may affect specific specialties. Two such proposals would implement multiple payment reductions to additional radiology services.
The rule would reduce payments for diagnostic imaging equipment used in CT and MRI imaging. The proposal would apply the multiple procedure payment reduction (MPPR) to more than 100 procedures. Currently, the MPPR is applied to radiology families.
Further, the agency is proposing to apply the MPPR to certain physical therapy services. Specifically, CMS wants to apply the 50 percent payment reduction to the PE component of the second and subsequent therapy services when multiple “always therapy” services are furnished to the same patient on the same date of service.
Other Significant Changes
Other changes being considered include:
- Payment incentives for:
- primary care
- general surgeons performing major surgery in health professional shortage areas (HPSAs)
- Increased payments for certified nurse midwives
The proposed rule went on display June 25. To see the proposed rule, go to: http://www.federalregister.gov/OFRUpload/OFRData/2010-15900_PI.pdf.
Deborah C. Hall
Clinical/Technical Editor |