CMS Doesn't Budge on Consults in Final 2011 Physician Fee Schedule

November 5, 2010

The Centers for Medicare and Medicaid Services (CMS) released its final Physician Fee Schedule this week. Without congressional intervention, the projected conversion factor is $25.5217 (30% lower than the current payment rate). The following is a summary of provisions that will affect neurologists starting January 1, 2011.

Consultation Codes

Despite opposition from the AAN and joint specialty society survey data showing the negative impact the decision has had on patient care and coordination among physicians, CMS continues to believe that "in most cases there is no substantial difference in physician work between E/M visits and services that would otherwise be reported with CPT consultation codes." The agency sites numerous failed attempts to receive clarification on the codes from physicians and the American Medical Association (AMA) as the impetus for the 2010 change.

Though they are making no changes to their decision at this time, the agency will "continue to monitor the impact of this policy, especially as it relates to care coordination among physicians."

Primary Care Incentive Payment

CMS does not finalize any changes to the proposed primary care incentive payment that are beneficial to neurologists. The agency asserts that it simply does not have authority to expand the incentive payments to physicians that are not enrolled in Medicare with a primary specialty designation other than: 08-family practice, 11-internal medicine, 37-pediatrics, or 38-geriatrics as part of this program since these are the specialties that were specifically listed in the legislation.

The AAN continues to push for a legislative fix to this issue.

Rebasing the Medicare Economic Index (MEI)

The MEI is an index often used in the calculation of the increases in the prevailing charge levels that help to determine allowed charges for physician services. In a positive decision, CMS will rebase and revise the MEI to reflect appropriate physicians' expenses in 2006 (the MEI currently reflects expenses from 2000); and will convene a Medicare Economic Index Technical Advisory Panel (MEI TAP) to study all aspects of the MEI including its cost categories, their associated cost weights and price proxies, and the adjustment of the index by an economy-wide measure of multi-factor productivity.

Neurology-specific Codes

Canalith Repositioning Treatment (95992)
Neurologists specializing in neuro-otology will be pleased to learn that CMS will recognize canalith repositioning treatment as a separately billable procedure and will begin offering reimbursement for CPT code 95992 starting January 1.

In addition to new CPT codes for neurology, the values for several existing neurology codes are changing in 2011. Look for a separate article addressing those changes.

Extension of Physician Fee Schedule Mental Health Add-On

CMS will extend the 5% increase in Medicare payment under the Physician Fee Schedule from January 1, 2010 to December 31, 2010, as stipulated in the ACA.

Physician Quality Reporting Initiative (PQRI)

Incentive payments for the PQRI program in 2011 will drop to 1% for qualified eligible professionals who satisfactorily submit PQRI measures data (the incentive payment was 2% in 2010). For 2012 through 2014, incentive payments will drop further to 0.5%. Note that the Accountable Care Act (ACA) requires a negative payment adjustment beginning in 2015 for eligible professionals who do not satisfactorily submit quality data.

The claims-based reporting threshold has been reduced from 80% in 2010 to 50% in 2011. This means that more neurologists participating in the program via claims-based reporting should be eligible to receive the incentive payment in 2011.

CMS realizes that the current PQRI feedback reports are inadequate. The agency will continue to make the reports more user-friendly (i.e. easier to access and read/interpret).

View AAN resources to help you participate in PQRI.

Incentives for Electronic Prescribing (eRx)—The Electronic Prescribing Program

In 2011, incentive payments for the eRx Program will be 1% (down from 2% in previous years). The incentive payment will remain at 1% in 2012, and will drop to 0.5% in 2013. Payment reductions begin in 2012 for eligible professionals who do not e-prescribe, starting at 1% in 2012 and advancing to 1.5% in 2013 and 2% in 2014.

The reporting period is 12 months, the entire calendar year. Participation is available through claims, registry, and electronic health record (EHR) reporting. There are also two group practice options for 2011. Professionals must report on 25 unique e-prescribing events to be successful; and CMS intends to provide interim feedback reports to help physicians monitor their progress.

Successful e-prescribers will be posted on the CMS website. Physicians who earn incentives through the Medicare EHR Incentive Program are not eligible for an eRx bonus.

Medicare Telehealth Services

CMS is adding subsequent hospital care services (CPT® codes 99231, 99232 & 99233)—with a limitation for the patient's admitting practitioners of one telehealth visit every three days—to the list of telehealth services for which payment will be made at the applicable PFS payment amount for the service of the provider.

Imaging-related Provisions

Expanding the Multiple Procedure Payment Reduction (MPPR) Policy for Imaging Services
CMS will apply the 50% MPPR to all ultrasound, CT, CTA, MRI, and MRA services to which the current contiguous body area and modality-specific policy applies, regardless of the specific combinations of imaging services furnished to the patient in a single session. Despite receiving examples of legitimate cases where redundancies would not occur, CMS believes that applying the MPPR to these services is consistent with the agency's overall strategy to pay more appropriately for services that are commonly furnished together.

Notifying Patients in Writing about where they may Receive Advanced Imaging Services
Starting January 1, 2011, referring physicians of advanced imaging services must provide a written disclosure at the time of the referral that includes the name, address, and phone number of five other suppliers within a 25-mile radius of the physician's office location at the time of referral that can perform the services for which the patient is being referred. The physician should be able to document or otherwise establish that they have complied with the disclosure requirement. For example, the physician could document in the patient's chart that the notice was given to the patient.

A physician may choose to include language on the disclosure informing patients that inclusion of other suppliers on the document is not intended as an endorsement or recommendation. Physicians may include hospitals on the list, but those do not count towards the five suppliers required. The list is not limited to suppliers who receive accreditation or suppliers who are accepting new Medicare patients. However referring physicians should make a "reasonable effort" to ensure that the suppliers listed are viable options for their patients.

The disclosure notice is intended to allow patients to make informed choices regarding where they receive imaging services.

---

Member Comments (0 comments)

Disclaimer: The opinions expressed in this posting are those of the author only and do not represent the views of the American Academy of Neurology or any of its affiliated subsidiaries.

Please login to view and submit comments.