Written by Marilyn Glidden, CPC, CPMA, CGSC, CGIC
· In past years, the proposed PFS has focused on the rates for the upcoming year. This time, the proposed schedule has a more limited scope due to the Protecting Access to Medicare Act (PAMA) of 2014 — signed into law on April 1 – which provides for a 0% increase in fees for services rendered between January 1 and March 31, 2015. However, CMS announced a negative 20.9% update for the remainder of 2015 following the expiration of PAMA.
· CMS opted to ignore the existing CPT® codes for complex chronic care services, instead announcing that it will create a new code – dubbed GXXX1 for now. GXXX1 is intended to describe services furnished to patients with multiple (two or more) chronic conditions expected to last at least 12 months or until the death of the patient, and which place the patient at significant risk of death, acute exacerbation/decompensation, or functional decline. The new code, proposed at the rate of $41.92, stipulates that the service must be for 20 minutes or more and billed only once in a 30-day span for qualified patients. In another expansion of reimbursement, group behavioral counseling for obesity can soon be reported and billed under two new proposed codes – GXXX2 and GXXX3, the latter for patients participating in larger groups (up to 10 patients).
· For practices that have converted to provider-based services – a common strategy to boost reimbursement for hospitals and health systems after acquiring physician practices – CMS warns: “…we continue to seek a better understanding regarding the growing trend toward hospital acquisition of physician offices.” CMS notes that “MedPAC continues to question the appropriateness of increased Medicare payment and beneficiary cost-sharing when physician offices become hospital outpatient departments, and to recommend that Medicare pay selected hospital outpatient services at PFS rates.” In order to gather data, CMS proposes a new modifier for provider-based practices to use, but offers no details about it other than to request comments from readers.
· Perhaps the most unanticipated revelation in the proposed PFS is CMS’ intention to assess the payment system for global surgical packages. Historically, procedures and surgeries have been paid under a 10- or 90-day period, with all services rendered during that time period – including the pre-operative, post-operative, as well as the surgery itself – included in a single, “global” payment. (Minor procedures and surgeries typically have a 0-day package, which means that any services billed outside of the surgery are paid separately.) After citing significant concerns with this long-standing payment method, CMS reveals its objective to “transition… over several years all 10- and 90-day global codes to 0-day global codes.” The schedule calls for 10-day codes to make the switch in 2017 and the remaining codes in 2018.
· The Medicare law waives deductible and coinsurance applicable to screening colonoscopy. Increasingly, anesthesia separately provided by an anesthesia professional is becoming the prevalent practice in connection with screening colonoscopies, replacing the previous standard of moderate sedation provided intravenously by the endoscopist, which was bundled into the payment for the screening colonoscopy codes. When provided separately with a screening colonoscopy, Medicare did not waive deductible and coinsurance associated with the separately provided anesthesia. If adopted in the final rule, this revision would have the beneficial result of further reducing beneficiaries’ cost-sharing obligations under Part B. This is because the expanded definition of screening colonoscopy would bring anesthesia furnished in conjunction with the service within the scope of the provision that Medicare Part B pays 100 percent of the Medicare payment amount established under the PFS for certain colorectal cancer screening tests.
· CMS identified 80 more potentially “misvalued” codes in its proposed 2015 Medicare Physician Fee Schedule (MPFS), and 20% pertain to radiology.
It’s important to note that these are all proposed changes; the final rule is expected to be released by November 1.
References-
http://www.gpo.gov/fdsys/pkg/FR-2014-07-11/pdf/2014-15948.pdf