Requirements of E-prescribing incentive program

2011 E-Prescribing Incentive Program Requirements

CMS proposes to continue with the 2010 e-prescribing reporting requirement in 2011, which is to require eligible physicians to report on 25 services in 2011 involving electronic prescriptions in order to qualify for incentives. We appreciate CMS’ consideration of the AMA’s recommendation to minimize the e-prescribing reporting burden. We support CMS’ proposal that for 2011, eligible physicians report the e-prescribing G-code, G8553, only twenty-five times for applicable Medicare office visit and service codes in order to receive the e-prescribing incentive, which totals up to one percent of their Medicare allowable charges. In addition, the AMA agrees with CMS’ proposal to allow several mechanisms for physicians to submit e-prescribing information (e.g., vis a vis Medicare Part B claims, a qualified registry, or a qualified EHR product). Please also refer to our comments on requirements for qualified registries and the EHR reporting option under the PQRI section. We remain committed to working with CMS to pursue significant outreach to the physician community on the 2011 e-prescribing incentive program details.
2012 and 2013 E-Prescribing Penalty Programs

CMS has also proposed criteria for applying penalties in 2012 and 2013 for physicians and group practices that are deemed to be unsuccessful e-prescribers. The law that established the Medicare e-prescribing incentive program, the “Medicare Improvements for Patients and Providers Act of 2008” (MIPPA) (P.L. 110-275), requires a penalty phase for eligible physicians who do not e-prescribe during 2012 through 2014. According to MIPPA, physicians who are eligible but choose not to participate in the 2012 or 2013 Medicare e-prescribing incentive program and do not qualify for a hardship exemption would be subject to a one percent Medicare payment reduction based on their Medicare Part B allowed charges (1.5 percent in 2013). MIPPA does provide the Secretary of HHS with the authority to exempt eligible physicians from penalties for hardship reasons. CMS’ proposal is to levy financial penalties in 2012 and 2013 against physicians who fail to report the e-prescribing measure ten times during the first six months in 2011.

We strongly oppose CMS’ proposal to levy financial penalties in 2012 and 2013 against physicians who fail to report the e-prescribing measure during the first six months in 2011 (January 1, 2011 through June 30, 2011). CMS’ proposal conflicts with the intent of the law, which clearly delays penalties until 2012. The law states that the penalty would apply “with respect to covered professional services furnished by an eligible professional during 2012, 2013, or 2014.” Applying penalties to services rendered in 2011 conflicts with the above-mentioned language in the law. Congress clearly intended to provide CMS as much flexibility as possible to come up with a penalty program that is fair and reasonable. Reviewing e-prescribing activity during the first six months of 2011 in order to assess penalties in 2012 and 2013 is an imbalanced approach. CMS has yet to produce the 2009 e-prescribing data and to address whether there were any problems in e-prescribing reporting. Inflicting financial penalties in 2012 and 2013 based on 2011 e-prescribing activity without fully assessing the 2009 and 2010 program, including adoption and use rates, is unfair and unreasonable. We insist that CMS revise the 2012 and 2013 penalty criteria. Financial penalties should only be levied in 2012 and 2013 against Medicare eligible physicians who fail to qualify for an exemption and fail to e-prescribe ten permissible prescriptions by the end of 2012 or by the end of 2013. Unlike CMS’ proposal, our recommended approach is entirely consistent with the intent of the law.

CMS proposes two narrow categories for exempting eligible physicians from the e-prescribing penalty: eligible physician/group practice practices in rural area with limited high speed internet access; and eligible physician/group practice practices in an area with limited available pharmacies for e-prescribing. Although we support these exception categories, we strongly recommend that CMS add more exception categories.

CMS has failed to consider that many physicians postponed purchasing an e-prescribing software or application in order to take advantage of Medicare and Medicaid EHR incentives prescribed by the “American Recovery and Reinvestment Act” (ARRA) (P.L. 111-5). ARRA was signed into law in February 2009, less than eight months after the enactment of the e-prescribing incentive program, and authorizes incentives for up to five years to eligible physicians who demonstrate meaningful use of an EHR, that includes e-prescribing functionality. The Medicare e-prescribing incentive program and the Medicare EHR incentive program are at odds with each other. According to ARRA, physicians who choose to participate in the Medicare EHR incentive program can not participate in the Medicare e-prescribing incentive program simultaneously. In order to avoid an e-prescribing penalty, physicians would have to invest in a stand alone e-prescribing application along with a certified EHR system which would pose a significant financial, administrative hardship on them. Physicians should therefore, not be penalized because it makes more economic, practical sense to choose to participate in the EHR incentive program and for investing in an electronic system that performs more than just e-prescribing.

There is also flexibility in the EHR incentive program on the start date for EHR use. Physicians are eligible for incentives even if they wait until 2014 to take part in the EHR incentive program. Another critical factor that needs to be considered is the fact that most physician practices are small and many of these physicians, like the rest of the population, are reaching retirement age in large numbers. It will be economically burdensome for physicians who intend to retire in the next five years to install and utilize an e-prescribing system as they continue to face looming Medicare payment cuts. We are also concerned that many of these physicians may decide to close their Medicare panels or opt out of Medicare to avoid penalties during the end stage of their clinical careers, which would adversely affect access to care for our nation’s elderly and disabled. Physicians who are currently eligible for Social Security retirement benefits or will be eligible for Social Security retirement benefits by 2014 should have the opportunity to apply for an exemption. In general, a person must be at least age 62 to start collecting Social Security retirement benefits. Another exception category should be for physicians who prescribe controlled substances so that they have adequate time to purchase and install Drug Enforcement Administration (DEA) compliant e-prescribing applications, which are not yet readily available.

In addition to CMS’ above-mentioned proposed exemption categories, we strongly recommend that CMS exempt other categories of eligible physicians from the 2012 and 2013 penalties, including: physicians who plan on participating in the EHR incentive program beginning in 2012, 2013, or 2014; physicians who are currently eligible for Social Security benefits or will be eligible for Social Security benefits by 2014; and physicians who prescribe controlled substances and are working to comply with the new DEA e-prescribing requirements. A “G” code should be designated for each of these additional exception categories and physicians should be able to report the applicable “G” code(s) once in 2012 and in 2013 in order to be exempt from the 2012 and 2013 penalty programs.

Proposed 2011 PQRI Quality Measures and Measures Groups

Table 51- 2010 PQRI Measures Not Proposed for Inclusion in PQRI 2011

•    The AMA supports the proposal to retire measures #114 and #115 and replace these retired measures with the new measure PCPI measure-Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention.
•    Measure # 135: Chronic Kidney Disease-Influenza Immunization. The AMA respectfully requests that CMS reconsider measure #135 for inclusion in PQRI 2011. The proposed rule states that this measure was considered for National Quality Forum (NQF) Endorsement, but ultimately not NQF-endorsed. This is incorrect. Measure #135 has not yet been reviewed by NQF, and therefore still meets the requirements for inclusion in the CMS PQRI program.

Tables 52 & 53- Proposed 2011 Measures Selected from the 2010 PQRI Program

•    The AMA supports the continued inclusion of the measures listed in Table 52. However, CMS should be aware that the PCPI has received inquires from various stakeholders related to Measure #193 – Perioperative Temperature Management. Based on inquiries received, which questioned how the process component of the measure is defined, the PCPI work group that developed the measure reconvened in 2010 to review the evidence base. Upon reviewing updated guidelines and other changes to the evidence base, the work group convened a webinar inviting open presentations from interested stakeholders in measure #193. The work group considered the relevance of evidence and information presented during the webinar to the existing definitions in the process component of the measure (i.e., definition of active warming). Additionally, the work group directed PCPI staff to draft for its consideration a potentially more clinically-relevant version of the measure focused on the outcome component only (i.e., maintaining normal intraoperative temperature). The revision of the measure is ongoing, and will require the development of detailed specifications, an open public comment period, and PCPI approval upon work group review of comments and final consensus on the measure.

Table 54: Proposed New Individual Measures for PQRI 2011

•    Care Transitions Measures: The AMA appreciates that CMS recognizes the importance of the four Care Transitions measures and for this reason has included them in the measures proposed for PQRI 2011. While the AMA looks forward to implementation of these measures in a national program, the Care Transitions measures were not designed for individual physician level measurement. These measures are specified at the facility (hospital) level, using the UB04 administrative data to identify the denominator population. Given that one of the PQRI program requirements is that the measures are for services covered by the Physician Fee Schedule, it does not seem feasible to include these in the PQRI program. The AMA will work with the Society for Hospital Medicine to determine whether these measures would be appropriate for a hospital-level quality reporting program. As a point of clarification, the National Committee for Quality Assurance is incorrectly included as a joint measure developer on these measures. The measures were developed by the PCPI in collaboration with the American Board of Internal Medicine Foundation, the American College of Physicians, and the Society for Hospital Medicine.

•    Hypertension: Plan of Care- The AMA-PCPI, in collaboration with the American College of Cardiology Foundation/American Heart Association (ACCF/AHA) recommends that this measure not be finalized for inclusion in PQRI 2011 individual measures (claims or registry) Hypertension-Plan of Care. When this measure was originally developed, it was developed as a “test measure” and was not designed for individual physician accountability, but rather internal quality improvement. The CAD/Hypertension measurement set is currently undergoing full maintenance and update by the PCPI/ACCF/AHA Measure Development work group. The expert work group has recommended that this measure be retired and will be replaced with another measure. The updated Hypertension measurement set is in its final stages of development, and the PCPI anticipates to have a new measure for consideration in PQRI 2012.

•    Melanoma: Overutilization of Imaging Studies in Stage 0-IA Melanoma: this measure is proposed for either claims or registry reporting. The AMA would like to propose that the existing Melanoma measures #137 and #138 (currently registry only) also be proposed for either claims-based or registry-based reporting. This will provide consistency in reporting for dermatologists reporting on the Melanoma measures. In PQRI 2010, measures #137 and #138 are only available for registry-based reporting.
•    Radiology: Reminder System for Mammograms; the AMA supports the inclusion of this new measure.
•    Asthma: Assessment of Asthma Risk- Emergency Department (ED)/Inpatient Setting and Asthma: Discharge Plan- Emergency Department/Inpatient Setting. The AMA does not recommend these two measures be finalized for PQRI 2011 because they both are for the ED/Inpatient setting only and are not aligned in terms of care setting with the existing Asthma measures (#53, #64) in PQRI. CMS proposed an Asthma Measures Group for 2011 comprised of these two measures and the two existing Asthma measures in PQRI (#53, #64). However, as noted in comments for Table 70, these measures are not appropriate for inclusion in the Asthma Measures Group due to the varying settings of care. The AMA recommends that CMS consider adding the following Asthma measures for inclusion in PQRI 2011 for individual reporting (claims and registry) 1) Asthma: Tobacco Use: Screening- Ambulatory Care Setting; 2) Asthma: Tobacco Use: Intervention- Ambulatory Care Setting. The inclusion of these AMA proposed measures would enable CMS to proceed with creating an Asthma Measures Group unique to one setting of care.


•    Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention; the AMA supports the inclusion of this updated PCPI measure for tobacco use.

Understand public reporting PQRI data

Public Reporting of PQRI Data

The ACA requires the Secretary of HHS to develop a Physician Compare Internet Web site by January 1, 2011, on which information on physicians enrolled in the Medicare program and who participate in the PQRI program would be posted. CMS proposes for the 2011 PQRI to use the current Physician and Other Health Care Professional Directory as a foundation for the Physician Compare Web site. As with the 2010 PQRI, CMS will continue to make public the names of physicians and group practices that satisfactorily submit quality data for the 2011 PQRI. Specifically, CMS proposes to post the names of physicians who: (1) submit data on the 2011 PQRI quality measures through one of the reporting mechanisms available for the 2011 PQRI; (2) meet one of the proposed satisfactory reporting criteria of individual measures or measures groups for the 2011 PQRI as described above; and (3) qualify to earn a PQRI incentive payment for covered professional services furnished during the applicable 2011 PQRI reporting period, for purposes of satisfying the requirements on the Physician Compare Web site.

Similarly, for purposes of publicly reporting the names of group practices, on the Physician Compare Web site, for 2011, CMS proposes to post the names of group practices that: (1) submit data on the 2011 PQRI quality measures through one of the proposed group practice reporting options; (2) meet the proposed criteria for satisfactory reporting under the respective group practice reporting option; and (3) qualify to earn a PQRI incentive payment for covered professional services furnished during the applicable 2011 PQRI reporting period.
CMS also discusses that it is not proposing that performance information be made publicly available at either the group practice or individual level as a condition of participation in the 2011 PQRI. The AMA agrees with and supports CMS’ determination in this regard.
CMS discusses that section 10331 of the ACA, however, requires that not later than January 1, 2013, and with respect to reporting periods that begin no earlier than January 1, 2012, CMS must implement a plan for making publicly available through Physician Compare, information on physician performance, including measures collected under the PQRI. CMS will expand the information that is publicly posted on the Physician Compare Web site in future years and will be further described in future rulemaking.

The AMA looks forward to providing input into the design of the Physician Compare Web site. It is important to promote physician engagement in quality improvement though such factors as accurate benchmarking and other beneficial functions. We also suggest a process by which a physician or group can review and update their demographic information. The AMA understands this was a major challenge when the CMS Hospital Compare Web site was initiated.
Further, public reporting of performance information, if not approached thoughtfully, can have unintentional adverse consequences for patients. For example, patient de-selection can occur for individuals at higher-risk for illness due to age, diagnosis, severity of illness, multiple co-morbidities, or economic and cultural characteristics that make them less adherent with established protocols. Further, health literacy may not be adequate to comprehend basic medical information. Programs must be designed so that appropriate and accurate information is available to patients to enable them to make educated decisions about their health care needs.
If done correctly, public reporting has the potential to help provide such appropriate and accurate information to patients. There remain, however, several critical issues that must be resolved before public reporting provisions can be implemented. There must be a method for ensuring that any publicly reported information is: (i) correctly attributed to those involved in the care; (ii) appropriately risk-adjusted; and, (iii) accurate, user-friendly, relevant and helpful to the consumer/patient. Moreover, as CMS has acknowledged, an important aspect of a quality reporting program is that physicians have the opportunity to review their data on reporting rates on PQRI quality measures. Physicians and other providers involved in the treatment of a patient must have the opportunity for prior review and comment and the right to appeal with regard to any data that is part of the public review process. Any such comments should also be included with any publicly reported data. This is necessary to give an accurate and complete picture of what is otherwise only a snapshot, and possibly skewed, view of the patient care provided by physicians and other professionals or providers involved in the patient’s care.

Other factors that must be considered as part of any initiative to make performance data available to the public are as follows:
•    To date, there has been no formal, rigorous evaluation of the PQRI to determine such factors as: its impact on quality of care, whether it allows for fair and meaningful comparison of performance among physicians, and whether the data on physician participation is valid and can be verified.
•    A detailed educational program for the public should be undertaken to explain the PQRI and openly address its limitations, including barriers to physician participation and the fact that quality measures used in the program take into account only a small fraction of all dimensions that explain overall physician performance.
•    CMS should provide physicians an opportunity to explain why they did not participate in the voluntary PQRI and detail any quality improvement initiatives in which the physician is participating. This information should be provided to the public by CMS. Many physicians are participating in health care quality improvement projects conducted by Medicare’s Quality Improvement Organizations, CMS’ Coverage with Evidence Development mandates, health plans and various other quality initiatives. Physicians should have an opportunity to highlight these quality improvement efforts.

Consultation code survey by ACA

Consultation Codes

In the proposed rule, CMS requests input on Medicare coding and payment policies, including the discontinuation of CPT consultation codes this year. As conveyed in a June 18 letter signed by the AMA and 33 medical specialty organizations, the policy has forced some physicians to cut back services to Medicare patients and discouraged communication between clinicians at the very time CMS is looking for ways to improve care coordination. A survey of affected specialties suggests that continuation of the current policy will lead to additional cutbacks in care and make it impossible for many specialists to purchase electronic medical records systems and adopt new technologies required to launch the transformation envisioned in the ACA.

Specific Survey Findings include:

•    Twenty percent of the 5,500 physicians who completed the survey have reduced the number of new Medicare patients in their practice, 12% have reduced time spent with Medicare patients and 10% have reduced or eliminated consultations on hospital inpatients.

•    Thirty-nine percent say they will defer purchase of new equipment and/or information technology to compensate for lost revenues. More than a third (34%) are eliminating staff.

•    Six percent have already followed CMS’s suggestion that they no longer need to send a written report back to the referring physician and 19% plan to stop providing a report.

•    Although CMS predicted that no specialty would see Medicare revenues decline by more than 3%, nearly three-fourths (72%) of survey respondents saw declines of more than 5% and 30% faced losses greater than 15%.

These findings confirm the AMA’s view that CMS should reverse its current policy and resume payment for consultation codes in Medicare. If the agency declines to adopt a complete solution, it should, at the very least, modify two other policies—involving prolonged services and new patient definitions—that have compounded the problem caused by elimination of the consultation codes.

As laid out in the previously-mentioned letter, in determining whether a service meets the prolonged service criteria, CPT stipulates that, for the inpatient setting, in addition to time spent “face-to-face” with patients, physicians can include time spent on the patients’ floor or unit performing other tasks related to their care. Were CMS to apply the same definition as CPT, consulting specialists could use the prolonged services to obtain fairer reimbursement for particularly long and challenging cases they previously would have billed as consultations. CMS only recognizes the face-to-face time, however, and further discourages coordination of care by essentially denying payment for activities such as creating and reviewing charts, communicating with the family and coordinating with other health care professionals. Cases where it would benefit a physician to use the prolonged service code are relatively limited and their use could be monitored through claims edits. Consequently, it does not appear that conforming to CPT policy on these codes would lead to large increases in Medicare expenditures and the AMA is again requesting that CMS modify its interpretation of the prolonged service codes to match the CPT descriptors.

The issue involving new patient definitions occurs because unlike the consultation codes, visit codes distinguish between new and established patients. The difference can be significant—about $60 for the most complex office visits—and it affects a substantial number of specialist physicians. In the aforementioned survey, for example, 33% of all respondents and more than 70% of some specialties said that more than 25% of their consultations in 2009 were with patients who had been seen previously by another member of the same specialty and group within the past three years.

In CPT, new patients are defined as those who have not been seen by the same physician or another member of the same group and sub-specialty within the last three years. In Medicare, however, a new patient is one “who has not received any professional services, i.e., E/M service or other face-to-face service (e.g., surgical procedure) from the physician or physician group practice (same physician specialty) within the previous 3 years. The problem is that physicians often focus on a narrower range of services than are recognized in Medicare’s current list of 42 medical specialties. Thus, for example, if an electrophysiologist treats a particular patient and two years later, the patient is seen by an interventional cardiologist in the same group, the patient will be viewed as an established patient even though the two cardiologists have different areas of expertise.

The current situation is inequitable and the AMA believes that Medicare should comply with the CPT policy of identifying patients seen by physicians in a different sub-specialty as “new” patients. As pointed out in the June 18 letter, correcting its budget neutrality assumptions would provide some additional funding CMS could use to offset or partially offset any cost associated with this change. We recognize, however, that due to variations in the way that different specialties have dealt with the issue of extended training and focused expertise, setting the criteria for determining Medicare-recognized sub-specialties or equivalent expertise will require some further analysis. The AMA would be pleased to assist CMS in identifying affected specialties and creating a work group that could help with this analysis.

ICDs for OB/GYN, Neurology, Personal History, Foreign Body

OB/GYN 

Several new codes have been added that are related to obstetrics and gynecological services (OB/GYN). See the 2011 ICD-9-CM manual for additional information on the following additions:
•    Congenital Anomalies of the Uterus (752.31 thru 752.39)
•    Congenital Anomalies of Genital Organs (752.43 thru 752.47)
•    Personal History of Vaginal or Vulvar Disease (V13.23 or V13.24)
•    Intrauterine Contraceptive Device Management (V25.11 thru V25.13)
•    Multiple Gestation Placenta Status (V91.00 thru V91.99) 

Neurology

Seven new Symptoms, Signs and Ill-Defined Conditions diagnoses were added in order to describe cognitive deficits in patients who have suffered a traumatic brain injury (TBI). The new codes include the following:
•    799.50 – Unspecified signs and symptoms involving cognition
•    799.51 – Attention or concentration deficit
•    799.52 – Cognitive communication deficit
•    799.53 – Visuospatial deficit
•    799.54 – Psychomotor deficit
•    799.55 – Frontal lobe and executive function deficit
•    799.59 – Other signs and symptoms involving cognition 

Personal History
Eight new personal history codes (V13.62 thru V13.69) were added this year to document corrected congenital conditions (See the ICD-9 manual for more detailed definitions). These codes ought to be used in addition to the diagnosis for the condition itself. For example, a child with a surgically repaired cleft would be documented as 749.00, cleft palate, and V13.64,
personal history of corrected congenital malformations of eye, ear, face and neck.

Foreign Body

Several new codes were added this year in regards to foreign bodies. Providers must distinguish between foreign bodies that have been fully removed, as opposed to foreign bodies that remain in the body. With retained foreign bodies, code selection is based on the type of foreign body present. The new codes are listed as: personal history of retained foreign body fully removed (V15.53), and retained foreign body status (V90.01 thru V90.89).

Electronic Prescribing Incentive Program Requirements and penalty program

Electronic Prescribing

2011 Electronic Prescribing Incentive Program Requirements and 2012 and 2013 Electronic Prescribing Penalty Programs

In summary, CMS proposes to continue with the 2010 e-prescribing reporting requirement in 2011, which is to require eligible physicians to report on 25 services in 2011 involving electronic prescriptions in order to qualify for incentives. CMS also plans to publicly report the names of 2011 successful e-prescribers on CMS’ website.

In addition, CMS has provided and seeks input on the 2012 and 2013 penalty phases of the e-prescribing program. CMS’ proposal is to levy financial penalties in 2012 and 2013 against physicians who fail to report the e-prescribing measure during the first six months in 2011.

We strongly support CMS’ proposed requirements for the 2011 e-prescribing incentive payment program, which is to reduce the reporting burden from 50 percent of all applicable services, which was the requirement in 2009, to reporting only 25 services involving electronic prescriptions. We do however, strongly oppose CMS’ proposal to impose financial penalties in 2012 and 2013 against physicians based on their e-prescribing activity during the first six months of 2011. Instead, we strongly urge CMS to review 2012 and 2013 e-prescribing activity (not 2011 e-prescribing activity) in order to assess penalties in 2012 and 2013. We also strongly recommend that CMS add more exception categories so that physicians who face hardship are exempt from penalties in 2012 and 2013. Finally, we recommend feedback reports from CMS to assess the incentive program, the establishment of an appeals process, and that CMS ensure that the posting of the names of successful e-prescribers is done correctly.

Medicare oxygen equipement service coverage

Oxygen and Oxygen Equipment

For stationary and portable oxygen equipment furnished on or after January 1, 2006, a 36-month cap applies on monthly payments. A listing of the applicable HCPCS codes is available in Chapter 5 of the Supplier Manual.

For stationary and portable oxygen equipment and oxygen contents furnished prior to January 1, 2006, payments were made for the duration of use of the equipment when medically necessary.
Contractors began the 36-month count on January 1, 2006, for beneficiaries that were receiving oxygen therapy prior to January 1, 2006. Months prior to January 1, 2006, are not included in the 36-month count.

On the first day after the 36th month anniversary for which payment has been made, the supplier must transfer the title for the stationary and/or portable oxygen equipment to the beneficiary. On that same day, the title for the equipment is transferred to the patient and monthly payments can begin to be made for oxygen contents used with patient owned gaseous and liquid oxygen equipment.

Modifiers appropriate for oxygen and oxygen equipment are:

•    RR Rental
•    QE Use if the prescribed amount of oxygen is less than 1 LPM
•    QF Use if the prescribed amount of oxygen exceeds 4 LPM and portable oxygen is prescribed
•    QG Use if the prescribed amount of oxygen is greater than 4 LPM
•    QH Use if an oxygen conserving device is being used with an oxygen delivery system

Medicare Diabetes Screening guideline - CPT 82947, 82950 , 82951

Diabetes Screening

The diabetes screening tests include a fasting blood glucose test, post-glucose challenge tests, and either an oral glucose tolerance test with a glucose challenge of 75 grams of glucose for non-pregnant adults or a 2-hour post-glucose challenge test alone. This screening is covered twice within a 12-month period.

Individuals are eligible for the benefit if they have the following risk factors:
• Hypertension.
• Dyslipidemia.
• Obesity (body mass index 30 kg/m2 or more).
• Previous identification of an elevated impaired fasting glucose or glucose tolerance.
• At least two of the following:
o Overweight (body mass index greater than 25 kg/m2, but less than 30).
o A family history of diabetes.
o A history of gestational diabetes mellitus or delivery of a baby weighing greater than 9 pounds.
o 65 years of age or older.

Patients previously diagnosed as diabetic are not covered. Individuals diagnosed as pre-diabetic are eligible for this benefit. Pre-diabetes is defined as a fasting glucose level of 100-125 mg/dL, or a 2 hour post-glucose challenge of 140-199 mg/dL. Individuals not meeting the pre-diabetes criteria are eligible for one screening test per year.

Medicare covers these tests when reported with diagnosis code V77.1 (screening for diabetes mellitus) and one of the following CPT codes:

• 82947 - Glucose; quantitative, blood (except reagent strip)
• 82950 - Glucose; post glucose dose (includes glucose)
• 82951 - Glucose; tolerance test (GTT), three specimens (includes glucose)

Does Medicare cover 99381 - 99397 - screen services

Medicare Screening Services

Physicians are often confused about how to document and report preventive services provided to their Medicare patients. This document is designed to assist physicians in documenting, reporting and receiving reimbursement for these services.

Medicare does not cover comprehensive preventive visits (99381-99397). However, Medicare does cover certain screening services which are often performed during preventive visits such as:

• Screening pelvic exam
• Collection of screening Pap smear specimen
• Interpretation of the Pap smear test (reported by the laboratory)
• Screening hemoccult
• Screening mammography
• Screening bone mass measurement
• Initial preventive physical examination (Welcome to Medicare examination)
• Diabetes screening
• Cardiovascular blood test
• Tobacco use cessation counseling

The table at the end of this document provides an overview of Medicare screening services. The Centers for Medicare and Medicaid (CMS) have published several educational products that describe covered screening services available to Medicare patients.

Medicare rate cut - final update for physician

Good News for Medicare Patients and Their Providers
 
Congress Passes Legislation to Avoid Double-Digit Cuts and Reprocess 2010 Claims

This week, Congress passed important legislation resulting in two important developments for ASNC members:

• SGR Cuts Delayed. The primary function of the Medicare and Medicaid Extenders Act of 2010 is to postpone the scheduled cuts to Medicare physician payments until December 31, 2011. Without this legislation, all physicians participating in Medicare would have received a 25 percent reduction in reimbursement starting January 1. The one-year delay offers the physician community more time to work with the Centers for Medicare & Medicaid Services and Congress on a permanent solution to the flawed sustainable growth rate (SGR) formula.
•  
• Funding for CMS to Reprocess Claims. Another important provision of the Medicare and Medicaid Extenders Act is an allocation of $200 million to CMS to reprocess claims from 2010. This funding will allow CMS to reprocess claims for myocardial perfusion imaging services, which were positively impacted by a technical correction to practice expense inputs for the procedures last March. ASNC will notify members as soon as CMS announces its methodology for contractors to use in reprocessing these claims.

ASNC extends its gratitude to its members who have contacted their legislators on both of these issues. Your outreach has resulted in great news for the entire nuclear cardiology community.

Medicare holiday update for christmas and new year

Christmas and New Year’s Day Holiday – Electronic Data Interchange (EDI) Availability

Highmark Medicare Services will be observing the Christmas holiday on Thursday, December 23, 2010, and Friday, December 24, 2010, as well as the New Year’s Day holiday on Friday, December 31, 2010.  Our business doors will be closed and the Highmark Medicare Services EDI Help Desk will not be available.  However, you may continue utilizing electronic data interchange (EDI) services.

December 23 and 24 and Holiday Schedule

On December 23, 2010, the EDI platforms will be available for claim submission and report retrieval.  There will be a batch claim processing cycle executed for this date. Medicare checks and Electronic Remittance Advice (ERA) will be generated on this day. EDI claims received after 4 PM Eastern Standard Time (EST) on December 23, 2010, will be entered into the processing system on December 27, 2010.  The Multi-Carrier System (MCS) Edit Report for these claims will be available for retrieval on December 28, 2010.

On December 24, 2010, the EDI platforms will be available for claim submission and report retrieval. However, there will not be a batch claim processing cycle executed for this date. Medicare checks and ERA will NOT be generated on this day.  The MCS Edit Report for EDI claims received after 4 PM EST on December 23, 2010 will be available for retrieval on December 28, 2010.

December 31 Holiday Schedule

On December 31, 2010, the EDI platforms will be available for claim submission and report retrieval. However, there will not be a batch claim processing cycle executed for this date. Medicare checks and ERA will NOT be generated on this day.  EDI claims received after 4 PM EST on December 30, 2010, will be entered into the processing system on January 3, 2011. The MCS Edit Report for these claims will be available for retrieval on January 4, 2011.

Miscellaneous ICD - DX 278.03, 724.02 , 780.33 , 784.92, 970.89, e000.2, v49.86

Miscellaneous ICDs

Several other diagnosis code changes were included in this year’s updates, but they do not fit into any of the previously mentioned groups. A brief description of these additional codes is listed below:

•    278.03 – Obesity hypoventilation syndrome
•    724.02 – Spinal stenosis, lumbar region, without neurogenic claudication (Providers                    must specify with/without claudication)
•    724.03 – Spinal stenosis, lumbar region, with neurogenic claudication (Providers must                 specify with/without claudication)
•    780.33 – Post traumatic seizures
•    784.92 – Jaw pain (Previously reported as 526.9, unspecified disease of jaws)
•    970.81 – Poisoning by cocaine
•    970.89 – Poisoning by other central nervous system stimulants
•    E000.2 – Volunteer activity
•    V11.4   – Personal history of combat and operational stress reaction
•    V49.86 – Do not resuscitate status
•    V49.87 – Physical restraints status
•    V62.85 – Homicidal Ideation
•    V88.11 – Acquired total absence of pancreas (Previously reported as V45.79, other                     acquired absence of organ)
•    V88.12 – Acquired partial absence of pancreas (Previously reported as V45.79, other acquired absence of organ) 

Coding Books

As responsible coders, it is always a good idea to purchase new ICD-9, CPT® and HCPCS manuals every year. Coding manuals can be purchased easily from a variety of sources, such as the AAPC or AHIMA websites. Furthermore, if you are planning to take a certification class this year, you will need updated manuals for any test that you take (Note: Make sure any books you purchase are approved by the testing organization).

E-Prescribing incentive program feedback review

Feedback Report on E-Prescribing Incentive Program and Appeals Process

We also remain concerned that despite the AMA’s numerous requests, CMS has not yet produced 2009 e-prescribing data or issued 2009 incentive payments. Assessing the 2009 e-prescribing data is essential for evaluating the success of the incentive program and for applying lessons learned to the e-prescribing as well as other related programs like the Medicare and Medicaid EHR incentive programs. We urge CMS to provide feedback reports as soon as practicable so that physicians have timely, actionable information on potential problems in their e-prescribing reporting.

We also urge CMS to include a mechanism for physicians to appeal any aspect of the e-prescribing incentive program (e.g., payments or eligibility). We believe it is critical that physicians have an opportunity to appeal decisions that affect their ability to get incentives. Given the pitfalls experienced with the Medicare PQRI, we strongly recommend that a timely feedback loop and appeals process be built into the program to allow physicians to address reporting problems and appeal decisions that affect their eligibility to take part in the program or that affect their ability to get incentives.

Reporting of Successful E-Prescribers

In accordance with the law, CMS plans to publicly report the names of 2011 successful e-prescribers on the CMS website. We urge CMS to take appropriate measures to ensure the accuracy of the list of successful e-prescribers and to provide the appropriate disclaimers for the website listing. CMS should consider delaying the posting until CMS is able to pursue an educational campaign and is able to post appropriate disclaimers along with the list of successful e-prescribers. Physicians and patients should understand: the purpose for the posting given that this incentive program just started in 2009; that adjustments to the program have been made since 2009; and that the law does not allow physicians to participate in this program and others (e.g., Medicare EHR incentive program) simultaneously so many physicians have to select one incentive program over another. Please also refer to our comments on public reporting under the PQRI section.

Know Medicare screening services fully - CPT and covered DX

Summary of Medicare Screening Services

Possible Procedure/HCPCS Codes	Coverage	Patient Criteria	Patient Financial Responsibility	Provider Criteria	Possible Diagnosis Codes
Screening Pelvis Examination
G0101	Every 2 years	Not high risk	20 % allowable No Part B deductible	None stated	V76.2, V76.47, V76.49, V72.31
	Annually	High risk			V15.89
Collection of Pap Smear Specimen
Q0091	Every 2 years	Not high risk	20 % allowable No Part B deductible	None stated	V76.2, V76.47, V76.49, V72.31
	Annually	High risk			V15.89
Screening Hemoccult
82270 G0328	Annually	>50 years old	None	None stated	V76.51, V76.41
Screening Mammography
77057, +77052 G0202	Annually	>40 years old	20 % allowable No Part B deductible	None stated	V76.12, V76.11
Screening Bone Mass Measurement
77078, 77079, 77080, 77081, 77083, 76977, G0130	Once every 24 months	Patients at risk	20% allowable Deductible applies	Test ordered by physician or qualifed non physician practitioner who is treating patient.	Determined by Local Carriers*
Initial Preventive Physical Examination (Welcome to Medicare Examination)
G0402, G0403, G0404, G0405	Once	Within first 12 months of Medicare coverage	20% allowable Deductible waived, but co-insurance provision apply	Test ordered by physician or qualifed non physician practitioner who is treating patient.	V070.0
Diabetes Screening
82947, 82950, 82951	Twice in 12 month period	Patients at risk	None	None stated	V77.1
Cardiovascular Screening Blood Test
82465, 84478, 83718, 80061	Every 5 years	All Medicare beneficiaries	None	Test must be ordered by physician and used in management of patient	V81.0, V81.1, V81.2
Tobacco Use Cessation Counseling
99406, 99407	2 cessation attempts in 12 month period (1 attempt=up to 4 sessions)	Patient has condition or is receiving treatment that is being adversely affected by tobacco use	20% allowable Deductible applies	Provided by a physician, physician assistant, nurse practitioner, clinical nurse specialist, qualified psychologist or clinical social worker	Use code indicating patient's condition or treatment affected by tobacco use

Is Medical necessity cetificate is must for ambulance transfers?

Certificate of Medical Necessity for Ambulance Transfers

Recent CERT findings have identified concerns regarding the improper use of Certificates of Medical Necessity (CMN)/ Physician Certification Statement (PCS) and the Advanced Beneficiary Notice (ABN) to justify ambulance transport of Medicare beneficiaries. This issue has resulted in the denial of four ambulance claims processed by Highmark Medicare Services and recoupment of the associated payments. Furthermore, when extrapolated, these four errors alone will add approximately $30 million to this year’s national Medicare “fraud, waste, and abuse” figure to be reported in November 2010.

To address this problem, ambulance companies and physicians must be sure that the patient’s medical record clearly supports the need for ambulance transport and includes the specific information that render the ambulance transport medically necessary. Medical necessity is established when the patient’s condition is such that use of any other method of transportation is contraindicated. If another means of transportation could be used without endangering the individual’s health, whether or not such other transportation is actually available, no payment can be made for ambulance services. Please note that the supporting documentation needs to describe the patient’s condition at the time of transport, not what occurred years ago (as an outdated CMN/PCS may do). In addition, inclusion of a signed CMN/PCS in the medical record does not, by itself, establish the medical necessity of the transport; all other program criteria must be met
in order for payment to be rendered.

Medicare will not pay for transports that are not clearly medically necessary and reasonable. Emergency Medical Services providers should also be cognizant that the patient’s condition has not changed such that a CMN/PCS would no longer be valid. As a reminder, the physician’s order must be dated no earlier than 60 days before the date the service is furnished.

• A patient who is able to walk from the porch to the ambulance is likely not eligible for ambulance transfer in routine non-emergent settings.
• A patient whose CMN/PCS states that continuous oxygen is necessary, but whose trip sheet documents that no oxygen was needed or used, is likely not eligible for ambulance transfer in routine non-emergent settings.

As noted earlier, even if a physician writes an order for a patient to go by ambulance, that alone does not prove medical necessity. All other program criteria must be met in order for payment to be made. Transports that are not medically necessary should be brought to the attention of the provider signing the CMN/PCS and the billing company so the claim can be submitted to Medicare with the appropriate modifier for denial. The claim should be reported with the GA modifier if the patient signed an ABN which acknowledges that the patient was informed the transport would not be paid by Medicare. ABNs are rarely appropriate for ambulance services and are only appropriate for use in non-emergency situations. The GZ modifier should be reported on the claim if the beneficiary did not sign an ABN and is unaware that Medicare will not pay for the transport.

Group Practice Reporting Options in PQRI program

Group Practice Reporting Options (GPRO)

CMS proposes for the 2011 PQRI to change the definition of “group practice” to allow a minimum group size of 2 (in contrast to the 2010 minimum group size of 200) to enable more group practices to participate in the PQRI GPRO. The AMA applauds CMS’ decision to change the definition of group practice from 200 to 2, as it will allow more physician practices to participate in the GPRO for 2011.

We are also pleased that CMS has called for deeming eligible group practices participating in the Physician Group Practice (PGP), Medicare Care Management Performance and Electronic Health Record demonstrations to be participating in PQRI. As such, all eligible professionals participating in these demonstrations automatically receive PQRI bonus payments. Adopting this proposal will help reduce the reporting burden for physicians.

CMS proposes for the 2011 PQRI GPRO I (large group practices) that it will validate that the group practice consists of a minimum of 200 NPIs and will supply group practices with this list. This is a change from 2010, and the AMA seeks clarification on how it will validate NPIs.
The AMA supports CMS’ decision to allow those group practices selected to participate in the 2010 GPRO to automatically participate in the 2011 PQRI GPRO, without being required to complete the 2011 GPRO I self-nomination process.

CMS invites comments regarding its proposal to publicly report GPRO II information with respect to satisfactory PQRI participation. The AMA seeks clarification on what the agency means by “information.” “Performance” information would be problematic, considering 2011 would be the first year for the GPRO II. GPRO II information for public reporting must not include performance information.

Maintenance of Certification Reporting Option in PQRI program

Maintenance of Certification Reporting Option

Section 3002(c) of the ACA requires a mechanism under which a physician may provide data on quality measures through a Maintenance of Certification Program (MOCP) operated by a specialty body of the American Board of Medical Specialties (ABMS), with an additional 0.5 percent incentive payment for years 2011 through 2014 if certain requirements are met. These requirements include that the physician must satisfactorily submit data on quality measures under the PQRI for a year and have such data submitted on their behalf through the MOCP. Physicians must also more frequently than is required to qualify for or maintain Board certification status, participate in an MOCP for a year, and successfully complete a qualified MOCP for a year.

CMS must provide further clarification on the requisite interconnected steps and processes for participating in the PQRI and MOCP to qualify for the additional 0.5 percent incentive. Without clearer articulation, physicians will not be able to understand the necessary processes to qualify under what is already a detailed and at times overwhelming incentive program. Further, requiring physicians to interact with both CMS carriers and the Medical Boards on an added PQRI reporting option allows for confusion and duplication of effort. If this additional reporting option is to succeed, CMS and the Boards must work together prior to January 1, 2011, to clarify the parameters and processes of this added reporting option, and communicate PQRI MOCP reporting option requirements clearly and often to physicians.

Further, to engage in an MOCP “more frequently” in the current health care environment, comprised of new requirements and programs, e.g., RUR meaningful use, will severely deter or even prevent many physicians from electing the MOCP option in 2011. The AMA understands that most Boards do not have a fully developed and tested Part IV MOCP, which is referred to as “practice assessment.” Therefore, if most Boards do not have operational and tested “practice assessment” capability, it is not possible for physicians participate in the program at all, much less “more frequently.” We look forward to working with CMS and the Boards to improve the availability of operational and tested practice assessment programs, such as condition-specific Practice Improvement Modules (PIMs). These modules incorporate quality measures that permit physicians to complete the module using their own patient population to produce a quality improvement score.

Physicians will further have difficulty meeting the “more frequent” standard because, as we understand, some practice assessment activity must be competed every one to four years. “More frequent” compliance could occur every two years, for example, and therefore, would not align with current PQRI reporting periods. In addition, meeting the “more frequent” standard in these instances may not yield meaningful learning from the collection and reporting of quality measures because evidence-based medicine, although a dynamic process, may not have substantially changed.

Even if a physician has the ability to participate in a practice assessment on a “more frequent” basis, issues of accurate data capture and transmission to CMS remain questionable. If practice assessment data for a physician were submitted through an MOCP that meets the criteria for a registry under the PQRI, the only PQRI qualified Board registry currently available, according to the 2010 PQRI Qualified Registries, would be the American Board of Family Medicine. Since no other Board registries exist under the PQRI, it is questionable whether they would have the capability to submit data for the 2011 PQRI (and beyond). While more Boards may request to qualify as a registry in 2011 or satisfy the rule by “meeting the criteria for a registry,” as noted in the proposal, most Boards will not be able to do so, preventing most physician specialties from electing to participate in the PQRI MOCP reporting option.

Additionally, the AMA believes there is inadequate time to test whether MOCPs have the capabilities to collect and transmit quality data to CMS accurately and consistently. Testing must occur first. If MOCP or CMS systems are faulty, CMS must provide a formal opportunity for physicians to file a complaint.
To qualify for the additional incentive payment, the MOCP should submit to CMS in a form or manner specified by the Secretary, that the physician has successfully completed a qualified MOCP practice assessment for such year, as well as the methods, measures, and data used under the MOCP and qualified MOCP practice assessment. Only “if requested by the Secretary,” does information on the survey of patient experience need to be provided. The AMA urges patient experience information not be submitted, as the collection methods and data accuracy associated with patient experience lack uniformity and validity.

Under the ACA, the Secretary has the discretion to incorporate participation in an MOCP and successful completion of a qualified MOCP practice assessment into quality composite measures for purposes of the physician fee schedule payment modifier under section 3007 of the ACA. Considering incorporation of MOCP as part of the physician fee schedule payment modifier is premature. The Secretary should not adopt this approach until there is ample time to understand and act upon lessons learned with the PQRI MOC reporting option.

In addition to requiring Boards to either operate a qualified PQRI registry or to self-nominate to submit MOCP data to CMS on behalf of their members, CMS is also considering requiring the various Boards to submit data to ABMS and ABMS would then channel this information from the Boards to CMS. The AMA understands that the medical Boards and their representative organizations do not have the tools or resources to facilitate this type of data transfer. While this may be a temporary option for handling the data transfer from smaller Boards, it is an inefficient, piecemeal approach which places unnecessary data transfer burden and additional costs on the larger Boards that have not yet proven they can manage submission directly to CMS. The AMA remains concerned about the integrity of physician quality data, and it is critical that CMS not focus on data transfer for the sake of data transfer, but on adopting structured and understandable objectives for transferring and interpreting health care quality data.

Integration of PQRI and EHR reporting

Integration of PQRI and EHR reporting

Section 3002(d) of the ACA requires CMS to move toward integration of EHR measures with respect to the PQRI program. The AMA strongly supports efforts to streamline the clinical quality measures used in both the PQRI and EHR reporting programs. We encourage CMS to work with the PCPI to improve the development, and accelerate the testing, of clinically relevant measures for all Medicare physician specialties.

In order to align the two programs, clear program objectives must first be established. Currently, PQRI is a pay-for-reporting program and the CMS EHR Incentive Program is to demonstrate meaningful use of a certified EHR system. After the program objectives have been established and aligned, the measures and format for reporting the measures must then be aligned. The steps that the AMA recommends to achieve alignment of the PQRI and EHR Incentive program include:

•    Establish common program objectives;

•    Align the measures and establish a common format for reporting;

•    Once the "measures" and "reporting format" have been finalized and are aligned, the measures should be tested to see if they can be implemented in an EHR system; and

•    Upon completion of system testing, the measures should be piloted in an actual clinical environment. Pilots are very common in information technology. In fact, any technology implementation or rollout typically has a pilot test completed. Pilot testing provides real world results and feedback in a selected and controlled environment. Upon completion of pilot testing, an evaluation will need to be performed to determine that the results meet the original program objectives.

PQRI - Qualified registries

Qualified Registries

CMS proposes to post on the PQRI section of the CMS Web site a list of qualified registries for the 2011 PQRI, including the registry name, contact information, and the 2011 measure(s) and/or measures group(s) and e-prescribing reporting (if qualified) for which the registry is qualified and intends to report. At the February 2, 2010, PQRI Listening Session, the AMA and other attendees recommended that CMS post additional registry information including cost to participate; number of past or current participants; frequency of registry feedback reports; and success rate of participants. CMS did not reflect these comments in the proposed rule, and the AMA urges CMS to seriously consider these recommendations and include these additional topics of information to better assist physicians in selecting a registry most appropriate for their practice. In addition, the AMA recommends that PQRI participants have an opportunity to file complaints directly with CMS regarding particular registries.

As discussed in the proposed rule, CMS continues to be concerned that an individual physician or a small practice does not have either the resources or the capabilities to successfully submit quality measures results and numerator and denominator data on PQRI individual measures or measures groups through the registry data submission process. The AMA shares this concern, which is why we continue to have reservations about the requirement that physicians must meet all 15 core measures (including clinical quality measure reporting) and five additional measures from a defined menu in order to qualify for meaningful use (MU) program incentives.

The PCPI seeks to test its measures across a variety of Medicare incentive programs using different data sources, and has a long-established protocol to conduct such testing. Our difficulty has been identifying practice sites that participated in PQRI claims reporting for a complete year on specific measurement sets, and who have the capacity to participate in a testing project. It appears the qualified registries may have such information readily available and be in a position to collaborate with the PCPI on testing quality measures. The AMA welcomes an opportunity to discuss quality measures testing with CMS and the qualified registries.

Appeal process on PQRI - review of determination

Appeals Process

Sec. 3002 (f)(2) of ACA requires the Secretary to establish by not later than January 1, 2011, an informal appeals process so that physicians can seek review of the determination that the physician did not satisfactorily submit data on quality measures under the PQRI. CMS proposes to base the informal process on its current inquiry process whereby a physician can contact the Quality Net Help Desk (via phone or e-mail) for general PQRI and e-prescribing incentive program information, information on PQRI feedback report availability and access, and/or information on PQRI Portal password issues.

The AMA supports a PQRI appeals process, which is critical for re-evaluating the participation status of a physician who may have been incorrectly deemed not successful. We have strong concerns, however, with use of the current structure of the Quality Net Help Desk. Physicians have had many difficulties in accessing and obtaining reliable information from the Quality Net Help Desk. At times, they could not get through, or worse, the Help Desk representative was ill-equipped to answer their specific questions, which has led to frustration among physicians who are attempting to successfully participate in the PQRI. Therefore, the AMA urges that CMS significantly improve the Quality Net Help Desk by adding more telephone lines and hiring more trained and experienced, qualified staff. If the Quality Help Desk is not adequately resourced to handle the additional processes related to an informal PQRI appeals process, CMS’ efforts will not be viewed as sincere in trying to add a successful informal PQRI appeals process. We also urge that CMS post on its Web site the names of physicians who have been determined to be a successful participant upon appeal.

Ultrasonic Knee Injections CPT 76942

Ultrasonic Guidance for Knee Injections

Audits were recently performed by Highmark Medicare Services’ Medical Review Department for procedure code 76942, ultrasonic guidance for needle placement (e.g., biopsy, aspiration, injection, localization device), imaging supervision and interpretation.
In reviewing the medical records provided to support these services, it was determined that providers were using ultrasound guidance for knee joint injections. The documentation did not provide any information which would support the medical necessity for using ultrasound guidance for knee injections.

Medical necessity is defined as the need for an item(s) or service(s), to be reasonable and necessary for the diagnosis or treatment of disease, injury or defect. The need for the item or service must be clearly documented in the patient’s medical record. Medically necessary services or items are:

• Appropriate for the symptoms and diagnosis or treatment of the patient’s condition, illness, disease or injury; and
• Provided for the diagnosis or the direct care of the patient’s condition, illness, disease or injury; and
• In accordance with current standards of good medical practice; and
• Not primarily for the convenience of the patient or provider; and
• The most appropriate supply or level of service that can be safely provided to the patient.

The use of ultrasound guidance for knee joint injections may be considered medically reasonable and necessary by Highmark Medicare Services if the documentation supports one of the following:

• The failure of the initial attempt at the knee joint injection where the provider is unable to aspirate any fluid.
• The size of the patient’s knee(s), due to morbid obesity or disease process, inhibits the provider’s ability to inject the knee(s) without ultrasound guidance.
• The provider is planning to drain a popliteal (Baker’s) cyst.
Although there is data to support that ultrasound guidance improves the accuracy of knee joint injections and reduces procedural pain in some cases, the data does not support improved clinical outcomes to support the coverage of ultrasound guidance for all knee joint injections. In addition, package inserts for drugs used for knee joint injections do not indicate the necessity of the use of ultrasound guidance for safe and effective usage.

Therefore, unless there is documentation provided to support the medical necessity for the ultrasound guidance for knee joint injections, the ultrasound guidance may be denied as coverage and reimbursement of healthcare services provided to Medicare beneficiaries requires that services be medically necessary in order to be eligible for reimbursement.

Impact of revising the PE GPCI in accordance with proposed MEI revisions

The large number of changes in the GPCIs that are being proposed simultaneously make it difficult to sort out the impacts of specific elements of this proposed rule. The AMA is concerned, however, that the proposal to revise the PE GPCI in accordance with the proposed revisions to the MEI would lead to cuts in a number of localities in 2011, one year earlier than Congress had called for budget neutral changes to the PE GPCI in the ACA.

Many of the new categories that have been separated out in the MEI office expense category are being grouped with medical equipment, materials and supplies which are treated in the GPCI as having national prices rather than local prices. As a result, a major change that occurs in the translation of the MEI changes to the PE GPCI is that the portion of the PE GPCI that is the same everywhere in the country instead of varying by locality grows from 29% currently up to 42% in the proposed rule.

These changes in the MEI and GPCI components, their weights, and the proportion of national vs. local pricing in the GPCI heighten the 2011 impact of the ACA requirement that only one-half of the geographic differences in rent be recognized. Localities with a PE GPCI below 1.0 see payment increases in 2011 because only half the geographic differences in rent are recognized, and these localities see further increases because the weight assigned to rent is reduced. The ACA holds harmless localities with PE GPCIs above 1.0 because they would see payment cuts if only half the geographic differences in rent were recognized. Under CMS’ proposal, however, these localities, which are primarily large metropolitan areas, will face cuts in 2011 due to the reduced weight for physician office rent. These cuts appear to contradict Congress’ intent as shown in the hold-harmless provision that applies to the PE GPCI provisions of the ACA for 2010 and 2011.

GPCI update by CMS FOR 2011 & 2012

GPCI Update

CMS proposes a number of changes to the GPCIs, including those that are pursuant to the “Patient Protection and Affordable Care Act”(ACA), as well as other changes due to the use of more recent data, while still others would result from proposed revisions to the MEI:

•    The work GPCI floor of 1.0 would be extended only through 2010, as required by the ACA, and thus is not reflected in the proposed 2011 work GPCI.

•    The PE GPCI would reflect only one-half of the geographic differences in employee wages and office rents for each of 2010 and 2011, as required by the ACA, increasing payments in localities with a PE GPCI below 1.0. The ACA requires that each locality be held harmless so that the PE GPCI in localities with a PE GPCI above 1.0 are not reduced as a result of the change in the methodology for the PE GPCI.

•    A permanent, non-budget neutral floor of 1.0 for the PE GPCI will be implemented for five “frontier” states (MT, WY, ND, SD, and NV), as required by the ACA.

•    The ACA requires CMS to evaluate certain aspects of the PE GPCI and implement indicated revisions in a budget neutral manner no later than January 1, 2012. Specifically, CMS is required to analyze the office expense component of the GPCI, including the extent to which types of office expenses are determined in local markets instead of national markets, the weights assigned to each of the components of the PE GPCI, and the feasibility of using actual data, for example, physician office rent data, in place of proxies like apartment rental data. Instead of waiting until the proposed payment rule for 2012, CMS has completed this ACA-required review of the PE GPCI and proposes to implement the indicated changes in 2011.

•    As required under longstanding existing law, CMS proposes its every three-year GPCI update, including use of 2006 through 2008 Bureau of Labor Statistics (BLS) Occupational Employment Statistics data in place of the professional earnings data from the 2000 Census. Also as required by existing law, this will be phased in over two years, in 2011 and 2012.

•    As discussed above, CMS has also proposed a number of changes to the MEI which, if adopted, would significantly affect the GPCIs. CMS proposes to rebase the MEI to 2006 using data from the PPI survey, which decreases the weight for the work component of the physician payment schedule and increases the weights for the PE and liability insurance cost components. When these MEI changes are applied to the GPCIs, they apply less weight to the work GPCI and more weight to the PE and professional liability insurance (PLI) GPCIs in each locality.

•    CMS proposes to use BEA data to disaggregate the office expense component of the MEI by creating separate categories for utilities, chemical, paper, rubber and plastics, telephone, postage, “all other labor-related” expenses, fixed capital, and moveable capital. When these MEI changes are applied to the PE GPCI, it leads to different weights being assigned to different components of the PE GPCI.

PQRI reporting periods for FY 2011

Reporting Periods

AMA supports the agency’s proposal to retain 2010 PQRI reporting periods for FY 2011. CMS proposes to retain the claims-based reporting mechanism for 2011, but notes that the agency continues to consider significantly limiting the claims-based mechanism of reporting clinical quality measures in future program years. This limitation continues to be contingent upon there being an adequate number and variety of registries available and/or the continuation/expansion of the electronic health record (EHR) reporting option. Potentially, CMS would continue to retain claims-based reporting in years after 2011 principally for the reporting of structural measures and in circumstances where claims-based reporting is the only available mechanism for certain categories of physicians to report PQRI quality measures. The AMA encourages CMS to be cautious in how it determines to phase-out the claims-based reporting option until it is abundantly clear that all physicians understand and are able to consistently and accurately capture quality measures using EHRs or registries.

CMS must also consider whether the eventual elimination of claims-based reporting would unnecessarily penalize physicians who do not own an EHR or participate in a registry because of extenuating circumstances, e.g., small, rural providers lacking digital connection. The availability of a claims-based reporting option enables most physicians to participate in the PQRI without incurring significant technology. Transitioning away from claims-based reporting too quickly, without consideration of the small or rural provider, could inappropriately burden physicians who are making a good faith effort to report measures for quality improvement.

Regardless of the reporting mechanism, CMS should provide developers of measures utilized in the PQRI with support to carry out validity and reliability testing of measures. The AMA Physician Consortium for Performance Improvement (PCPI) has significant experience in testing quality measures in various platforms and would be a valuable resource as CMS continues to evaluate all reporting options for the PQRI.

Medicare Economic Index - what is this

Medicare Economic Index

CMS proposes to convene a technical panel later this year to review all aspects of the MEI, including the inputs, input weights, price measurement proxies, and productivity adjustment. The panel’s analysis and recommendations will be considered in future rulemaking. The AMA has long requested that CMS address the problem that the “market basket” of inputs whose prices are measured in the MEI is outdated and, despite periodic rebasing, has not been comprehensively revised since it was originally developed in 1973.

Accordingly, the AMA welcomes the proposal for a technical panel to review all aspects of the MEI. At the same time, we are puzzled by the CMS proposal to reconfigure the office expense element of the MEI before the panel has even begun its work. Instead, we urge CMS to withdraw its proposal to rebase and revise the MEI in 2011 and develop a new MEI proposal after the panel conducts a comprehensive review.

CMS proposes to separate out and price nine new MEI components, including chemicals, paper, rubber and plastics. Although it references data on these components derived from the Bureau of Economic Analysis (BEA), no rationale has been provided for separately pricing these components. The AMA has long argued that the factors (or inputs) involved in 21st century medical practice are vastly different than when the MEI was first developed, and additional inputs are needed to ensure that the current MEI adequately measures the costs of practicing medicine. Today’s physicians must comply with an array of government-imposed regulatory requirements that did not exist in 1973, including those relating to: Medicare prescription drug plans and formulary compliance; compliance with rules governing referrals and interactions with other providers; detailed coverage policies including requirements for particular tests to be completed at specific intervals; advanced beneficiary notices; certificates of medical necessity; rules governing Medicare and Medicaid dual eligible patients; limited English proficiency rules; Medicare audits; the Health Insurance Portability and Accountability Act, Clinical Laboratory Improvement Act, Americans with Disabilities Act, and Emergency Medical Treatment and Labor Act; billing errors; quality monitoring and improvement; and patient safety. CMS is also promoting the use of electronic medical records and other new health information technology systems that facilitate physician participation in quality improvement initiatives.

To ensure compliance with these requirements, physicians often must take actions that increase their practice costs, including hiring additional office staff, attorneys for legal and regulatory compliance, as well as accountants and billing companies to ensure proper billing of claims to handle these additional responsibilities. These types of inputs are not currently taken into account for purposes of measuring the MEI, and therefore the MEI undervalues actual medical cost increases. Data from the Bureau of Labor Statistics show an increase of more than 18% in the number of people employed in physician offices since 2001. The MEI does not account for this increase.

Data published by the Medical Group Management Association (MGMA) in 2003 indicated that, between 1992 and 2002, the number of staff per full time equivalent physician increased by 18.8%.
CMS recently incorporated findings from the new Physician Practice Information (PPI) survey into the Practice Expense (PE) relative values; before that it relied on data from the AMA Socioeconomic Monitoring System (SMS). With the time gap between the two surveys, the PPI and SMS surveys may not be directly comparable, but a comparison of the two indicates that medical practice costs increased 79% from 2000-2006. Looking at the SMS alone, the SMS indicated a 35% increase from 1994-2000. The MEI, however, only increased 18% from 2000-2006. As shown below, MGMA data also show higher growth than the MEI.

Clearly, every other available measure of physician expense growth shows faster growth than the MEI. In addition to providing no rationale for the revisions it proposes in the MEI inputs, such as rubber and plastics, these revisions do not do anything to improve the adequacy of the MEI. In the proposed rule, CMS estimates the 2011 MEI at just 0.3%, and the addition of the new components that CMS has proposed based on BEA data do nothing to increase it. With the MEI shrinking to nothing while their costs continue to rise, today’s physicians can detect no resemblance between the MEI and the costs they face every day in practice.

In addition to the new office expense inputs, CMS proposes to re-weight the work, PE and liability expense components of the MEI to match the data from the PPI survey. It further proposes to increase the PE and liability expense RVUs and decrease the conversion factor so that the relative value scale will match the new MEI weights. Finally, as discussed below, CMS proposes a number of changes to the GPCIs in order to make the GPCIs match the new weights in the MEI and to make the inputs in the PE GPCI match the revised office expense inputs in the MEI.
We urge CMS to delay all of these proposed changes until CMS has had an opportunity to convene the technical panel and thoroughly review the needed changes in the MEI.

Implementation of changes to the MEI, the RVUs, the conversion factor and the GPCIs in 2011 would play havoc with 2011 payments for many physician specialties and localities based on proposed MEI changes that may change again, perhaps substantially, after the technical review panel is convened. At a time when physicians are already facing enormous pay cuts due to the Sustainable Growth Rate (SGR) formula, it does not make sense to move forward with proposed changes until CMS has a complete MEI proposal.

physician payment schedule for 2011

Proposed 2011 Physician Payment Schedule

On August 24, 2010 the AMA submitted a comment letter to the Centers for Medicare and Medicaid Services’ (CMS) regarding the proposed physician fee schedule rule for CY 2011. The AMA's principal recommendations are as follows:

•    The AMA strongly supports the proposed comprehensive review of the Medicare Economic Index (MEI). The MEI needs to reflect the realities of medical practice in the 21st century and the AMA welcomes the proposed review. Until this review of the MEI is completed, CMS should withdraw the changes it has proposed to the MEI for CY 2011, as well as the revisions to the relative value units (RVUs) and geographic practice cost indexes (GPCIs) that arise from the proposed changes to the MEI.
•    CMS should revise the Physician Quality Reporting Initiative (PQRI) feedback report proposal to ensure that this process improves successful participation in the PQRI program.
•    To implement a successful informal PQRI appeals process, CMS should significantly improve the Quality Net Help Desk by adding more telephone lines and hiring more trained and experienced, qualified staff.
•    The AMA applauds CMS’ decision to change the definition of group practice from 200 to 2, as it will allow more physician practices to participate in the group practice reporting option (GPRO) for 2011.
•    CMS must publish detailed specifications for individual measures and measures groups for the PQRI November 15, 2010.

•    The AMA applauds CMS’ decision to reduce the PQRI reporting sample requirement from 80 percent to 50 percent for FY 2011. The AMA urges CMS to also use its existing authority to apply the new 50 percent threshold retrospectively to the 2010 reporting year.

•    The AMA supports enhancing the measures and methods used in the resource use Physician Resource Use Measurement and Reporting Program (RUR). Under this program, CMS must adequately prepare for handling additional feedback report requests and distribution techniques, and until adequate risk adjustment and attribution models are widely tested and applicable, these reports should not be publicly reportable.

•    We strongly support CMS’ proposed requirements for the 2011 electronic prescribing (e-prescribing) incentive payment program, which is to require reporting on only 25 services involving electronic prescriptions.

•    We strongly oppose CMS’ proposal to impose financial penalties in 2012 and 2013 against physicians based on their e-prescribing activity during the first six months of 2011. Instead, we strongly urge CMS to review 2012 and 2013 e-prescribing activity (not 2011 e-prescribing activity) in order to assess penalties in 2012 and 2013.

•    We strongly recommend that CMS add more exception categories so that more physicians facing hardship will be eligible for an exemption from e-prescribing penalties in 2012 and 2013.

•    We also recommend that CMS provide feedback reports to physicians and establish an appeals process to allow physicians to appeal decisions that affect their eligibility to take part in the e-prescribing program or that affect their ability to get e-prescribing incentives.

•    CMS should take appropriate measures to ensure the accuracy of the list of successful e-prescribers and to provide the appropriate disclaimers for the website listing.

•    The AMA strongly supports better coverage for preventive care. CMS should work through the established Current Procedural Terminology (CPT) Editorial Panel and the Relative Value System Update Committee (RUC) process to adopt existing CPT codes for the annual preventive visits rather than establishing separate Healthcare Common Procedure Coding System (HCPCS) G-Codes for these services.

•    CMS should expand the availability of the primary care incentive payments by interpreting “allowed charges” as charges under the physician fee schedule, and not as all Part B charges.
•    CMS should ensure that the general surgery bonus payments promote access to these important services for patients by modifying the Health Professional Shortage Area (HPSA) criteria to allow a non-HPSA hospital to be part of a HPSA if: (i) the hospital is adjacent to a HPSA; (ii) the patient resides in a HPSA; or (iii) the general surgeon maintains an office in a HPSA.

•    CMS should seek input from the RUC and its Health Care Professionals Advisory Committee on the efficiencies or reduced resources involved in services provided to the same patient in the same session or on the same day rather than implementing arbitrary multiple procedural payment reductions for imaging and therapy services.

•    The ACA contained a number of provisions that apply retroactively, which requires CMS to re-process claims for various physicians’ services. CMS should issue guidance to its contractors about reprocessing these claims in a manner that minimizes the burden on physicians and avoids further confusion and payment delays. CMS should also make this guidance publicly available so that physician organizations can disseminate it to our members.

More detailed analysis of the AMA's recommendations on specific issues can be found below and in the comment letter to CMS.

Medicare qualifier list code and definition

Qualifier List

0B - State License Number
1A - Blue Cross Provider Number
1B - Blue Shield Provider Number
1C - Medicare Provider Number
1D - Medicaid Provider Number
1G - Provider UPIN Number
1H - Campus Identification Number
1J - Facility ID Number
B3 - Preferred Provider Organization Number BQ - Health Maintenance Organization Code Number EI - Employer's Identification Number FH - Clinic Number
G2 - Provider Commercial Number
G5 - Provider Site Number
LU - Location Number
SY - Social Security Number
U3 - Unique Supplier Identification Number
X5 - State Industrial Accident Provider Number

This information is typed into the PINS field (under Insurance).

Origin/Destination modifiers for Medicare

Modifier Listing for Medicare Part B

Origin/Destination modifiers

D Diagnostic or therapeutic site
E Residential, custodial facility
G Hospital-based dialysis facility
H Hospital
I Site of transfer between modes of ambulance transfer
J Non-hospital based dialysis facility
N Skilled nursing facility
P Physician’s office
R Residence
S Scene of accident or acute event
X Intermediate stop at physician’s office on the way to the hospital

what is Medicare - Part A , part B - basics

Federal Benefit Program: Medicare

Description:

Medicare is a health insurance program for people 65 years of age or older, some disabled people under 65 years, and people with End-Stage Renal Disease (permanent kidney failure treated with dialysis or a transplant). Medicare coverage is comprised of two parts: Hospital Insurance (Part A) and Medical Insurance (Part B).

Eligibility Criteria:

You must be 65 years of age or older and a citizen or permanent resident of the United States. You might also qualify for coverage if you are a younger person with a disability or with End-Stage Renal disease (permanent kidney failure requiring dialysis or transplant) or Lou Gehrig's Disease.

Hospital Insurance (Part A):

You can get Part A at age 65 without having to pay premiums if:
•  You are already receiving retirement benefits from Social Security or the Railroad Retirement Board.
•  You are eligible to receive Social Security or Railroad benefits but have not yet filed for them.
•  You or your spouse had Medicare-covered government employment.

Medical Insurance (Part B):

If you are under 65, you can get Part B without having to pay premiums if:
•  You have received Social Security or Railroad Retirement Board disability benefit for 24 months.
•  You are a kidney dialysis or kidney transplant patient.

What Does a Medicare Advantage Plan Cover?

Medicare Advantage Plan - Understanding Medicare Part C

Medicare HMO and PPO Coverage and Options

A Medicare Advantage Plan is offered by private health insurance companies that are approved by Medicare and have a contract to provide you with Medicare benefits.

What Does a Medicare Advantage Plan Cover?

If you join a Medicare Advantage Plan, the plan must provide all of your Part A (Hospital Insurance) and Part B (Medical Insurance) benefits, including emergency and urgent care. The only major benefit not covered by these plans is hospice care – this benefit is covered by Original Medicare even if you choose a Medicare Advantage Plan.

Many Medicare Advantage Plans offer extra coverage, such as vision, hearing, dental, and general checkups and other health and wellness programs. Most advantage plans include Medicare prescription drug coverage (Medicare Part D).

Most Medicare Advantage Plans are managed care plans, usually a health maintenance organization (HMO) or a preferred provider organization (PPO). These plans may require that you choose a primary care physician (PCP), get a referral from your PCP to see a specialist, and use only doctors, hospitals, and other medical facilities and services that are part of that health plan’s provider network.

Some private health insurance companies offer a Medicare Advantage Plan known as a Private Fee-for-Service (PFFS) Plan that may allow you to see any doctor or use any Medicare-approved hospital. However, unlike Original Medicare, you may have a copayment for doctor visits and not all providers may be willing to treat you. However, in a PFFS Plan you do not have to choose a PCP and you do not need a referral to see a specialist.