ADVANCED BENEFICIARY NOTIFICATION and related modifier

ADVANCED BENEFICIARY NOTIFICATION

Medicare screening services are limited to a specific frequency (e.g., once every 2 years, once every year). A physician may not know whether a patient is eligible for this service in a given year. If she is not eligible, the service will be denied. Therefore, the physician should ask the patient to sign an advance beneficiary notice of noncoverage (ABN) using the form provided by Medicare.

Claims for Medicare patients should be submitted with the appropriate HCPCS modifier.

• GA modifier indicates that an ABN form has been signed.
• GZ modifier indicates that an ABN form has not been signed. (Item or service expected to be denied as not reasonable and necessary)
• GY modifier indicates that the service provided is not a covered Medicare benefit. The service is being reported to Medicare in order to receive a denial.

Using the appropriate modifier ensures that the patient will receive the correct information on her Explanation of Benefits (EOB). For example, when a service is reported with a GY modifier, the EOB will state that it is not covered and therefore is the patient’s responsibility.

Neoplasm Diagnosis Codes 237.71, 237.72 & v85.41 - v85.45 , 787.60, 787.63

New Neoplasm Diagnosis Codes

The American Medical Association (AMA) added two new diagnosis codes to document neurofibromatosis (NF), a genetic disorder that causes tumors to grow primarily on nerve tissues, as well as, on bone and skin. There are now three specific types of neurofibromatosis:

1.  von Recklinghausen’s Disease (237.71) – The most common type of NF
2.  Acoustic (237.72) - Patients lose hearing
3. *New Schwannomatosis (237.73) - Patients have multiple Schwannoma-type tumors on the cranial, spinal and peripheral nerves, but do not lose hearing

Note: If the patient is diagnosed with NF, but it is not specific to these three types, use 237.79, Other Neurofibromatosis.

Body Mass Index

The diagnosis codes for reporting Body Mass Index (BMI) have been expanded, and code V85.4, body mass index 40.0 and over, was deleted.

Providers now have the ability to document a BMI that is greater than 40.0. The new
BMI codes include the following:
•    V85.41 – Body Mass Index 40.0-44.9, adult
•    V85.42 – Body Mass Index 45.0-49.9, adult
•    V85.43 – Body Mass Index 50.0-59.9, adult
•    V85.44 – Body Mass Index 60.0-69.9, adult
•    V85.45 – Body Mass Index 70 and over, adult

Aortic Ectasia

Four new diagnosis codes were created to describe aortic ectasia (the swelling and weakening
of the wall of the aorta). Providers must select the appropriate diagnosis code based on where the swelling or weakening of the aortic wall has occurred: unspecified (447.70), thoracic (447.71), abdominal (447.72), or thoracoabdominal (447.73).

Previously, the only diagnosis providers had to document these conditions was code 441.9, aortic aneurysm, unspecified. Unfortunately, these conditions are not really aneurysms, but conditions that may lead to an aneurysm over time. As of October 1, code 441.9 should only be used for documented aneurysms, not potential aneurysms.

Digestive System

A new diagnosis code, 560.32, Fecal Impaction, was created to document patients that require manual or surgical intervention due to fecal impaction. Previously, this condition would have been reported as 560.39, other impaction of intestine.
Code 787.6, incontinent feces, was deleted for this year, and replaced with the following four diagnosis codes:

•    787.60 – Full incontinence of feces
•    787.61 – Incomplete defecation
•    787.62 – Fecal smearing
•    787.63 – Fecal urgency

Transfusions DX code 999.60, 999.70 , 999.85 & 780.66

New Diagnosis Codes Related to Transfusions

Hemolytic Transfusion Reaction (999.60-999.6, 999.70-999.80, and 999.83-999.85) 
This year, the diagnoses related to a hemolytic transfusion reaction (due to either ABO/non-ABO or Rh/non-Rh Incompatibility) have been expanded. Hemolytic Transfusion Reactions (HTRs) are defined based on the timing of the reaction. Patients can suffer from a(n):  
         
1.    Acute Hemolytic Transfusion Reaction (AHTR) – Occurs within 24 hours of a transfusion

2.    Delayed Hemolytic Transfusion Reaction (DHTR) – Occurs between 24 hours and 28 days of a transfusion 

These conditions were previously reported as 999.6, ABO incompatibility reaction, or as 999.7, Rh incompatibility reaction. Codes 999.6 and 999.7 will no longer be valid as of October 1, 2010.
Hemochromatosis (275.01 thru 275.09)
Hemochromatosis is an iron metabolic disorder, and the new codes establish why the iron is not metabolizing. Hemochromatosis may be hereditary, due to a repeated red blood cell transfusion, or caused by other iron metabolic disorders. These conditions were previously reported as 275.0, disorders of iron metabolism. Code 275.0 has been deleted.

Other Transfusion-Related Diagnoses (Fluid Overload and Secondary Thrombocytopenia)
Code 276.6, fluid overload, has been deleted this year. Providers must now distinguish between fluid overload caused by a transfusion of blood or blood components, and a fluid overload caused by other reasons. The new diagnosis codes are as follows:

•    276.61, Transfusion Associated Circulatory Disorder (TACO) - Occurs during or within 6 hours of a transfusion
•    276.69, Other fluid overload 

Code 287.4, secondary thrombocytopenia, has been deleted this year. Posttransfusion purpura (PTP), a condition characterized by a sudden severe thrombocytopenia (platelet count < 10,000), can occur 5 to 12 days after a transfusion. For secondary thrombocytopenia that develops as a result of a transfusion, report code 287.41, posttransfusion purpura. For secondary thrombocytopenia that develops for reasons other than a transfusion, report code 287.49, other secondary thrombocytopenia.

Nonhemolytic Transfusion Reaction

Patients can develop a post transfusion fever when passively transfused cytokines react with recipient antibodies and transfused leukocytes. In this situation, there is no destruction of red blood cells, but the patient experiences fever and chills within 4 hours of the transfusion. To report this condition, use code 780.66, febrile nonhemolytic transfusion reaction (FNHTR).

Updating Superbills every year - success for Good Medical billing company

Updating Superbills for the New Year

Coding Corner - Updating Superbills for the New Year - Some of these code not active in 2011

Summer is ending and fall is just around the corner. Kids are going back to school, football season has begun, and for coders, it is the time of year when the first set of major encounter form revisions takes place. Form updates and revisions are an important part in maintaining the accuracy and correct coding of claims. The more up-to-date and relevant your encounter forms are, the less risk you will have for denials and decreased reimbursement.

Those tasked with the responsibility of revising or creating new encounter forms must review any code changes to see if they affect their practice. In addition, employees must navigate major holiday and vacation schedules by physicians and staff in order to generate viable encounter forms by the October and January implementation dates.
In short, life is busy and there is much to do over the next three months to prepare for the new year.

Code Changes

This year’s diagnosis changes include 122 new, 11 deleted and 10 revised codes (Continue reading below for more information on diagnosis code updates). In addition, several new immunizations became active as of July 1, 2010. The new immunizations include:

•    90664 – Influenza Virus Vaccine, pandemic formulation, live, intransal
•    90666 – Influenza Virus Vaccine, pandemic formulation, split virus, preservative free,                  intramuscular
•    90667 – Influenza Virus Vaccine, pandemic formulation, split virus, adjuvanted,                        intramuscular
•    90668 – Influenza Virus Vaccine, pandemic formulation, split virus, intramuscular- Check current Medicare policy

Note: CPT® 90654 (Influenza Virus Vaccine, split virus, preservative free, intradermal use) is also a new code, but its implementation date is not until January 1, 2011.

Flu and Pneumonia Shot Clinics

During the fall, it is very common for medical practices to hold a flu clinic for their patients. If you have many patients that schedule a visit for flu or pneumonia shots alone, it might be valuable to create an encounter form just for flu and pneumonia shots. Often, a flu shot form can be created in a relatively short amount of time and at a lower cost than standard encounter forms.

superbill entering - Paper and Electronic Encounter Forms

Charge capture: Paper and Electronic Encounter Forms

Physicians and Non-Physician Practitioners (NPPs) may want to distance themselves from coding, but implementing an Electronic Health Record (EHR) moves them in the opposite direction. If using an EHR, after completing the note, the clinician selects the CPT® and ICD-9 codes (the procedure and diagnosis codes) that describe the service performed. These electronic charging systems have benefits and drawbacks, similar to and different from paper encounter forms.

Keep reading to learn about the benefits and pitfalls of both charging systems, and how to improve them. Why take the time out of your insanely busy week to do this?
Because physician code selection is as accurate as the tool used to select the code: no more, no less.

Let's start with electronic charging.

Beware of abbreviations and shortened descriptions

A cardiologist looked at this description in the drop down box of his EHR.  "EP Consult".  The cardiologist read: Electro Physiology Consult.  The programmer meant, "Established Patient Consult."  Do you see the problem with this?  The abbreviation was open to interpretation, and isn't a standard CPT® abbreviation.  And, consults are not defined as new or established visits, further confusing the matter.  It's true: there is only so much space in the drop down charge entry box.  But, shortened descriptions and abbreviations are an invitation to inaccurate code selection.

How about searching for CPT® or ICD-9 codes?

Searching an electronic data base is not always easy or productive.  One group using a diagnosis code look up integrated into their EHR made a major error.  The search term:  confusion.  An elderly patient presented to the hospital, and one of the patient's symptoms was confusion.  The search engine returned the ICD-9 code for psychosis.  A more accurate code would be altered mental status. This incorrect code--psychosis--was submitted on hundreds of claims.  A psychiatric diagnosis was reported in place of a medical symptom.  Hope it wasn't my mother's claim.

Can't find the procedure code?

What did a physician or NPP do the past when the code wasn't on the encounter form?  Write a brief description, and leave it for the coder.  What does a clinician using an EHR charging system do?  Too often the answer is bill for an E/M service only, and move on, leaving the service unbilled.  It is critical to have a process that allows the physician to send the record to the coder in this situation.

The case of the missing CPT® book

A huge pitfall of electronic charging is that the office doesn't buy enough (or any!) CPT® books.  Recently, I was at an office and asked for a CPT® book.  They brought me a 2007 CPT® book and a 2005 ICD-9 book.  Really, those were the most recent editions.

The editorial comments in the CPT® book are critical to correct and accurate coding.  Be sure to read them.  The AMA isn't paying me to say this: buy new books (for CPT®, buy the AMA's Professional Edition) and don't leave them in their plastic wrappers!

Paper?

And, oh the joys of the paper encounter form!  Yes, we know there are deleted codes on the form, but we have 10,000 of them in the basement, and they are expensive and our doctor wants us to use them up!  Burn them!  Update your paper encounter form every year.

While you're at it, take out all of the shortened descriptions and abbreviations for minor surgical procedures.  This is the biggest source of errors I find in primary care practices: wrong CPT® codes for minor procedures, linked directly to wrong, incomplete and confusing descriptions of minor procedures, medications, and ancillary services.  Develop a separate charge slip for these, that lists all of the procedures and services your clinicians perform with their full descriptions.
Remind the MDs and NPPs in your office that they are paid based on CPT® codes, and not on the number of diagnosis codes they circle.  Eight diagnosis codes do not increase the payment for the service.  It does give the charge entry person heartburn: which of these eight should I list (I can only enter four) and which should be first?  Ask the clinician to number the  most relevant diagnosis codes.  Only four.

Our goal: coding accuracy. One step to achieve it is accurate charging documents, whether on paper or on line.

Physician code selection is as accurate as the tool used to select the code.

The code is as accurate as the tool: no more, no less.

Nursing home discharge service CPT 99315, 99316

Nursing home discharge services

Either a physician or an NPP may bill for discharge services from a skilled nursing facility or a nursing facility.  There are two discharge day management codes from a nursing facility.  99315 is for discharge day management 30 minutes or less, and 99316 is for discharge day management over 30 minutes.  Include in the time all of the services provided in the discharge:  meeting with the patient and family, examining the patient, discharge paperwork, and instructions to caregivers.
There are no specific history, exam or medical decision making requirements for this service.

Bill for the service on the date that the physician or NPP has a face-to-face service with the patient, even if that is not the day the patient goes home.  For example, if the physician sees the patient on Friday, June 1, and arranges for the patient to be discharged on Saturday, and the physician does not see the patient on Saturday, bill for the discharge on June 1, the day the patient was seen.

The physician may only bill for death pronouncement if he/she saw the patient on that day.  There is no billing for completing the paperwork, talking to the family and doing a discharge summary if the physician did not go to the nursing facility to see the patient.

Here is what the Medicare Claims Processing Manual says:

I  SNF/NF Discharge Day Management Service

Medicare Part B payment policy requires a face-to-face visit with the patient provided by
the physician or the qualified NPP to meet the SNF/NF discharge day management
service as defined by the CPT® code.  The E/M discharge day management visit shall be
reported for the date of the actual visit by the physician or qualified NPP even if the
patient is discharged from the facility on a different calendar date. The CPT® codes 99315
– 99316 shall be reported for this visit.  The Discharge Day Management Service may be
reported using CPT® code 99315 or 99316, depending on the code requirement, for a
patient who has expired, but only if the physician or qualified NPP personally performed
the death pronouncement.

Medicare yearly conversion factor - 1992 - 2010

The Medicare conversion factor

The Medicare conversion factor is a scaling factor that converts the geographically adjusted number of relative value units (RVUs) for each service in the Medicare physician payment schedule into a dollar payment amount. The initial Medicare conversion factor was set at $31.001 in 1992. Subsequent conversion factor updates have been based on three factors:

•    The Medicare economic index
•    An expenditure target “performance adjustment”
•    Miscellaneous adjustments including those for “budget neutrality”



History of Medicare Conversion Factors

 

Year	Conversion Factor	% Change	Primary Care Conversion Factor	% Change	Surgical Care Conversion Factor	% Change	Other Nonsurgical Conversion Factor	% Change
1992	$31.0010		N/A		N/A		N/A
1993	N/A				$31.9620		$31.2490
1994	N/A		$33.7180		$35.1580	10.0	$32.9050	5.3
1995	N/A		$36.3820	7.9	$39.4470	12.2	$34.6160	5.2
1996	N/A		$35.4173	-2.7	$40.7986	3.4	$34.6293	0.0
1997	N/A		$35.7671	1.0	$40.9603	0.4	$33.8454	-2.3
1998	$36.6873
1999	$34.7315	-5.3
2000	$36.6137	5.4
2001	$38.2581	4.5
2002	$36.1992	-5.4
2003	$36.7856	1.6
2004	$37.3374	1.5
2005	$37.8975	1.5
2006	$37.8975	0.0
2007	$37.8975	0.0
2008	$38.0870	0.5
2009	$36.0666	-5.3
2010	$36.0791*	0.0

Initially, the Medicare Physician Payment Schedule included distinct conversion factors for various categories of services. In 1998, a single conversion factor was offset by elimination of the work adjustor and increases in the practice expense and PLI RVUs. The reduction in the 2009 conversion factor was offset by elimination of the work adjustor from the third Five-Year
Review.

Medicare payment calculation formula

The formula for calculating the payment schedule

The Omnibus Budget Reconciliation Act of 1989 (OBRA 89) geographic adjustment provision requires all three components of the relative value for a service—physician work relative value units (RVUs), practice expense RVUs, and professional liability insurance (PLI) RVUs—to be adjusted by the corresponding GPCI for the locality. In effect, this provision increases the number of components in the payment schedule from three to the following six:

Physician work RVUs
Physician work GPCI
Practice expense RVUs
Practice expense GPCI
PLI RVUs
PLI GPCI

The formula for calculating payment schedule amounts entails adjusting RVUs, which correspond to services, by the GPCIs, which correspond to payment localities.

The general formula for calculating Medicare payment amounts for 2010 is expressed as:
     Work RVU1 x Work (GPCI)2   
+    Practice Expense (PE) RVU x PE GPCI   
+    Malpractice (PLI) RVU x PLI GPCI   
________________________________________   
     = Total RVU   
x    CY 2010 Conversion Factor of $36.0791   
________________________________________   
     = Medicare Payment   

1 The 2010 physician work, practice expenses, and malpractice RVUs may be found in Medicare RBRVS: The Physicians’ Guide.

2 The Geographic Practice Cost Index (GPCIs) for calendar year (CY) 2010 may also be found in Medicare RBRVS: The Physicians’ Guide.

Three factorys for Medicare physician payment schdule

The Medicare Physician Payment Schedule

The Medicare payment schedule's impact on a physician's Medicare payments is primarily a function of three key factors:

The resource-based relative value scale (RBRVS)
The geographic practice cost indexes (GPCIs)

The monetary conversion factor

The enabling legislation and regulations, as well as Medicare carrier correspondence and forms, refer to the Medicare physician payment schedule as a “fee schedule.” From the AMA’s perspective, the distinction between a payment schedule and a fee schedule is extremely important: a fee is what physicians establish as the fair price for the services they provide; a payment is what Medicare approves as the reimbursement level for the service. All references to the “full Medicare payment schedule” include the 80 percent that Medicare pays and the 20 percent patient coinsurance. Likewise, transition “approved amounts” also include the patient coinsurance.

Medicare will cover physical exam code - G0438, G0439

Effective 2011, Medicare would cover for physical examinations and below are the two new codes. Please have this updated in the respective software and fee schedule.

New CPT codes to report Annual Wellness Visit (only for Medicare)

G0438 - Annual wellness visit, includes a personalized prevention plan of service (PPPS), first visit, (Short descriptor – Annual wellness first)

G0439 - Annual wellness visit, includes a personalized prevention plan of service (PPPS), subsequent visit, (Short descriptor – Annual wellness subseq)

Splints & Casts cpt code payment - Q4004,Q4005, Q4048,Q4049

Splints & Casts Payment limit

Code	Payment Limit
Q4004	$110.92
Q4005	$11.81
Q4006	$26.62
Q4007	$5.92
Q4008	$13.31
Q4009	$7.89
Q4010	$17.75
Q4011	$3.94
Q4012	$8.88
Q4013	$14.36
Q4014	$24.21
Q4015	$7.18
Q4016	$12.10
Q4017	$8.30
Q4018	$13.23
Q4019	$4.16
Q4020	$6.62
Q4021	$6.14
Q4022	$11.08
Q4023	$3.09
Q4024	$5.54
Q4025	$34.44
Q4026	$107.54
Q4027	$17.23
Q4028	$53.78
Q4029	$26.34
Q4030	$69.33
Q4031	$13.17
Q4032	$34.66
Q4033	$24.57
Q4034	$61.10
Q4035	$12.28
Q4036	$30.56
Q4037	$14.99
Q4038	$37.55
Q4039	$7.51
Q4040	$18.76
Q4041	$18.22
Q4042	$31.11
Q4043	$9.12
Q4044	$15.56
Q4045	$10.58
Q4046	$17.02
Q4047	$5.28
Q4048	$8.51
Q4049	$1.93

Cardiovascular System added CPT AND deleted CPT - 33620, 33621, 33622,37227

Cardiovascular System – 20 New & 23 Deleted

New CPT codes
 
33620 - APPLICATION RIGHT & LEFT PULMONARY ARTERY BANDS
33621 - TTHRC CATHETER INSERT FOR STENT PLACEMENT
33622 - RECONSTRUCTION COMPLEX CARDIAC ANOMALY
37220 - REVASCULARIZATION ILIAC ARTERY ANGIOP 1ST VSL
37221 - REVSC OPN/PRQ ILIAC ART W/STNT PLMT & ANGIOP UNI
37222 - REVASCULARIZATION ILIAC ART ANGIOP EA IPSI VSL
37223 - REVSC OPN/PRQ ILIAC ART W/STNT & ANGIOP IPSI VSL
37224 - REVSC OPN/PRG FEM/POP W/ANGIOPLASTY UNI
37225 - REVSC OPN/PRQ FEM/POP W/ATHRC/ANGIOP SM VSL
37226 - REVSC OPN/PRQ FEM/POP W/STNT/ANGIOP SM VSL
37227 - REVSC OPN/PRQ FEM/POP W/STNT/ATHRC/ANGIOP SM VSL
37228 - REVSC OPN/PRQ TIB/PERO W/ANGIOPLASTY UNI
37229 - REVSC OPN/PRQ TIB/PERO W/ATHRC/ANGIOP SM VSL
37230 - REVSC OPN/PRQ TIB/PERO W/STNT/ANGIOP SM VSL
37231 - REVSC OPN/PRQ TIB/PERO W/STNT/ATHR/ANGIOP SM VSL
37232 - REVSC OPN/PRQ TIB/PERO W/ANGIOPLASTY UNI EA VSL
37233 - REVSC OPN/PRQ TIB/PERO W/ATHRC/ANGIOP UNI EA VSL
37234 - REVSC OPN/PRQ TIB/PERO W/STNT/ANGIOP UNI EA VSL
37235 - REVSC OPN/PRQ TIB/PERO W/STNT/ATHR/ANGIOP EA VSL
38900 - INTRAOP SENTINEL LYMPH ID W/DYE NJX

Deleted Codes
35454 – 35474 Transluminal balloon angioplasty
35480 - 35495 Transluminal peripheral atherectomy
39520 - 39531 Repair, diaphragmatic hernia

Debridement cpt code - 11045, 11046, 11047 - Musculoskeletal 22551,22552 ADDED cpt code

New CPT codes (Add-on Codes)

11045 - Debridement Subcutaneous Tissue, each additional 20 sq cm
11046 - Debridement Muscle/Fascia, each additional 20 sq cm
11047 - Debridement Bone, each additional 20 sq cm

Deleted codes

11040 & 11041 Debridement; skin; partial & full thickness

Musculoskeletal System – 5 New Codes

22551 - ARTHRD ANT INTERBODY DECOMPRESS CERVICAL BELW C2
22552 - ARTHRD ANT INTERDY CERVCL BELW C2 EA ADDL NTRSPC
29914 - ARTHROSCOPY HIP W/FEMOROPLASTY
29915 - ARTHROSCOPY HIP W/ACETABULOPLASTY
29916 - ARTHROSCOPY HIP W/LABRAL REPAIR

Respiratory System – 4 New Codes

31295 - NSL/SINUS NDSC SURG W/DILAT MAXILLARY SINUS
31296 - NSL/SINUS NDSC SURG W/DILAT FRONTAL SINUS
31297 - NSL/SINUS NDSC SURG W/DILAT SPHENOID SINUS
31634 - BRONCHOSCOPY BALLOON OCCLUSION

CPT code 99224, 99225, 99226 - Newly added CPT

New Added Codes for 2011

Evaluation and Management – 3 New Codes

99224 - Subsequent observation care, per day, for the evaluation and management of a patient, which requires at least 2 of these 3 key components: Problem focused interval history; Problem focused examination; Medical decision making that is straightforward or of low complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the patient is stable, recovering, or improving. Physicians typically spend 15 minutes at the bedside and on the patient’s hospital floor or unit.

99225 - Subsequent observation care, per day, for the evaluation and management of a patient, which requires at least 2 of these 3 key components: An expanded problem focused interval history; An expanded problem focused examination; Medical decision making of moderate complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the patient is responding inadequately to therapy or has developed a minor complication. Physicians typically spend 25 minutes at the bedside and on the patient’s hospital floor or unit

99226 - Subsequent observation care, per day, for the evaluation and management of a patient, which requires at least 2 of these 3 key components: A detailed interval history; A detailed examination; Medical decision making of high complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the patient is unstable or has developed a significant complication or a significant new problem. Physicians typically spend 35 minutes at the bedside and on the patient’s hospital floor or unit.

Primary Care Bonus Payments

Bonus Payment for Primary Care and General Surgery Services

Primary Care Bonus Payments
The proposed rule implements section 5501 of the ACA which provides a 10 percent incentive payment over five years for primary care practitioners for whom primary care services accounted for at least 60 percent of the allowed charges. This provision raises the question of what constitutes “allowed charges.” CMS is interpreting the legislative language to mean allowed charges under Medicare Part B. This would include a number of services that are not paid under the Part B Medicare physician fee schedule, such as clinical diagnostic laboratory services or drugs and vaccines furnished in a physician’s office, which would make it much more difficult for a physician to reach the 60 percent threshold. CMS’ broad interpretation of “allowed charges” would significantly narrow the number of primary care practitioners who would be eligible for the payment incentive.

The AMA urges CMS to narrow its interpretation of “allowed charges” consistent with both the intent and statutory language of this provision. The payment incentive is intended to promote primary care as a physician specialty. According to HHS’ most recent data, there are 6,204 primary care health professional shortage areas with 65 million people living in them. It would take 16,643 practitioners to meet their need for primary care providers (a population to practitioner ratio of 2,000:1).

The primary care incentive is intended to address both the shortage of primary care physicians and to promote preventive care and care coordination as a means to help reduce growth in Medicare services. CMS’ broad interpretation of “allowed charges” undermines the intent of this provision since many physicians would not be eligible for the incentive payment. This would potentially affect both urban and rural physicians, but it would especially hurt patients living in rural communities. For example, a primary care physician practicing in a rural area, with few or no other primary care physicians and no physicians who specialize in services beyond primary care, is likely to furnish many types of services to patients (including clinical laboratory services and drugs and vaccines furnished in the physician’s office) to which the patient may not otherwise have access. CMS proposes to include charges for all of these services in the 60 percent of allowed charges threshold, yet these services are not even paid under the physician fee schedule. The primary care bonus is especially intended to help support these primary care physicians, but under CMS’ narrow interpretation, these physicians will be much less likely to be eligible for the incentive payment unless they discontinue offering certain services that patients may not be able to receive elsewhere. Further, if physicians in these areas are not eligible for the bonus, this will further damage recruitment efforts for these shortage areas.

Finally, we believe the statutory language in section 5501 requires only physician fee schedule services to be counted as “allowed charges.” The language specifically provides that the incentive payment is for certain practitioners “for whom primary care services accounted for at least 60 percent of the allowed charges under this part for such physician or practitioner in a prior period as determined appropriate by the Secretary.” There are several uses of the phrase “under this part” in section 5501, and each time this phrase is used, it is in reference to services that are provided and paid under the Medicare physician fee schedule. For example, section 5501(a) uses the phrase “under this part” as follows:

“In the case of primary care services furnished on or after January 1, 2011, and before January 1, 2016, by a primary care practitioner, in addition to the amount of payment that would otherwise be made for such services under this part, there also shall be paid (on a monthly or quarterly basis) an amount equal to 10 percent of the payment amount for the service under this part.”
Here, “under this part” is referring to primary care services, as defined in section

Medicare coverage of - reduce alcohol, smoking cessation, adult immunization

Screening and behavioral counseling in primary care to reduce alcohol misuse

The US Preventive Services Task Force (USPSTF) gives screening and behavioral counseling interventions in primary care to reduce alcohol misuse a B rating, and we urge CMS to cover these services as part of the annual wellness visit/personalized prevention plan. The USPSTF states:

"Effective interventions to reduce alcohol misuse include an initial counseling session of about 15 minutes, feedback, advice, and goal-setting. Most also include further assistance and follow-up. Multi-contact interventions for patients ranging widely in age (12-75 years) are shown to reduce mean alcohol consumption by 3-9 drinks per week, with effects lasting up to 6-12 months after the intervention."
Existing CPT Codes for this intervention fully describe these recommended actions, and we urge CMS to include these codes as a covered preventive care service in the final rule.

Smoking Cessation

The RUC has already developed CPT codes for smoking cessation, yet CMS is developing slightly different coding through the national coverage determination process (NCD). We urge CMS to adopt the existing CPT Codes for smoking cessation and cover these services as part of the annual wellness visit/personalized prevention plan.

Recommended Adult Immunizations

When the USPSTF ceased making recommendations with regard to vaccines after CY 1996, it demonstrated its support of the CDC’s Advisory Committee on Immunization Practices (ACIP) recommendations by including them in the USPSTF dissemination materials. The AMA urges CMS to adopt the ACIP-recommended adult immunization schedule for adults 65 years and older. This would include, in addition to influenza, pneumococcal and hepatitis B vaccines, the vaccines for Herpes Zoster and Tetanus (Td).

Additionally, as supported by a recent survey published in the Annals of Internal Medicine (Hurley et al, May 4, 2010 vol. 152 no. 9 555-560), payment for vaccines via Part D Medicare is a barrier to physicians administering the vaccine. With the coverage for shingles vaccine (reimbursed via Medicare Part D) at an unacceptably low two percent rate, the AMA urges that all vaccines recommended by the ACIP and covered by Medicare be reimbursed via Medicare Part B. This would bring all vaccines in line with the influenza, pneumococcal and hepatitis B vaccines, which are paid under Medicare Part B.
Assessment of individual functional ability and level of safety should include screening for visual acuity

The AMA applauds inclusion of functional status screening in the first annual wellness visit. However, we are concerned that CMS includes screening only for hearing impairment and not for visual impairment. While the USPSTF has removed visual acuity screening from a B to an I rating because of the lack of scientific research in this area, visual acuity is an important part of multi-factorial fall risk assessment and correction of visual problems is essential in fall prevention programs. The 2009 Guideline for the Prevention of Falls in Older Persons, a joint endeavor of the American Geriatrics Society, the British Geriatrics Society, and the American Academy of Orthopaedic Surgeons, provides a thorough review of the evidence and recommends that physicians complete a multi-factorial fall risk assessment including: (i) history of falls; (ii) medications; (iii) gait, balance and mobility; (iv) visual acuity; (v) other neurological impairments; (vi) muscle strength; (vii) heart rate and rhythm; (viii) postural hypotension; (ix) feet and footware; and (x) environmental hazards. Clearly, the scientific evidence supports the recommendation to screen for and treat visual impairments, and we therefore urge CMS to include visual acuity services in the annual wellness visit.

Health Risk Assessment

The ACA requires that a health risk assessment (HRA) be included in the new annual wellness visit benefit January 1, 2011. CMS acknowledges, however that the HRA guidelines (with standards for interactive telephonic and web-based HRAs) and the model HRA tool also required by the ACA are not yet available. CMS, therefore, has not included requirements related to the HRA in the proposed rule. The AMA urges CMS to continue to develop the HRA guidelines, in consultation with the AMA and other relevant stakeholders representing physicians. These HRA program should also be pilot-tested before being widely imposed to determine such critical factors as the effectiveness of the guidelines and the administrative burden imposed on the physicians.

Medicare - Annual Wellness Visit Providing Personalized Prevention Plan Services

Medicare Preventative Services

CMS is proposing to implement section 4104 of the ACA, which provides Medicare Part B coverage of an “Annual Wellness Visit Providing Personalized Prevention Plan Services.” CMS is proposing payment for these new Medicare services through the use of two new HCPCS G Codes. Yet, CPT already has codes that could be used for these services. The AMA, therefore, urges CMS to work through the established CPT Editorial Panel and the RUC process to adopt these existing codes for these services.

The AMA continues to have strong concerns about CMS’ development of HCPCS G codes instead of requesting the development and valuation of appropriate codes through the CPT Editorial Panel and the RUC. Development and valuation of codes through this regular process avoids massive billing confusion and ensures credibility of the coding process. There is an enormous amount of effort and expertise that is required by each specialty in developing coding proposals, conducting surveys to determine physician time and work, convening consensus panels, and determining appropriate direct PE inputs for each new CPT code that is created. The results of these efforts are then validated through multi-specialty groups of physicians, including CPT Advisors, the CPT Editorial Panel and the RUC. This process provides stability and credibility to the development of a code, and ensures that code descriptors and recommended RVUs are developed and maintained by physician experts who represent those providing these new services.

Further, the AMA strongly supports better coverage for Medicare preventive care, and we commend implementation of preventive care benefits. We urge CMS, however, to address several important issues related to implement of this ACA provision.

Measures Available for EHR Reporting and PQRI 2011

Tables 55 & 56: Measures Available for EHR Reporting

The AMA commends CMS for expanding the measures available for EHR reporting and specifically supports inclusion of PCPI measures for EHR reporting.

Tables 57-69

The AMA supports the continued inclusion of the proposed measure groups for PQRI 2011.
Tables 55 & 56: Measures Available for EHR Reporting

The AMA commends CMS for expanding the measures available for EHR reporting and specifically supports inclusion of PCPI measures for EHR reporting.
Tables 57-69
The AMA supports the continued inclusion of the proposed measure groups for PQRI 2011.
Table 70: Proposed Measures for the Asthma Measures Group

The AMA supports the proposed addition of an Asthma Measures Group. However, the measures proposed for inclusion in the Asthma Measures group do not lend themselves to a measures group, due to the fact that measures #53 and #64 are for the ambulatory setting, and the two new proposed measures (Assessment of Asthma Risk and Asthma: Discharge Plan) are for use in the ED or inpatient settings only. Because of the variation in care setting among the measures, the AMA does not recommend these four measures be included in a measures group. One alternative would be to consider the following measures for individual reporting (claims, registry) and for the Asthma Measures Group that were submitted to CMS for consideration during the “Call for Measures for PQRI 2011”:
•    Asthma: Tobacco Use- Screening -Ambulatory Setting.
•    Asthma: Tobacco Use- Intervention -Ambulatory Setting.
In addition to the measures that were proposed for PQRI 2011, we respectfully request that CMS consider the following measures for inclusion in the PQRI 2011 program:
These measures were submitted to CMS for consideration during the call for measures, but were not included in the measures proposed for PQRI 2011. All three of these measures are being recommended for NQF Endorsement:
•    Otitis Media with Effusion: Antihistamines or Decongestants- Avoidance of Inappropriate Use.
•    Otitis Media with Effusion: Systemic Microbials- Avoidance of Inappropriate Use.
•    Otitis Media with Effusion: Systemic Corticosteroids- Avoidance of Inappropriate Use.

The AMA urges publication of detailed specifications for individual measures and measures groups by November 15, 2010. The agency has until December 31, 2010 to post detailed measure specifications. To ensure physician practices have the requisite time to identify clinically relevant measures and understand their specifications before day one of the program (January 1, 2011), detailed measure information must be posted by November 15, 2010.
Qualification Requirements for EHR Vendors and Products
CMS proposes that previously qualified vendors and new vendors will be required to incorporate any new EHR measures (measures electronically-specified) added to the PQRI for the reporting year in which they wish to maintain their PQRI qualification. Vendors must also update their electronic measure specifications and data transmission schema, should either or both change. The AMA urges that CMS work to align measure specifications across programs and vendors, so that physicians feel comfortable with their ability to accurately and consistently report quality measures.

The AMA applauds CMS’ decision to reduce the reporting sample requirement from 80 percent to 50 percent for FY 2011. At the December 17, 2009, Practicing Physicians Advisory Council meeting, CMS discussed the PQRI reporting rate threshold options and presented data on the potential impact of a modified reporting threshold. According to the presentation, 82 percent of PQRI TIN/NPI participants in 2008 reported on at least 50 percent of their patient cases for at least one measure. CMS estimates that if a 50 percent reporting threshold had been applied for 2008, approximately 66 percent of PQRI TIN/NPI participants would have been incentive eligible. AMA also urged CMS, in a letter dated April 30, 2010, to use its authority to establish a 50 percent threshold for successful participation, as it would better reflect the current realities of the PQRI reporting environment for participating physicians. The AMA urges CMS to also use its existing authority to apply the new 50 percent threshold retrospectively to the 2010 reporting year.
For registry-based reporting in 2011, in contrast to prior program years, CMS proposes to require that the minimum patient numbers or percentages must be met by Medicare Part B fee-for-service patients (FFS) exclusively and not non-Medicare Part B FFS patients. The rationale for this is the difficulty of analyzing data CMS receives from registries, which include patients other than Medicare Part B FFS patients. The AMA understands that the requirements for registries to be considered “qualified” include the ability to separate out and report on Medicare Part B FFS patients. The same requirement exists for qualified EHRs. If CMS requires that the minimum patient numbers or percentages be met by only Medicare Part B FFS, many specialties may not be able to meet the minimum patient numbers to be considered a successful PQRI participant. For hospital reporting, CMS receives data from all payers, which indicates that CMS should be able to capture data on both Medicare Part B FFS and non-Medicare Part B FFS. Limiting the patient population will skew the results for some physicians depending on their patient population and severely limit the value of the results for quality improvement and payment incentive. As a result, PQRI participation may be viewed as a “regulatory requirement” by physicians instead of a tool to support quality improvement.

CMS proposes that qualified registries use “PQRI measure specifications and the CMS- provided measure calculation algorithm to calculate reporting rates or performance rates …if aggregated measures data is continued for 2011 PQRI registry reporting.” The AMA recommends that CMS involve the measure developers who maintain the measures included in the PQRI program in this process. This will ensure that the calculation of algorithms, including performance and exception (exclusion) rates are calculated consistently with the intent of the measure as originally developed and subsequently endorsed by the NQF. CMS should work with measure developers, such as the AMA-PCPI, to solicit feedback on program algorithms.

Throughout the proposed requirements for registries, CMS refers to the submission of numerator and denominator data. The AMA recommends that exception data be added as a requirement and that registries be required to report to CMS a physician’s numerator, denominator, and exception data. The addition of exception data is consistent with the approach included in the Final Rule for Stage 1 of the CMS EHR Incentive Program (meaningful use).

Proposed Measures for the Asthma Measures Group

The AMA supports the proposed addition of an Asthma Measures Group. However, the measures proposed for inclusion in the Asthma Measures group do not lend themselves to a measures group, due to the fact that measures #53 and #64 are for the ambulatory setting, and the two new proposed measures (Assessment of Asthma Risk and Asthma: Discharge Plan) are for use in the ED or inpatient settings only. Because of the variation in care setting among the measures, the AMA does not recommend these four measures be included in a measures group. One alternative would be to consider the following measures for individual reporting (claims, registry) and for the Asthma Measures Group that were submitted to CMS for consideration during the “Call for Measures for PQRI 2011”:

•    Asthma: Tobacco Use- Screening -Ambulatory Setting.
•    Asthma: Tobacco Use- Intervention -Ambulatory Setting.
In addition to the measures that were proposed for PQRI 2011, we respectfully request that CMS consider the following measures for inclusion in the PQRI 2011 program:
These measures were submitted to CMS for consideration during the call for measures, but were not included in the measures proposed for PQRI 2011. All three of these measures are being recommended for NQF Endorsement:
•    Otitis Media with Effusion: Antihistamines or Decongestants- Avoidance of Inappropriate Use.
•    Otitis Media with Effusion: Systemic Microbials- Avoidance of Inappropriate Use.
•    Otitis Media with Effusion: Systemic Corticosteroids- Avoidance of Inappropriate Use.
The AMA urges publication of detailed specifications for individual measures and measures groups by November 15, 2010. The agency has until December 31, 2010 to post detailed measure specifications. To ensure physician practices have the requisite time to identify clinically relevant measures and understand their specifications before day one of the program (January 1, 2011), detailed measure information must be posted by November 15, 2010.

Qualification Requirements for EHR Vendors and Products

CMS proposes that previously qualified vendors and new vendors will be required to incorporate any new EHR measures (measures electronically-specified) added to the PQRI for the reporting year in which they wish to maintain their PQRI qualification. Vendors must also update their electronic measure specifications and data transmission schema, should either or both change. The AMA urges that CMS work to align measure specifications across programs and vendors, so that physicians feel comfortable with their ability to accurately and consistently report quality measures.

The AMA applauds CMS’ decision to reduce the reporting sample requirement from 80 percent to 50 percent for FY 2011. At the December 17, 2009, Practicing Physicians Advisory Council meeting, CMS discussed the PQRI reporting rate threshold options and presented data on the potential impact of a modified reporting threshold. According to the presentation, 82 percent of PQRI TIN/NPI participants in 2008 reported on at least 50 percent of their patient cases for at least one measure. CMS estimates that if a 50 percent reporting threshold had been applied for 2008, approximately 66 percent of PQRI TIN/NPI participants would have been incentive eligible. AMA also urged CMS, in a letter dated April 30, 2010, to use its authority to establish a 50 percent threshold for successful participation, as it would better reflect the current realities of the PQRI reporting environment for participating physicians. The AMA urges CMS to also use its existing authority to apply the new 50 percent threshold retrospectively to the 2010 reporting year.
For registry-based reporting in 2011, in contrast to prior program years, CMS proposes to require that the minimum patient numbers or percentages must be met by Medicare Part B fee-for-service patients (FFS) exclusively and not non-Medicare Part B FFS patients. The rationale for this is the difficulty of analyzing data CMS receives from registries, which include patients other than Medicare Part B FFS patients. The AMA understands that the requirements for registries to be considered “qualified” include the ability to separate out and report on Medicare Part B FFS patients. The same requirement exists for qualified EHRs. If CMS requires that the minimum patient numbers or percentages be met by only Medicare Part B FFS, many specialties may not be able to meet the minimum patient numbers to be considered a successful PQRI participant. For hospital reporting, CMS receives data from all payers, which indicates that CMS should be able to capture data on both Medicare Part B FFS and non-Medicare Part B FFS. Limiting the patient population will skew the results for some physicians depending on their patient population and severely limit the value of the results for quality improvement and payment incentive. As a result, PQRI participation may be viewed as a “regulatory requirement” by physicians instead of a tool to support quality improvement.

CMS proposes that qualified registries use “PQRI measure specifications and the CMS- provided measure calculation algorithm to calculate reporting rates or performance rates …if aggregated measures data is continued for 2011 PQRI registry reporting.” The AMA recommends that CMS involve the measure developers who maintain the measures included in the PQRI program in this process. This will ensure that the calculation of algorithms, including performance and exception (exclusion) rates are calculated consistently with the intent of the measure as originally developed and subsequently endorsed by the NQF. CMS should work with measure developers, such as the AMA-PCPI, to solicit feedback on program algorithms.

Throughout the proposed requirements for registries, CMS refers to the submission of numerator and denominator data. The AMA recommends that exception data be added as a requirement and that registries be required to report to CMS a physician’s numerator, denominator, and exception data. The addition of exception data is consistent with the approach included in the Final Rule for Stage 1 of the CMS EHR Incentive Program (meaningful use).