Further CMS Guidance on Consultation Services

MLN Matters® SE1010 provides further clarity from CMS for those who who perform initial E/M services previously reported by CPT consultation codes for Medicare beneficiaries and submit claims to Medicare MACs for those services. The document follows a Q&A format. It includes the first information I have seen from CMS regarding low-level inpatient consultation codes 99251 and 99252. A question on page 3 asks how services previously reported with these codes should be billed since they do not meet key requirements for 99221-99223.

Access 2007 Re-Run and 2008 PQRI Feedback Reports

Physicians may now access their 2007 re-run and 2008 Physician Quality Reporting Initiative (PQRI) data through a new tool. CMS has created the “Verify Report Portal” which is available on the PQRI Qualitynet Portal. In addition to PQRI information, these reports will provide individual physicians with information on their Medicare Part B Physician Fee Schedule allowed charges for the 2007 or 2008 PQRI reporting period, upon which an incentive payment is based.

The tool is available at https://www.qualitynet.org/portal/server.pt.

SGR Delay Expires March 1

The clock is ticking—tell your senators to repeal the SGR. With a 21 percent cut in Medicare physician payments scheduled to take effect in just 20 days, the time to persuade lawmakers to pass a permanent repeal of Medicare's sustainable growth rate (SGR) formula is ticking away. Contact your U.S. senators and insist that they pass legislation to repeal the SGR formula to avert the cuts, which are slated to take effect March 1. Use the AMA's toll-free grassroots hotline at (800) 833-6354 or write them an e-mail.

CMS Holds Claims and Extends Provider Enrollment

Last week Congress temporarily averted the 21.2% Medicare physician payment cut. On December 19, President Obama signed the bill which will stop the cuts until March 1, 2010. Other changes reflected in the 2010 Medicare Physician Fee Schedule final rule will still take effect on January 1, 2010 and may have a slight impact on the conversion factor used for the first two months of 2010. Similar to other years, since Congress acted so late in the year to avert the cut, CMS will hold claims for the first 10 business days of January (January 1 through January 15) for 2010 dates of service to allow its contractors time to update their systems and pay claims based on the updated rates CMS does not anticipate any cash flow problems for physicians since by law no claims are paid prior to 14 days after receipt anyway.

In addition, CMS has extended the 2010 Annual Participation Enrollment Program end date from January 31, 2010, to March 17, 2010. Physicians still have time to consider their participation options with the Medicare program. Additional information can be found on the AMA's web site. The effective date for any participation status change during this extension remains January 1, 2010, and will be in force for the entire year. Medicare contractors will accept and process any participation elections or withdrawals made during the extended enrollment period that are received or post-marked on or before March 17, 2010.

House Votes to Delay SGR Cuts

This afternoon, the House passed a 2-month extension of expiring appropriations for the Department of Defense that included a 2-month extension of the sustainable growth rate (SGR). In other words, the legislation would stop the 21.2% Medicare pay cut scheduled take effect on January 1 for a period that will end March 1, 2010. The legislation does not affect any of the other payment policies included in the final 2010 fee schedule rule; those will take effect on schedule.

A cloture motion on the DoD extension bill was filed in the Senate today. Votes on cloture and passage should be completed this weekend.

HIPAA 5010 Resources for January 2012

Are you preparing for the compliance deadlines for the Health Insurance Portability and Accountability Act (HIPAA) 5010 standard transactions, the next version of HIPAA? Beginning Jan. 1, 2012, physicians will be required to use only the 5010 standard transactions when conducting them electronically. The AMA has prepared several educational resources to assist physicians with implementing the 5010 standard transactions.

Texas Judge Rules EMG, MUA are Beyond Scope of Chiropractors

In a November 24th ruling, Austin State District Judge Stephen Yelenosky said state law prevents chiropractors from performing clinical needle electromyography (EMG) or spinal manipulation under anesthesia (MUA). Yelenosky granted a Texas Medical Association and Texas Medical Board request for a partial summary judgment against the Texas Board of Chiropractic Examiners and the Texas Chiropractic Association.

"Judge Yelenosky ruled that chiropractors cannot perform needle EMGs or manipulation under anesthesia because both of those procedures are beyond the chiropractors' lawful scope of practice," said Austin attorney David F. Bragg, one of the lawyers for TMA. The chiropractors are expected to appeal the ruling, he said.

TMA sued in 2006 to block the chiropractic board's rules that would permit chiropractors to perform clinical needle EMG and MUA, because both procedures constitute the clinical and legal practice of medicine. View the full press release at the TMA website.

Medicare Changes for 2010

Medicare’s 2010 final rule confirms that physicians face steep cuts of 21.2% in 2010. Permanent repeal of the flawed sustainable growth rate (SGR) formula is an essential element of comprehensive health system reform. In October, the Senate failed to pass a bill (S. 1776) that would fix the problem, while the House is expected to vote soon on a different bill (H.R. 3961) that would also fix the problem.

The rule includes other changes for EDX physicians as well. A proposal for Medicare to stop accepting consultation codes (99241-99245, 99251-99255) as of January 1, 2010 was finalized and included in the rule. Physicians will instead report the office visit codes (99201-99205, 99211-99215) to Medicare for these services. For inpatients, use hospital care codes (99221-99223) or initial nursing facility care visit (99304-99306) evaluation and management (E/M) codes for the first visit during a patient’s admission to a hospital or nursing facility. In its proposal to eliminate the consultation codes, Medicare cited continued provider dissatisfaction with Medicare documentation requirements, confusion between a consultation and a transfer of care, and similarity in the physician work of consults and office visits, despite the work higher value. The AANEM and many other entities commented in opposition to this change and the fast implementation to no avail.

To maintain budget neutrality the RVUs for other office visit E/M services will be increased proportionately, about 6%. Work RVUs for hospital and nursing facility visits will be increased approximately 2%. The table below shows how the removal of consult codes and subsequent redistribution of value affects key E/M codes.

* Calculated before 21.5% SGR cut is applied. **Inpatient codes have only three corresponding levels of service.

Finally, CMS currently utilizes practice expense (PE) data and physician hours from the 1995-1999 AMA Socioeconomic Monitoring System (SMS) survey to calculate “practice expense per hour” estimation and direct to indirect cost ratio for each specialty. This data and the accompanying PE and malpractice (MP) RVUs are being updated with new survey data from 2007-2008 that was compiled through joint efforts of AMA, CMS, and over 70 national health care organizations. Implementation of these data will redistribute practice expense payment among specialties during a 4-year transition period.

Physical medicine and rehabilitation physicians will receive a 2% increase from transitional practice expense RVU changes in 2010, increasing to a 6% increase in 2013. Neurologists will receive a 1% transitional increase in 2010, culminating in a 4% increase in 2013. As part of the redistribution, a number of other specialties will see net reductions in 2010 through the 2013 transition, as seen in this table.

FTC Delays Red Flag Rules 3rd Time

The Federal Trade Commission recently announced its third delay in implementation of the Red Flags Rule. Implementation of the rules has been delayed until June 1, 2010. The AMA has been urging the FTC and Congress that physicians are not "creditors" and should not be subject to the rule. View the FTC's release for more information on the delay.

The AANEM encourages its members to be cognizant of these rules and will continue to report on anticipated implementation and the work of the AMA on this issue. The AMA has developed resources for implementation of these rules.