CMS Issues 2013 Proposed Physician Fee Schedule

By Adrienne Dresevic, Esq. and Carey F. Kalmowitz, Esq.

August 2012—The Centers for Medicare & Medicaid Services (CMS) displayed the 2013 Medicare Proposed Physician Fee Schedule (the “PPFS”) on July 6, 2012 (the PPFS was published July 30, 2012 in the Federal Register). The PPFS implements the fourth and final year of transition to new practice expense relative units based on the American Medical Association’s Physician Practice Information Survey (PPIS) data. The PPFS updates payment policies and rates for services furnished to beneficiaries under the Medicare physician fee schedule and proposes other policy changes relating to Medicare Part B payments. This article will highlight some of the changes impacting imaging services. Overall, the PPFS will increase payments to primary care specialists and will decrease payments to select other specialties.

Multiple Procedure Reduction Payment Policy

CMS proposes to expand the Multiple Procedure Reduction Payment Policy (MPPR) to apply to the technical component (TC) of several services. For cardiovascular diagnostic services, CMS reviewed the code/pair combinations with the highest utilization (codes 75600 – 75893, 78414 – 78496, and 93000 – 93990). In regards to nuclear medicine, due to a technical error, the MPPR is not currently applied to CPT code 78306 (bone imaging; whole body) when followed by CPT code 78320 (bone imaging; SPECT). The MPPR will be applied to these codes beginning January 1, 2013.

Group Practices and the MPPR PC Expansion

For group practices, CMS proposes to apply the MPPR to the professional component (PC) and TC of the second and subsequent advanced imaging procedures furnished to the same patient in the same session by a single physician or physicians in the same practice groups. CMS’s reasoning for this expansion of the MPPR is that it believes there are certain efficiencies that exist when performing subsequent images on the same patient. Full payment is made for the TC of the highest paid procedure, and payment is subsequently reduced by 50% for each additional procedure when the MPPR applies. Likewise with the PC, the highest PC payment would continue to be paid in full while the PC for subsequent advanced imaging services will be reduced by 25%.

As many imaging providers may recall, this expanded MPPR rule was to originally be applied in calendar year (CY) 2012; however, due to certain operation limitations CMS was unable to apply it. CMS received severe criticism over this proposed change in CY 2011 prior to retracting its application for CY 2013. The MPPR was applied to individual physicians who furnished second and subsequent advanced imaging procedures in the same session during CY 2012. The operational limitations that CMS was experiencing have been resolved, and the MPPR will be applied to the PC and TC effective January 1, 2013.

Portable X-Ray Services

CMS proposes to expand the types of medical professionals who can order portable x-rays (and allow the portable x-ray supplier to receive payment). Due to regulations that were established in the late 1960s, CMS is currently only required to only reimburse portable x-rays suppliers for services ordered by MDs or DOs. The proposed change would expand the regulation to allow ordering by nurse practitioners, clinical nurse specialists, physician assistants, certified nurse-midwives, doctors of optometry, doctors of dental surgery, doctors of dental medicine, doctors of podiatric medicine, clinical psychologists, and clinical social workers. This update recognizes the fact that non-physician practitioners have become an increasingly important part of providing medical services.

This proposed expansion was initiated, in part, from provider feedback associated with a December 2011 Office of the Inspector General report which found that CMS was already paying millions of dollars a year in reimbursement for portable x-rays that were ordered by non-physicians. CMS has requested comments from the public regarding this change.

Interest Rates

CMS is proposing to use a “sliding scale” approach to interest rates used in the practice expense (PE) methodology. Interest rate assumptions will change from the current 11 percent to a range between 5.5 and 8 percent. CMS will update the interest rate assumption annually in its rulemaking based on the Prime rate or changes to the Small Business Administration’s formula determining maximum allowed interest rates. As a result of the lower interest rate assumption in the PE calculation, capital-intensive specialties are expected to decrease.

Potentially Misvalued Codes

For the first time this year, CMS is considering potentially misvalued codes that it received through the new public nomination process. CMS received public nominations for 36 CPT codes following the release of the 2012 Physician Fee Schedule Final Rule. One of the codes nominated is CPT code 77336: Continuing medical physics consultation, including assessment of treatment parameters, quality assurance of dose delivery, and review of patient treatment documentation in support of the radiation oncologist, reported per week of therapy. CMS has proposed to review this code and is seeking recommendations from public commenters relating to the direct PE inputs and physician work relative value units (RVUs). CMS is also seeking input on direct PE inputs for other services within this family of CPT codes.

CMS also proposes to review Harvard-valued services with allowed Medicare charges exceeding $10 million per year. Particular codes of interest are CPT code 36215 and CPT code 36245. CMS is requesting comments from the public on these as well as other codes listed in the PPFS.

Additionally, CMS is proposing changes related to the payment rates for intensity-modulated radiation treatment (IMRT) and stereotactic body radiation therapy (SBRT). CMS proposes that IMRT delivery (CPT code 77418) will have its time assumption adjusted from 60 minutes to 30 minutes. As a result, reimbursement for IMRT delivery will decrease by 40% in 2013. CMS also proposes to cut SBRT delivery (CPT code 77373) from 90 minutes to 60 minutes and reimbursement will decrease by 28% in 2013.

Physician Reporting

A change that was prompted by the Affordable Care Act is the requirement that CMS set up a physician compare website no later than January 1, 2013. The website will be designed to make information about physician performance publicly available. CMS is seeking comments on a number of aspects about this website.

Another physician reporting system, the Physician Quality Reporting System (PQRS), gives physicians incentives to provide information regarding quality measures for professional services. In CYs 2013 and 2014, CMS proposes using 264 individual measures and 26 group measures that eligible professionals can choose from. In 2013 and 2014, physicians will be paid for satisfactorily reporting data. Beginning in 2015, eligible professionals who do not satisfactorily report data will receive a payment adjustment.

Electronic Prescribing

The PPFS proposes changes to the electronic prescribing incentive program. Eligible professionals and group practices will receive incentive payments for successfully using the program through 2013. For physicians who do not use the program from 2012 through 2014, the program applies a payment adjustment. For groups of 2-24 eligible professionals, new criteria are being proposed in order to be considered a successful electronic prescriber. CMS also proposes new hardship exemptions to this rule for 2013 and 2014. Additionally, CMS proposes to establish an informal review process for this program.

CMS is accepting comments related to the proposal until September 4, 2012. The Medicare Physician Fee Schedule Final Rule is scheduled to be issued on or about November 1, 2012.

Adrienne Dresevic, Esq. graduated Magna Cum Laude from Wayne State University Law School. Practicing healthcare law, she concentrates in Stark and fraud/abuse, representing various diagnostic imaging providers, eg, IDTFs, mobile leasing entities, and radiology and multi-specialty group practices.

Carey F. Kalmowitz, Esq. graduated from NYU Law School. Practicing healthcare law, he concentrates on corporate and financial aspects, eg, structuring physician group practice transactions; diagnostic imaging and ancillary services, IDTFs, provider acquisitions, CON, compliance, and Stark and fraud/abuse.

The authors are members of The Health Law Partners, P.C. and may be reached at (248) 996-8510 or (212) 734-0128, or at www.thehlp.com.