Medicare Physician Fee Schedule Final Rule Summary
Multiple Procedure Payment Reduction (MPPR)
The calendar year (CY) 2013 Medicare Physician Fee Schedule (MPFS) final rule includes an extension of the multiple procedure payment reduction policy, with only slight modifications from the proposed rule. Of particular concern to ASNC, the final rule adds Current Procedural Terminology (CPT) code 93015 to the list of codes identified by the Centers for Medicare and Medicaid Services (CMS) as frequently billed. The cardiology codes are located in Table 12 of the final rule.
In comments to the proposed rule, ASNC argued that the very example provided by CMS to illustrate the MPPR policy, codes 78452 and 93306, undercut the agency’s rationale. ASNC asserted “myocardial perfusion single-photon emission computed tomography (SPECT) and transthoracic echocardiography are markedly different procedures and the assumption of duplicative services is misguided.” CMS disputed this assertion, stating that “the typical cardiovascular center performing these diagnostic tests commonly cross-train technicians to perform both procedures and that a single cardiologist often performs both tests for a single patient. In addition, we continue to believe that much of the pre-service work such as greeting and gowning the patient and reviewing medical records and previous images is redundant.”
In summary, CMS is extending this MPPR policy to the technical component of certain cardiovascular and ophthalmology diagnostic services. CMS would make full payment for the highest paid cardiovascular diagnostic service and reduce by 25 percent the technical component payment for subsequent cardiovascular diagnostic services furnished by the same physician or group practice to the same patient on the same day.
Physician Quality Reporting System (PQRS)
CMS continues to use PQRS as a means of promoting quality improvement initiatives and the reporting of quality information by physicians. In the CY 2013 rule, CMS aims to integrate the PQRS reporting requirements with the requirements of the Electronic Prescribing Incentive Program, the Electronic Health Record (EHR) Incentive Program, and the Value-Based Payment Modifier. Moreover, CMS issued a number of changes to facilitate participation. These changes include the following:
- Expanding the definition of a group practice to include groups of 2-24 eligible providers;
- Lowering the minimum required number of patient reports in the claims and registry reporting option from 30 to 20; and
- Including a six-month reporting option in 2013 and 2014 in addition to the 12-month period.
The CY 2013 rule also includes three group measures specific to cardiovascular diagnostic imaging:
- Cardiac Stress imaging not meeting appropriate use criteria: Preoperative evaluation in low risk surgery patients;
- Cardiac stress imaging not meeting appropriate use criteria: Routine testing after percutaneous coronary intervention (PCI); and
- Cardiac stress imaging not meeting appropriate use criteria: Testing in asymptomatic, low risk patients.
These three measures will be finalized for PQRS reporting in 2013 or 2014.
In the final rule, CMS reaffirmed its intent to use to base the PQRS payment adjustment year on a reporting period occurring two years prior. Thus, whether a physician successfully reports in 2013 will determine the payment adjustment in 2015. ASNC asserted the reporting period should occur closer to the payment adjustment year. CMS stated that it is not operationally feasible to create a full calendar year reporting period for the PQRS payment adjustment less than two years prior to the adjustment year and still avoid retroactive payments or the reprocessing of claims.
Electronic Prescribing (eRx) Incentive Program
Medicare offers a combination of incentive payments and downward payment adjustments to encourage electronic prescribing by eligible professionals (EPs). In 2013, the eRX Incentive Program will offer EPs a 0.5% bonus payment based on total estimated Medicare Part B allowed charges. The program will apply a 1.5% downward adjustment in 2013 and a 2.0% adjustment in 2014 to EPs who are not successful electronic prescribers.
CMS finalized a number of proposals to facilitate greater participation, including:
- Reducing the minimum group size from 25 EPs to two; and
- Lowering the reporting threshold for the 2013 incentive for groups comprising less than 25 professionals to 75 times. In response to comments, CMS will apply this lower threshold to 2014 as well.
In addition, CMS finalized the following new hardship exemptions to the 2013 and 2014 payment adjustments:
- Eligible professionals or group practices who achieve meaningful use during certain 2013 and 2014 eRx payment adjustment reporting periods.
- Eligible professionals or group practices who demonstrate intent to participate in the EHR Incentive Program and adoption of Certified EHR Technology.
CMS finalized its proposed informal review process for the 2013 incentive and the 2014 payment adjustment and intends to align it as much as possible with the review process available under the PQRS program.
Physician Value-Based Payment Modifier
The calendar year (CY) 2013 Medicare Physician Fee Schedule also implements the value-based payment modifier, a component of the Patient Protection and Affordable Care Act. This program will affect payment rates to physician groups based on the cost and quality of the care provided to Medicare beneficiaries. The program begins in 2015 and, under the proposed rule, initially applies to physician groups of 25 or more eligible professionals. In response to stakeholder comments, CMS set the minimum group size at 100 in the final rule. The Value Modifier applies to all physicians and physician groups beginning in 2017. The act requires budget neutrality-upward payments for high performance will be offset by downward adjustments.
The rule sets CY 2013 as the performance period for the CY 2015 payment adjustment. Physicians may avoid any adjustment in their payments if the group signs up for and participates successfully in one of several PQRS options. For groups that were not successful PQRS participants, 2015 Medicare payment rates would be cut by 1.0%. Successful PQRS participants have the option of either taking a zero payment adjustment in 2015 or opting to be judged through a three-tiered system that will incorporate both costs and quality. Low tier participants face 1.0% payment cuts, those in the middle will see no change, and those participants in the high tier will receive an increase that is undetermined at present.
The final rule imposes a number of alterations:
- CMS will apply the 1.0% downward adjustment only to those groups of physicians that do not participate in PQRS in CY 2013. Physician groups that attempted to participate but were unsuccessful will avoid the downward adjustment.
- Physician groups that self-nominate for the PQRS group practice reporting option (GPRO) and report a minimum of one measure will avoid any adjustment.
- In the use and development of cost measures and Medicare Episode Grouper data, CMS is committed to meeting with specialty societies to obtain feedback and ensure transparency.
The final rule sets the payment increase in the quality tier model at the unspecified amount specified in the proposed rule. CMS states it will consider ways to increase the amount of payment at risk as the agency gain more experience with value-based payment modifier methodologies.
PDF of this content
PDF of ASNC comment letter to the 2013 Medicare Physician Fee Schedule Final Rule
PDF of the 2013 Medicare Physician Fee Schedule – Final Relative Value Units for Nuclear Cardiology Procedures Chart
Link to the Final Rule