The Proposed Rule that details changes affecting the Medicare PFS will be published July 19, 2013 in the Federal Register. This begins the comment period that continues until Sept. 6, 2013.
If you want to participate in the comment process, you need to start somewhere. The best place is here, with a brief description of the key elements in the proposal.
Telehealth Services: These services would be expanded to include areas designated as health professional shortage areas (HPSAs) located in rural census tracts of urban areas as determined by the Office of Rural Health Policy. Additionally, transitional care management services would be considered eligible telehealth services.
Revisions To The Practice Expense Geographic Adjustment: PFS rates are calculated based on numerous factors as required by the Medicare law. The main goal is to adjust payments according to geographic differences in practice costs. To accomplish this, CMS assigns separate geographic practice cost indices (GPCIs) to the work, practice expenses (PE), and malpractice cost components of each of more than 7,000 physicians’ services. The proposed changes to the GPCIs would be phased in over 2014-2015 and are:
- New GPCIs using updated data as required by law every 3 years.
- Changes to the weights assigned to each GPCI (work, PE and malpractice) consistent with the recommendations of the Medicare Economic Index (MEI) Technical Advisor Panel (see below) that increases the weight of work and reduces the weight of practice expense.
- The proposed GPCIs reflect the elimination of the work “floor” and as a result 51 localities will have a work GPCI below 1.
Medicare Economic Index: MEI, the price index used to update the PFS for inflation, and sustainable growth rate are used in when calculating the total payment amounts in the PFS. The proposal reflects 2012 recommendations by a Technical Advisory Panel CMS that will revise the calculation of the MEI as well as changes in the RVU and GPCI weights assigned to work and practice expense to align with the MEI.
Miss-valued Codes: CMS as part of the ACA, has identified miss-valued codes requiring adjustment to payment rates. There are more than 200 codes with proposed rate changes. These codes currently reimburse higher for services performed in an office versus the fee paid in a hospital outpatient setting or ASC. The proposed rates would reflect a PFS office place of service reimbursement that is equal to the sum of the reimbursement to the facility and practitioner when service are rendered in an outpatient hospital or ACS place of service. There have been additional miss-valued codes identified by Medicare Contractors based on claim review that have proposed reimbursement changes.
Application of Therapy Caps to Critical Access Hospitals: They are proposing outpatient therapy services furnished in CAHs are added to the therapy cap limitations. This would apply two per beneficiary of the following outpatient therapy services:
- physical therapy and speech-language pathology services
- occupational therapy services.
Future change for 2015 included in this proposal:
Primary Care and Complex Chronic Care Management: The proposal would provide for an additional, separate payment for a practitioner that provides non-face-to-face complex chronic care management services for Medicare beneficiaries who have multiple, significant chronic conditions (two or more). This is how it would work:
- Coverage is based on the physician development and revision of a plan of care, communication with other treating health professionals, and medication management
- Beneficiaries would be required to have an Annual Wellness Visit (or an Initial Preventive Physical Examination (IPPE), if applicable)
- Would apply to a single practitioner that agrees to furnish these services and that obtains the beneficiary’s consent to receiving these services over a one-year period.
- Medicare would make the separate payment through two G-codes for establishing of a plan of care and furnishing care management over 90-day periods.
Included in the proposal are guidelines to develop practice standards that would support this payment. This may include requirements like real time access to records via HER and written protocols detailing the care management process.
To access the CMS Fact Sheet click here.
To read the entire proposed rule click here.