Key Implementation Dates
A detailed schedule of key implementation dates will be provided in an annual temporary instruction in advance of receiving the MPFS Database file. The following outlines significant disclosure activities and anticipated implementation dates. A detailed schedule is provided under separate cover by CMS.
Carriers must:
October:
• Download fee schedules
• Download HCPCS
November:
• Release participation materials and disclosure reports;
• Furnish yearly physician fee schedule amounts to CMS for carrier priced codes;
December:
• Furnish DMEPOS fee schedule and physician fee schedules to State Medicaid Agencies;
• Furnish conversion factors and inflation indexed charge data to the carrier State Medicaid Agencies;
• Process participation elections and withdrawals; and,
• Send a complete fee schedule to the State medical societies and State beneficiary associations.
January:
• Implement annual fee schedule amounts;
• Implement annual HCPCS update;
• Send an updated provider file to the Railroad Retirement Board; and
• Load MEDPARD equivalent information on the carrier Web site.
February:
• Submit participation counts to CMS Central Office via CROWD.
Showing posts with label Fee schedule. Show all posts
Showing posts with label Fee schedule. Show all posts
What is Par fee and Non par fee in Medicare
Q. I’ve been using the “First Coast Service Options fee schedule look-up” for Part B -- what do par fee, nonpar fee, and limiting charge mean?
A. Amounts listed under “par fee” represent the potential Medicare allowance for a physician or nonphysician practitioner who has signed a Medicare participation agreement (form CMS-460). (Click here for more information about the CMS-460.) Signing this agreement means the provider has agreed to accept Medicare allowances as payment in full; the benefits are therefore assigned to the provider.
Amounts listed under “nonpar fee” represent the potential Medicare allowance for a physician or nonphysician practitioner who has NOT signed a participation agreement; these allowances are generally 95 percent of the amount for a participating provider in the same area. Nonparticipating providers may choose to accept Medicare assignment or not.
The limiting charge is the maximum amount a nonparticipating provider may legally charge a beneficiary when filing an unassigned claim. The limiting charge for a service is 115 percent of the nonpar amount.
Q. Where can I obtain fee schedule policy indicators? For example, how can I find the global surgery days for a service? What about relative value units (RVUs) for a particular code?
A. Policy indicators for procedure codes in the Medicare physician fee schedule database (MPFSDB) are available in First Coast Service Options’ fee lookup tool. Select Medicare Physician and Nonphysician Practitioner Fee Schedule (MPFS) from the drop-down list enter a date of service, location, and procedure code, and select submit. Then select the “more” links in the modifier field to view MPFS policy indicators.
These Indicators include: global surgery including pre-operative, intra-operative, and post-operative days, PCTC (professional/technical component), multiple surgery, bilateral surgery, assistant surgery, cosurgery, team surgery, physician supervision requirements, and base codes for multiple endoscopy procedures. For more information regarding these indicators, click here.
Also included are work, practice expense and malpractice expense geographic practice cost indices (GPCIs) and relative value units (RVUs). Note: the allowances Medicare contractors use in their claims payment system use these factors, in combination with an annual conversion factor, but allowances are not calculated at the local level. The allowances are furnished to contractors by CMS after all calculations have been completed.
Q. In the fee schedule lookup tool -- what do the question marks in the column headers mean?
A. These are Tooltips. When the cursor is placed over the “?” on any of these items, helpful tooltips will appear, providing a description for each category.
A. Amounts listed under “par fee” represent the potential Medicare allowance for a physician or nonphysician practitioner who has signed a Medicare participation agreement (form CMS-460). (Click here for more information about the CMS-460.) Signing this agreement means the provider has agreed to accept Medicare allowances as payment in full; the benefits are therefore assigned to the provider.
Amounts listed under “nonpar fee” represent the potential Medicare allowance for a physician or nonphysician practitioner who has NOT signed a participation agreement; these allowances are generally 95 percent of the amount for a participating provider in the same area. Nonparticipating providers may choose to accept Medicare assignment or not.
The limiting charge is the maximum amount a nonparticipating provider may legally charge a beneficiary when filing an unassigned claim. The limiting charge for a service is 115 percent of the nonpar amount.
Q. Where can I obtain fee schedule policy indicators? For example, how can I find the global surgery days for a service? What about relative value units (RVUs) for a particular code?
A. Policy indicators for procedure codes in the Medicare physician fee schedule database (MPFSDB) are available in First Coast Service Options’ fee lookup tool. Select Medicare Physician and Nonphysician Practitioner Fee Schedule (MPFS) from the drop-down list enter a date of service, location, and procedure code, and select submit. Then select the “more” links in the modifier field to view MPFS policy indicators.
These Indicators include: global surgery including pre-operative, intra-operative, and post-operative days, PCTC (professional/technical component), multiple surgery, bilateral surgery, assistant surgery, cosurgery, team surgery, physician supervision requirements, and base codes for multiple endoscopy procedures. For more information regarding these indicators, click here.
Also included are work, practice expense and malpractice expense geographic practice cost indices (GPCIs) and relative value units (RVUs). Note: the allowances Medicare contractors use in their claims payment system use these factors, in combination with an annual conversion factor, but allowances are not calculated at the local level. The allowances are furnished to contractors by CMS after all calculations have been completed.
Q. In the fee schedule lookup tool -- what do the question marks in the column headers mean?
A. These are Tooltips. When the cursor is placed over the “?” on any of these items, helpful tooltips will appear, providing a description for each category.
Where Can I Check the Fee schedule for DME, physician fee?
Q. Where can I find fee schedules for my location and line of business?
A. Select your location (Florida, Puerto Rico, or the U.S. Virgin Islands) and line of business (Part A or Part B) on the homepage of the First Coast Service Options (First Coast) Medicare provider website. This will allow you to view information that pertains specifically to your geographic location as well as your type of business. After you have selected your location, you may easily select your line of business and go directly to the ”Fee Schedules” page in one step -- just select “Fee Schedules” from the category list on the Part A or Part B homepage.
You can also access the “Fee Schedules” page for your line of business from the “Quick Find” drop-down menu located in the left-hand navigation area on each page of the website.
Once you have arrived on the “Fee Schedules” page (Part A or Part B), you’ll have access to:
• The latest news and information about fee schedules in the “News” information box
• Location-specific fee information for Part A and Part B for most Medicare-covered procedure codes with First Coast’s easy-to-use, interactive look-up tool.
• Printable Part B portable document format (PDF) fee schedules and text-only fee schedule data files that can be imported into a spreadsheet or database.
• Fee schedules and fee schedule-related information from previous payment years in First Coast’s comprehensive archive
http://medicare.fcso.com/Fee_lookup/fee_schedule.asp
Q. Where can I find fees for durable medical equipment, prosthetics/orthotics, and supplies?
A. Fees for local and joint jurisdiction durable medical equipment, prosthetics/orthotics, and supplies (DMEPOS) may be found in First Coast Service Options’ fee schedule lookup and on the Centers for Medicare & Medicaid Services (CMS) website at: http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/DMEPOSFeeSched/DMEPOS-Fee-Schedule.html
Q. Where can I find fees for physician fee schedule services?
A. Fees for fee schedule services paid under the Medicare physician fee schedule database (MPFSDB), for Part A as well as Part B, may be found in First Coast Service Options’ fee schedule lookup, and under fee schedule data files for compressed, tab-delimited files. Additional information may be found here for Part A or here for Part B, and on the Centers for Medicare & Medicaid Services (CMS) website at: http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched/index.html external link.
Q. Where can I find fees for clinical laboratory services?
A. Fees for clinical laboratory services may be found in First Coast’s fee schedule lookup and under fee schedule data files for compressed, tab-delimited files. Additional information may be found here, and on the Centers for Medicare & Medicaid Services (CMS) website at: http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/ClinicalLabFeeSched/index.html external link.
A. Select your location (Florida, Puerto Rico, or the U.S. Virgin Islands) and line of business (Part A or Part B) on the homepage of the First Coast Service Options (First Coast) Medicare provider website. This will allow you to view information that pertains specifically to your geographic location as well as your type of business. After you have selected your location, you may easily select your line of business and go directly to the ”Fee Schedules” page in one step -- just select “Fee Schedules” from the category list on the Part A or Part B homepage.
You can also access the “Fee Schedules” page for your line of business from the “Quick Find” drop-down menu located in the left-hand navigation area on each page of the website.
Once you have arrived on the “Fee Schedules” page (Part A or Part B), you’ll have access to:
• The latest news and information about fee schedules in the “News” information box
• Location-specific fee information for Part A and Part B for most Medicare-covered procedure codes with First Coast’s easy-to-use, interactive look-up tool.
• Printable Part B portable document format (PDF) fee schedules and text-only fee schedule data files that can be imported into a spreadsheet or database.
• Fee schedules and fee schedule-related information from previous payment years in First Coast’s comprehensive archive
http://medicare.fcso.com/Fee_lookup/fee_schedule.asp
Q. Where can I find fees for durable medical equipment, prosthetics/orthotics, and supplies?
A. Fees for local and joint jurisdiction durable medical equipment, prosthetics/orthotics, and supplies (DMEPOS) may be found in First Coast Service Options’ fee schedule lookup and on the Centers for Medicare & Medicaid Services (CMS) website at: http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/DMEPOSFeeSched/DMEPOS-Fee-Schedule.html
Q. Where can I find fees for physician fee schedule services?
A. Fees for fee schedule services paid under the Medicare physician fee schedule database (MPFSDB), for Part A as well as Part B, may be found in First Coast Service Options’ fee schedule lookup, and under fee schedule data files for compressed, tab-delimited files. Additional information may be found here for Part A or here for Part B, and on the Centers for Medicare & Medicaid Services (CMS) website at: http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched/index.html external link.
Q. Where can I find fees for clinical laboratory services?
A. Fees for clinical laboratory services may be found in First Coast’s fee schedule lookup and under fee schedule data files for compressed, tab-delimited files. Additional information may be found here, and on the Centers for Medicare & Medicaid Services (CMS) website at: http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/ClinicalLabFeeSched/index.html external link.
Medicare schedule update - Important steps and dates involved in every year
Key Implementation Dates
A detailed schedule of key implementation dates will be provided in an annual temporary instruction in advance of receiving the MPFS Database file. The following outlines significant disclosure activities and anticipated implementation dates. A detailed schedule is provided under separate cover by CMS.
Carriers must:
October:
• Download fee schedules
• Download HCPCS
November:
• Release participation materials and disclosure reports;
• Furnish yearly physician fee schedule amounts to CMS for carrier priced codes;
December:
• Furnish DMEPOS fee schedule and physician fee schedules to State Medicaid Agencies;
• Furnish conversion factors and inflation indexed charge data to the carrier State Medicaid Agencies;
• Process participation elections and withdrawals; and,
• Send a complete fee schedule to the State medical societies and State beneficiary associations.
January:
• Implement annual fee schedule amounts;
• Implement annual HCPCS update;
• Send an updated provider file to the Railroad Retirement Board; and
• Load MEDPARD equivalent information on the carrier Web site.
February:
• Submit participation counts to CMS Central Office via CROWD.
A detailed schedule of key implementation dates will be provided in an annual temporary instruction in advance of receiving the MPFS Database file. The following outlines significant disclosure activities and anticipated implementation dates. A detailed schedule is provided under separate cover by CMS.
Carriers must:
October:
• Download fee schedules
• Download HCPCS
November:
• Release participation materials and disclosure reports;
• Furnish yearly physician fee schedule amounts to CMS for carrier priced codes;
December:
• Furnish DMEPOS fee schedule and physician fee schedules to State Medicaid Agencies;
• Furnish conversion factors and inflation indexed charge data to the carrier State Medicaid Agencies;
• Process participation elections and withdrawals; and,
• Send a complete fee schedule to the State medical societies and State beneficiary associations.
January:
• Implement annual fee schedule amounts;
• Implement annual HCPCS update;
• Send an updated provider file to the Railroad Retirement Board; and
• Load MEDPARD equivalent information on the carrier Web site.
February:
• Submit participation counts to CMS Central Office via CROWD.
Annual Medicare Physician Fee Schedule File Information
The CMS transmits the annual Medicare Physician Fee Schedule (MPFS) file electronically for carriers/MACs to download each year around late-October. The annual MPFS files (including anesthesia and purchased diagnostic) are effective January 1st. Carriers/MACs must implement these files each January, unless otherwise directed by CMS.
NOTE: There will be an annual recurring change request for the implementation of the yearly Medicare Physician Fee Schedule Files.
The CMS will advise all contractors, via email notification, when annual MPFS files are available for download from the mainframe. Carriers/MACs can retrieve the new files and begin the process of testing and loading the new fees into the system. Carriers/MACs must place the new fees, including the anesthesia conversion factor(s), on their Web site after the MPFS final rule is placed on display. (The CMS will send notification of when the MPFS final rule is put on display via email.)
In addition, there may be last minute corrections, therefore you may have to retrieve one or more MPFS corrected files. Notification of the availability of any correction files, including the file names, will be made via an email to Carriers and MACs.
NOTE: There will be an annual recurring change request for the implementation of the yearly Medicare Physician Fee Schedule Files.
The CMS will advise all contractors, via email notification, when annual MPFS files are available for download from the mainframe. Carriers/MACs can retrieve the new files and begin the process of testing and loading the new fees into the system. Carriers/MACs must place the new fees, including the anesthesia conversion factor(s), on their Web site after the MPFS final rule is placed on display. (The CMS will send notification of when the MPFS final rule is put on display via email.)
In addition, there may be last minute corrections, therefore you may have to retrieve one or more MPFS corrected files. Notification of the availability of any correction files, including the file names, will be made via an email to Carriers and MACs.
Office visit CPT, E&M code fee schedule - Florida Medicare
CPT Code Medicare Allowed Amount
99201 Office visit new level 1 $43.80
99202 Office visit new level 2 $74.53
99203 Office visit new level 3 $109.06
99204 Office visit new level 4 $166.63
99205 Office visit new level 5 $206.10
99211 Office visit est. level 1 $20.16
99212 Office visit est. level 2 $43.80
99213 Office visit est. level 3 $72.93
99214 Office visit est. level 4 $107.04
99215 Office visit est. level 5 $143.41
99241 Office Consult 15 min minor $47.21
99242 Office Consult 30 min low $89.22
99243 Office Consult 40 min moderate $121.56
99244 Office Consult 60 min mod/high $178.92
99245 Office Consult 80 min mod/low $219.34
99223 Hospital care initial level 3 $201.65
99231 Hospital care subsequent level 1 $38.71
99232 Hospital care subsequent level 2 $70.95
99233 Hospital care subequent level 3 $102.38
99235 Observ or inpatient hosp care $166.98
99238 Hosp discharge day mgmt;30 min or less $71.29
99251 I/P consult 20 min $48.26
99252 I/P consult 40 min low $74.50
99253 I/P consult 55 min moderate $112.82
99254 I/P consult 80 min moderate/high $161.96
99255 I/P consult 110 min moderate/high $202.13
99291 Critical care first hour $275.14
99374 Home hlth supervision 15 29 m $69.45
99395 Preventive checkup est 18 39 $117.19
99396 Preventive checkup est 40 64 $125.33
99397 Preventive checkup est 65 y $135.18
90471 Vaccine only $25.41
90658 Flu vac split 3 years intr
90732 Pneumococcal vaccine -0.5 ml $65.77
90749 Immunization procedure nec
90935 Hemodialysis one evaluation $72.04
90945 Dialysis one evaluation $85.30
90960 ESRD - 4 or more visits per month $284.51
90961 ESRD - for 2 to 3 visits per month $239.69
90962 ESRD - Per visit per month $185.58
90966 PD Home dialysis $239.36
90970 ESRD less than a month 20 yrs and old $7.93
93000 Electrocardiogram complete $18.37
93005 Electrocardiogram tracing onl $10.08
94640 Airway inhalation treatment $18.97
94664 Aerosol or vapor inhalations $18.31
96372 Injection admin code $25.41
G0008 Flu vaccine $23.78
G0009 Admin of pneumococcal vaccine $23.78
G0179 Phys Recertification For Medicare Cov $41.27
G0180 Home health certification $52.90
G0438 Short descriptor - Annual wellness first $169.05
G0439 Short descriptor - Annual wellness subsequent $110.58
G0101 Female examination/medicare $37.97
G0102 Prostat Cancer Screening $19.82
10040 Acne surgery $104.69
10060 Incision/drainage of abscess;simple $118.00
11042 Surgical cleansing of skin tis $119.95
11100 Biopsy of skin lesion $106.16
11302 Shave skin lesion trunk arm l $144.56
11400 Remove lesion trunk arm leg $126.21
17110 Destroy flat wart up to 14 le $113.01
69210 Remove impacted ear wax $53.43
81002 Urinalysis nonauto w/o scope $3.52
82270 Test for blood feces $4.48
82947 Assay of glucose quant $5.39
85610 Prothrombin time $5.40
86580 Tb intradermal test $8.10
88142 CYTOPATH C/V THIN LAYER $27.75
J0696 Rocephin 1 gram $0.72
J0881 Aranesp 5 mcg $3.44
J1080 Testosterone shot $5.78
J1815 Insulin Injection $0.53
J3301 Kenalog $1.79
J3420 B12 inj. $0.56
Q0091 Pap smear, sample retrieval $45.46
Q2037 Fluvirin vacc, 3 yrs & >, im $14.05
99201 Office visit new level 1 $43.80
99202 Office visit new level 2 $74.53
99203 Office visit new level 3 $109.06
99204 Office visit new level 4 $166.63
99205 Office visit new level 5 $206.10
99211 Office visit est. level 1 $20.16
99212 Office visit est. level 2 $43.80
99213 Office visit est. level 3 $72.93
99214 Office visit est. level 4 $107.04
99215 Office visit est. level 5 $143.41
99241 Office Consult 15 min minor $47.21
99242 Office Consult 30 min low $89.22
99243 Office Consult 40 min moderate $121.56
99244 Office Consult 60 min mod/high $178.92
99245 Office Consult 80 min mod/low $219.34
99223 Hospital care initial level 3 $201.65
99231 Hospital care subsequent level 1 $38.71
99232 Hospital care subsequent level 2 $70.95
99233 Hospital care subequent level 3 $102.38
99235 Observ or inpatient hosp care $166.98
99238 Hosp discharge day mgmt;30 min or less $71.29
99251 I/P consult 20 min $48.26
99252 I/P consult 40 min low $74.50
99253 I/P consult 55 min moderate $112.82
99254 I/P consult 80 min moderate/high $161.96
99255 I/P consult 110 min moderate/high $202.13
99291 Critical care first hour $275.14
99374 Home hlth supervision 15 29 m $69.45
99395 Preventive checkup est 18 39 $117.19
99396 Preventive checkup est 40 64 $125.33
99397 Preventive checkup est 65 y $135.18
90471 Vaccine only $25.41
90658 Flu vac split 3 years intr
90732 Pneumococcal vaccine -0.5 ml $65.77
90749 Immunization procedure nec
90935 Hemodialysis one evaluation $72.04
90945 Dialysis one evaluation $85.30
90960 ESRD - 4 or more visits per month $284.51
90961 ESRD - for 2 to 3 visits per month $239.69
90962 ESRD - Per visit per month $185.58
90966 PD Home dialysis $239.36
90970 ESRD less than a month 20 yrs and old $7.93
93000 Electrocardiogram complete $18.37
93005 Electrocardiogram tracing onl $10.08
94640 Airway inhalation treatment $18.97
94664 Aerosol or vapor inhalations $18.31
96372 Injection admin code $25.41
G0008 Flu vaccine $23.78
G0009 Admin of pneumococcal vaccine $23.78
G0179 Phys Recertification For Medicare Cov $41.27
G0180 Home health certification $52.90
G0438 Short descriptor - Annual wellness first $169.05
G0439 Short descriptor - Annual wellness subsequent $110.58
G0101 Female examination/medicare $37.97
G0102 Prostat Cancer Screening $19.82
10040 Acne surgery $104.69
10060 Incision/drainage of abscess;simple $118.00
11042 Surgical cleansing of skin tis $119.95
11100 Biopsy of skin lesion $106.16
11302 Shave skin lesion trunk arm l $144.56
11400 Remove lesion trunk arm leg $126.21
17110 Destroy flat wart up to 14 le $113.01
69210 Remove impacted ear wax $53.43
81002 Urinalysis nonauto w/o scope $3.52
82270 Test for blood feces $4.48
82947 Assay of glucose quant $5.39
85610 Prothrombin time $5.40
86580 Tb intradermal test $8.10
88142 CYTOPATH C/V THIN LAYER $27.75
J0696 Rocephin 1 gram $0.72
J0881 Aranesp 5 mcg $3.44
J1080 Testosterone shot $5.78
J1815 Insulin Injection $0.53
J3301 Kenalog $1.79
J3420 B12 inj. $0.56
Q0091 Pap smear, sample retrieval $45.46
Q2037 Fluvirin vacc, 3 yrs & >, im $14.05
Medicare part b payment and deductible update as of Feb 2012
New law includes physician update fix through February 2012
On Friday, December 23, 2011, President Obama signed into law the Temporary Payroll Tax Cut Continuation Act of 2011 (TPTCCA). This new law prevents a scheduled payment cut for physicians and other practitioners who treat Medicare patients from taking effect immediately. While the negative update for the 2012 Medicare Physician Fee Schedule is now scheduled to take effect on March 1, 2012, the administration remains strongly opposed to letting this cut take effect. As he has repeatedly made clear, President Obama is committed to a permanent solution to eliminating the sustainable growth rate’s cut. We will continue to work with Congress to achieve this goal.
The Centers for Medicare & Medicaid Services (CMS) has also recently implemented several important changes for Medicare providers and beneficiaries, and we would like to remind physicians and practitioners of some of these key changes for 2012. For many of your patients, Medicare costs will go down. Medicare cost-sharing for Part B services will decline in some cases and, for the first time, the Part B deductible will decrease, by $22, to $140.
Additionally, health care professionals will be paid more to provide certain important services for people with Medicare. CMS has increased the payment amount for the initial and annual wellness visit -- which has no cost sharing for patients -- to account for the introduction of health risk assessment (HRA). CMS believes it is important to balance the comprehensiveness of the HRA with the potential burden on patients and health professional time constraints. As such, in 2012, CMS will allow for variation in the content of the HRA.
The Medicare Part D prescription drug program has also been enhanced for 2012, with the coverage gap being further reduced as it is phased-out over the next several years. These improvements to the drug benefit from the Affordable Care Act have already saved millions of seniors nearly $2 billion.
CMS wishes to remind physicians and practitioners about the Primary Care Incentive Program. Again in 2012, primary care physicians, nurse practitioners, clinical nurse specialists, and physician assistants may be eligible to receive an incentive payment equal to 10 percent of their allowed charges for primary care services under Medicare Part B. This incentive is paid in addition to any physician incentive payments for services furnished in Health Professional Shortage Areas. Please remember that if a practitioner has reassigned his or her benefits to another entity, such as a group practice, Medicare will pay that entity and not the individual practitioner.
On Friday, December 23, 2011, President Obama signed into law the Temporary Payroll Tax Cut Continuation Act of 2011 (TPTCCA). This new law prevents a scheduled payment cut for physicians and other practitioners who treat Medicare patients from taking effect immediately. While the negative update for the 2012 Medicare Physician Fee Schedule is now scheduled to take effect on March 1, 2012, the administration remains strongly opposed to letting this cut take effect. As he has repeatedly made clear, President Obama is committed to a permanent solution to eliminating the sustainable growth rate’s cut. We will continue to work with Congress to achieve this goal.
The Centers for Medicare & Medicaid Services (CMS) has also recently implemented several important changes for Medicare providers and beneficiaries, and we would like to remind physicians and practitioners of some of these key changes for 2012. For many of your patients, Medicare costs will go down. Medicare cost-sharing for Part B services will decline in some cases and, for the first time, the Part B deductible will decrease, by $22, to $140.
Additionally, health care professionals will be paid more to provide certain important services for people with Medicare. CMS has increased the payment amount for the initial and annual wellness visit -- which has no cost sharing for patients -- to account for the introduction of health risk assessment (HRA). CMS believes it is important to balance the comprehensiveness of the HRA with the potential burden on patients and health professional time constraints. As such, in 2012, CMS will allow for variation in the content of the HRA.
The Medicare Part D prescription drug program has also been enhanced for 2012, with the coverage gap being further reduced as it is phased-out over the next several years. These improvements to the drug benefit from the Affordable Care Act have already saved millions of seniors nearly $2 billion.
CMS wishes to remind physicians and practitioners about the Primary Care Incentive Program. Again in 2012, primary care physicians, nurse practitioners, clinical nurse specialists, and physician assistants may be eligible to receive an incentive payment equal to 10 percent of their allowed charges for primary care services under Medicare Part B. This incentive is paid in addition to any physician incentive payments for services furnished in Health Professional Shortage Areas. Please remember that if a practitioner has reassigned his or her benefits to another entity, such as a group practice, Medicare will pay that entity and not the individual practitioner.
Medicare 2012 Fee schedule update
Payment rate changes for the 2012 Medicare physician fee schedule
The Centers for Medicare & Medicaid Services (CMS) issued a final rule with comment period that updates payment policies and rates for physicians and nonphysician practitioners (NPPs) for services paid under the Medicare physician fee schedule (MPFS) in calendar year (CY) 2012. More than one million providers of vital health services to Medicare beneficiaries – including physicians, limited license practitioners such as podiatrists, and NPPs such as nurse practitioners and physical therapists – are paid under the MPFS. CMS projects that total payments under the MPFS in CY 2012 will be approximately $80 billion.
CMS is required to issue a final rule that reflects current law. Under current law, providers will face steep across-the-board reductions in payment rates, based on a formula -- the sustainable growth rate (SGR) – that was adopted in the Balanced Budget Act of 1997. Without a change in the law from Congress, Medicare payment rates to providers paid under the MPFS will be reduced by 27.4 percent for services in CY 2012 – less than the 29.5 percent reduction that CMS had estimated in March of this year because Medicare cost growth has been lower than expected. This is the eleventh time the SGR formula has resulted in a payment cut, although the cuts have been averted through legislation in all but CY 2002. The Obama administration is committed to fixing the SGR and ensuring these payment cuts do not take effect.
In an effort to ensure Medicare is paying accurately for physician services and more closely managing the payment system, CMS has expanded the potentially misvalued code initiative in the CY 2012 final rule. This year, CMS is focusing on the codes billed by physicians in each specialty that result in the highest Medicare expenditures under the MPFS to determine whether these codes are overvalued. In the past, CMS has targeted specific codes for review that may have affected a few procedural specialties (e.g., cardiology, radiology, nuclear medicine); however, CMS has not taken a look at the highest expenditure codes across all specialties. This effort results in increased payments for primary care services that have historically been undervalued by the fee schedule.
CMS is also making changes in how it adjusts payment for geographic variation in the costs of practice. The Affordable Care Act and the Medicare and Medicaid Extensions Act made some temporary adjustments that were in place for two years while CMS and the Institute of Medicine (IOM) began to comprehensively study these issues. The final rule with comment period will appear in the November 28, 2011, Federal Register. CMS will accept comments on those provisions that are subject to comment until Tuesday, January 3, 2012, and will respond in the MPFS for CY 2013.
The Centers for Medicare & Medicaid Services (CMS) issued a final rule with comment period that updates payment policies and rates for physicians and nonphysician practitioners (NPPs) for services paid under the Medicare physician fee schedule (MPFS) in calendar year (CY) 2012. More than one million providers of vital health services to Medicare beneficiaries – including physicians, limited license practitioners such as podiatrists, and NPPs such as nurse practitioners and physical therapists – are paid under the MPFS. CMS projects that total payments under the MPFS in CY 2012 will be approximately $80 billion.
CMS is required to issue a final rule that reflects current law. Under current law, providers will face steep across-the-board reductions in payment rates, based on a formula -- the sustainable growth rate (SGR) – that was adopted in the Balanced Budget Act of 1997. Without a change in the law from Congress, Medicare payment rates to providers paid under the MPFS will be reduced by 27.4 percent for services in CY 2012 – less than the 29.5 percent reduction that CMS had estimated in March of this year because Medicare cost growth has been lower than expected. This is the eleventh time the SGR formula has resulted in a payment cut, although the cuts have been averted through legislation in all but CY 2002. The Obama administration is committed to fixing the SGR and ensuring these payment cuts do not take effect.
In an effort to ensure Medicare is paying accurately for physician services and more closely managing the payment system, CMS has expanded the potentially misvalued code initiative in the CY 2012 final rule. This year, CMS is focusing on the codes billed by physicians in each specialty that result in the highest Medicare expenditures under the MPFS to determine whether these codes are overvalued. In the past, CMS has targeted specific codes for review that may have affected a few procedural specialties (e.g., cardiology, radiology, nuclear medicine); however, CMS has not taken a look at the highest expenditure codes across all specialties. This effort results in increased payments for primary care services that have historically been undervalued by the fee schedule.
CMS is also making changes in how it adjusts payment for geographic variation in the costs of practice. The Affordable Care Act and the Medicare and Medicaid Extensions Act made some temporary adjustments that were in place for two years while CMS and the Institute of Medicine (IOM) began to comprehensively study these issues. The final rule with comment period will appear in the November 28, 2011, Federal Register. CMS will accept comments on those provisions that are subject to comment until Tuesday, January 3, 2012, and will respond in the MPFS for CY 2013.
Medicare Part D premium cost - patient out of pocket expense
2012 Medicare Prescription Drug Plan (part D) Premium Cost
Part D Monthly Premium
The chart below shows your estimated prescription drug plan monthly premium based on your income. If your income is above a certain limit, you will pay an income-related monthly adjustment amount in addition to your plan premium.
If Your Yearly Income in 2010 was
File Individual Tax Return File Joint Tax Return You pay
$85,000 or less $170,000 or less Your Plan Premium
above $85,001 up to $107,000 above $170,001 up to $214,000 $11.60 + Your Plan Premium
above $107,001 up to $160,000 above $214,001 up to $320,000 $29.90 + Your Plan Premium
above $160,001 up to $214,000 above $320,001 up to $428,000 $48.10 + Your Plan Premium
above $214,000 above $428,000 $66.40 + Your Plan Premium
Part D Monthly Premium
The chart below shows your estimated prescription drug plan monthly premium based on your income. If your income is above a certain limit, you will pay an income-related monthly adjustment amount in addition to your plan premium.
If Your Yearly Income in 2010 was
File Individual Tax Return File Joint Tax Return You pay
$85,000 or less $170,000 or less Your Plan Premium
above $85,001 up to $107,000 above $170,001 up to $214,000 $11.60 + Your Plan Premium
above $107,001 up to $160,000 above $214,001 up to $320,000 $29.90 + Your Plan Premium
above $160,001 up to $214,000 above $320,001 up to $428,000 $48.10 + Your Plan Premium
above $214,000 above $428,000 $66.40 + Your Plan Premium
Patient responsibility in 2012 Medicare Part B(Medical Insurance) Cost
Part B Monthly Premium
You pay a Part B premium each month. Most people will pay the standard premium amount. However, if your modified adjusted gross income as reported on your IRS tax return from 2 years ago is above a certain amount, you may pay more.
If Your Yearly Income in 2010 was
File Individual Tax Return File Joint Tax Return You pay
$85,000 or less $170,000 or less $99.90
above $85,001 up to $107,000 above $170,001 up to $214,000 $139.90
above $107,001 up to $160,000 above $214,001 up to $320,000 $199.80
above $160,001 up to $214,000 above $320,001 up to $428,000 $259.70
above $214,000 above $428,000 $319.70
Part B Services
Services : Part B Deductible
You pay $140 per year.
Services : Blood
You pay : In most cases, the provider gets blood from a blood bank at no charge, and you won't have to pay for it or replace it. However, you will pay a copayment for the blood processing and handling services for every unit of blood you get, and the Part B deductible applies.
If the provider has to buy blood for you, you must either pay the provider costs for the first 3 units of blood you get in a calendar year or have the blood donated by you or someone else.
You pay a copayment for additional units of blood you get as an outpatient (after the first 3), and the Part B deductible applies.
Services : Clinical Laboratory Services
You pay: $0 for Medicare-approved services.
Services : Home Health Services
You pay: $0 for Medicare-approved services. You pay 20% of the Medicare-approved amount for durable medical equipment.
Services : Medical and Other Services
You pay: 20% of the Medicare-approved amount for most doctor services (including most doctor services while you're a hospital inpatient), outpatient therapy*, and durable medical equipment.
Services : Mental Health Services
You pay: 40% of the Medicare-approved amount for most outpatient mental health care.
Services : Other Covered Services
You pay: copayment or coinsurance amounts.
Services : Outpatient Hospital Services
You pay: a coinsurance (for doctor services) or a copayment amount for most outpatient hospital services.
The copayment for a single service can't be more than the amount of the inpatient hospital deductible.
* In 2012, there may be limits on physical therapy, occupational therapy, and speech language pathology services. If so, there may be exceptions to these limits.
Note: All Medicare Advantage Plans must cover these services. Costs vary by plan and may be either higher or lower than those noted above. Review the Evidence of Coverage from your plan.
2012 Medicare Part -A (Hospital Insurance) Cost - How much beneficiary need to pay
Part A Services
Services : Blood
You Pay In most cases, the hospital gets blood from a blood bank at no charge, and you won't have to pay for it or replace it. If the hospital has to buy blood for you, you must either pay the hospital costs for the first 3 units of blood you get in a calendar year or have the blood donated.
Services : Home Health Care
You pay:
Services : Hospice Care
You pay:
Services : Hospital Inpatient Stay
You pay:
You pay:
Services : Blood
You Pay In most cases, the hospital gets blood from a blood bank at no charge, and you won't have to pay for it or replace it. If the hospital has to buy blood for you, you must either pay the hospital costs for the first 3 units of blood you get in a calendar year or have the blood donated.
Services : Home Health Care
You pay:
- $0 for home health care services
- 20% of the Medicare-approved amount for durable medical equipment
Services : Hospice Care
You pay:
- $0 for hospice care
- A copayment of up to $5 per prescription for outpatient prescription drugs for pain and symptom management
- 5% of the Medicare-approved amount for inpatient respite care (short-term care given by another caregiver, so the usual caregiver can rest)
Services : Hospital Inpatient Stay
You pay:
- $1,156 deductible per benefit period
- $0 for the first 60 days of each benefit period
- $289 per day for days 61-90 of each benefit period
- $578 per "lifetime reserve day" after day 90 of each benefit period (up to a maximum of 60 days over your lifetime)
You pay:
- $0 for the first 20 days each benefit period
- $144.50 per day for days 21-100 each benefit period
- All costs for each day after day 100 in a benefit period
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.
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.
physician payment schedule for 2011
Proposed 2011 Physician Payment Schedule
On August 24, 2010 the AMA submitted a comment letter to the Centers for Medicare and Medicaid Services’ (CMS) regarding the proposed physician fee schedule rule for CY 2011. The AMA's principal recommendations are as follows:
• The AMA strongly supports the proposed comprehensive review of the Medicare Economic Index (MEI). The MEI needs to reflect the realities of medical practice in the 21st century and the AMA welcomes the proposed review. Until this review of the MEI is completed, CMS should withdraw the changes it has proposed to the MEI for CY 2011, as well as the revisions to the relative value units (RVUs) and geographic practice cost indexes (GPCIs) that arise from the proposed changes to the MEI.
• CMS should revise the Physician Quality Reporting Initiative (PQRI) feedback report proposal to ensure that this process improves successful participation in the PQRI program.
• To implement a successful informal PQRI appeals process, CMS should significantly improve the Quality Net Help Desk by adding more telephone lines and hiring more trained and experienced, qualified staff.
• The AMA applauds CMS’ decision to change the definition of group practice from 200 to 2, as it will allow more physician practices to participate in the group practice reporting option (GPRO) for 2011.
• CMS must publish detailed specifications for individual measures and measures groups for the PQRI November 15, 2010.
• The AMA applauds CMS’ decision to reduce the PQRI reporting sample requirement from 80 percent to 50 percent for FY 2011. The AMA urges CMS to also use its existing authority to apply the new 50 percent threshold retrospectively to the 2010 reporting year.
• The AMA supports enhancing the measures and methods used in the resource use Physician Resource Use Measurement and Reporting Program (RUR). Under this program, CMS must adequately prepare for handling additional feedback report requests and distribution techniques, and until adequate risk adjustment and attribution models are widely tested and applicable, these reports should not be publicly reportable.
• We strongly support CMS’ proposed requirements for the 2011 electronic prescribing (e-prescribing) incentive payment program, which is to require reporting on only 25 services involving electronic prescriptions.
• We strongly oppose CMS’ proposal to impose financial penalties in 2012 and 2013 against physicians based on their e-prescribing activity during the first six months of 2011. Instead, we strongly urge CMS to review 2012 and 2013 e-prescribing activity (not 2011 e-prescribing activity) in order to assess penalties in 2012 and 2013.
• We strongly recommend that CMS add more exception categories so that more physicians facing hardship will be eligible for an exemption from e-prescribing penalties in 2012 and 2013.
• We also recommend that CMS provide feedback reports to physicians and establish an appeals process to allow physicians to appeal decisions that affect their eligibility to take part in the e-prescribing program or that affect their ability to get e-prescribing incentives.
• CMS should take appropriate measures to ensure the accuracy of the list of successful e-prescribers and to provide the appropriate disclaimers for the website listing.
• The AMA strongly supports better coverage for preventive care. CMS should work through the established Current Procedural Terminology (CPT) Editorial Panel and the Relative Value System Update Committee (RUC) process to adopt existing CPT codes for the annual preventive visits rather than establishing separate Healthcare Common Procedure Coding System (HCPCS) G-Codes for these services.
• CMS should expand the availability of the primary care incentive payments by interpreting “allowed charges” as charges under the physician fee schedule, and not as all Part B charges.
• CMS should ensure that the general surgery bonus payments promote access to these important services for patients by modifying the Health Professional Shortage Area (HPSA) criteria to allow a non-HPSA hospital to be part of a HPSA if: (i) the hospital is adjacent to a HPSA; (ii) the patient resides in a HPSA; or (iii) the general surgeon maintains an office in a HPSA.
• CMS should seek input from the RUC and its Health Care Professionals Advisory Committee on the efficiencies or reduced resources involved in services provided to the same patient in the same session or on the same day rather than implementing arbitrary multiple procedural payment reductions for imaging and therapy services.
• The ACA contained a number of provisions that apply retroactively, which requires CMS to re-process claims for various physicians’ services. CMS should issue guidance to its contractors about reprocessing these claims in a manner that minimizes the burden on physicians and avoids further confusion and payment delays. CMS should also make this guidance publicly available so that physician organizations can disseminate it to our members.
More detailed analysis of the AMA's recommendations on specific issues can be found below and in the comment letter to CMS.
On August 24, 2010 the AMA submitted a comment letter to the Centers for Medicare and Medicaid Services’ (CMS) regarding the proposed physician fee schedule rule for CY 2011. The AMA's principal recommendations are as follows:
• The AMA strongly supports the proposed comprehensive review of the Medicare Economic Index (MEI). The MEI needs to reflect the realities of medical practice in the 21st century and the AMA welcomes the proposed review. Until this review of the MEI is completed, CMS should withdraw the changes it has proposed to the MEI for CY 2011, as well as the revisions to the relative value units (RVUs) and geographic practice cost indexes (GPCIs) that arise from the proposed changes to the MEI.
• CMS should revise the Physician Quality Reporting Initiative (PQRI) feedback report proposal to ensure that this process improves successful participation in the PQRI program.
• To implement a successful informal PQRI appeals process, CMS should significantly improve the Quality Net Help Desk by adding more telephone lines and hiring more trained and experienced, qualified staff.
• The AMA applauds CMS’ decision to change the definition of group practice from 200 to 2, as it will allow more physician practices to participate in the group practice reporting option (GPRO) for 2011.
• CMS must publish detailed specifications for individual measures and measures groups for the PQRI November 15, 2010.
• The AMA applauds CMS’ decision to reduce the PQRI reporting sample requirement from 80 percent to 50 percent for FY 2011. The AMA urges CMS to also use its existing authority to apply the new 50 percent threshold retrospectively to the 2010 reporting year.
• The AMA supports enhancing the measures and methods used in the resource use Physician Resource Use Measurement and Reporting Program (RUR). Under this program, CMS must adequately prepare for handling additional feedback report requests and distribution techniques, and until adequate risk adjustment and attribution models are widely tested and applicable, these reports should not be publicly reportable.
• We strongly support CMS’ proposed requirements for the 2011 electronic prescribing (e-prescribing) incentive payment program, which is to require reporting on only 25 services involving electronic prescriptions.
• We strongly oppose CMS’ proposal to impose financial penalties in 2012 and 2013 against physicians based on their e-prescribing activity during the first six months of 2011. Instead, we strongly urge CMS to review 2012 and 2013 e-prescribing activity (not 2011 e-prescribing activity) in order to assess penalties in 2012 and 2013.
• We strongly recommend that CMS add more exception categories so that more physicians facing hardship will be eligible for an exemption from e-prescribing penalties in 2012 and 2013.
• We also recommend that CMS provide feedback reports to physicians and establish an appeals process to allow physicians to appeal decisions that affect their eligibility to take part in the e-prescribing program or that affect their ability to get e-prescribing incentives.
• CMS should take appropriate measures to ensure the accuracy of the list of successful e-prescribers and to provide the appropriate disclaimers for the website listing.
• The AMA strongly supports better coverage for preventive care. CMS should work through the established Current Procedural Terminology (CPT) Editorial Panel and the Relative Value System Update Committee (RUC) process to adopt existing CPT codes for the annual preventive visits rather than establishing separate Healthcare Common Procedure Coding System (HCPCS) G-Codes for these services.
• CMS should expand the availability of the primary care incentive payments by interpreting “allowed charges” as charges under the physician fee schedule, and not as all Part B charges.
• CMS should ensure that the general surgery bonus payments promote access to these important services for patients by modifying the Health Professional Shortage Area (HPSA) criteria to allow a non-HPSA hospital to be part of a HPSA if: (i) the hospital is adjacent to a HPSA; (ii) the patient resides in a HPSA; or (iii) the general surgeon maintains an office in a HPSA.
• CMS should seek input from the RUC and its Health Care Professionals Advisory Committee on the efficiencies or reduced resources involved in services provided to the same patient in the same session or on the same day rather than implementing arbitrary multiple procedural payment reductions for imaging and therapy services.
• The ACA contained a number of provisions that apply retroactively, which requires CMS to re-process claims for various physicians’ services. CMS should issue guidance to its contractors about reprocessing these claims in a manner that minimizes the burden on physicians and avoids further confusion and payment delays. CMS should also make this guidance publicly available so that physician organizations can disseminate it to our members.
More detailed analysis of the AMA's recommendations on specific issues can be found below and in the comment letter to CMS.
MEDICARE PREMIUMS, DEDUCTIBLES FOR 2011
Second, for most Part B beneficiaries a “hold-harmless” provision prevents their net Social Security benefit from decreasing as a result of an increase in the Part B premium. There was no increase in Social Security benefits for 2010, and, as a result of slow growth in the CPI, this result will occur again for 2011. Consequently, the increase in the Part B premium for 2011 will be paid by only a small percentage of Part B enrollees. Approximately 27 percent of beneficiaries are not protected by the hold-harmless provision because they are subject to the income-related additional premium amount (5 percent), they are new enrollees during the year (3 percent), or they do not have their Part B premiums withheld from Social Security benefit payments (19 percent, 17 percentage points of whom qualify for both Medicare and Medicaid and have their Part B premiums paid by Medicaid).
Although Part B premiums will remain flat in 2011 for the great majority of beneficiaries, program costs will still increase significantly. In order for Part B to be adequately funded in 2011, the 2011 contingency margin has been increased to account for this situation. However, this adjustment results in a larger-than-usual premium paid by or on behalf of a minority of Part B enrollees. No other means is available under current law to prevent a substantial decrease in account assets, which would jeopardize the ability to pay Part B benefits.
As required in the Medicare Prescription Drug, Improvement, and Modernization Act of 2003, beginning in 2007 the Part B premium a beneficiary pays each month is based on his or her annual income. Specifically, if a beneficiary’s “modified adjusted gross income” is greater than the legislated threshold amounts ($85,000 in 2011 for a beneficiary filing an individual income tax return or married and filing a separate return, and $170,000 for a beneficiary filing a joint tax return) the beneficiary is responsible for a larger portion of the estimated total cost of Part B benefit coverage. In addition to the standard 25 percent premium, affected beneficiaries must pay an income-related monthly adjustment amount. About 5 percent of current Part B enrollees are expected to be subject to the higher premium amounts.
The 2011 Part B monthly premium rates to be paid by beneficiaries who file an individual tax return (including those who are single, head of household, qualifying widow(er) with dependent child, or married filing separately who lived apart from their spouse for the entire taxable year), or who file a joint tax return are shown in the following table:
Beneficiaries who file an individual tax return with income: | Beneficiaries who file a joint tax return with income: | Part B income-related monthly adjustment amount | Total monthly Part B premium amount |
Less than or equal to $85,000 | Less than or equal to $170,000 | $0.00 | $115.40 |
Greater than $85,000 and less than or equal to $107,000 | Greater than $170,000 and less than or equal to $214,000 | $46.10 | $161.50 |
Greater than $107,000 and less than or equal to $160,000 | Greater than $214,000 and less than or equal to $320,000 | $115.30 | $230.70 |
Greater than $160,000 and less than or equal to $214,000 | Greater than $320,000 and less than or equal to $428,000 | $184.50 | $299.90 |
Greater than $214,000 | Greater than $428,000 | $253.70 | $369.10 |
In addition, the monthly premium rates to be paid by beneficiaries who are married, but file a separate return from their spouse and lived with their spouse at any time during the taxable year are as follows:
Beneficiaries who are married but file a separate tax return from their spouse: | Part B income-related monthly adjustment amount | Total monthly Part B premium amount |
Less than or equal to $85,000 | $0.00 | $115.40 |
Greater than $85,000 and less than or equal to $129,000 | $184.50 | $299.90 |
Greater than $129,000 | $253.70 | $369.10 |
As a result of the Medicare Modernization Act, the Part B deductible was increased to $110 in 2005 and is indexed by the annual percentage increase in the Part B actuarial rate for aged beneficiaries. In 2011, the Part B deductible will be $162. (The actuarial rate is set by law at one-half of the total estimated per-enrollee cost of Part B benefits and administrative expenses, adjusted as necessary to maintain an adequate contingency reserve.)
Proposed 2011 Physician Payment Schedule update
Proposed 2011 Physician Payment Schedule
On August 24, 2010 the AMA submitted a comment letter to the Centers for Medicare and Medicaid Services’ (CMS) regarding the proposed physician fee schedule rule for CY 2011. The AMA's principal recommendations are as follows:
• The AMA strongly supports the proposed comprehensive review of the Medicare Economic Index (MEI). The MEI needs to reflect the realities of medical practice in the 21st century and the AMA welcomes the proposed review. Until this review of the MEI is completed, CMS should withdraw the changes it has proposed to the MEI for CY 2011, as well as the revisions to the relative value units (RVUs) and geographic practice cost indexes (GPCIs) that arise from the proposed changes to the MEI.
• CMS should revise the Physician Quality Reporting Initiative (PQRI) feedback report proposal to ensure that this process improves successful participation in the PQRI program.
• To implement a successful informal PQRI appeals process, CMS should significantly improve the Quality Net Help Desk by adding more telephone lines and hiring more trained and experienced, qualified staff.
• The AMA applauds CMS’ decision to change the definition of group practice from 200 to 2, as it will allow more physician practices to participate in the group practice reporting option (GPRO) for 2011.
• CMS must publish detailed specifications for individual measures and measures groups for the PQRI November 15, 2010.
• The AMA applauds CMS’ decision to reduce the PQRI reporting sample requirement from 80 percent to 50 percent for FY 2011. The AMA urges CMS to also use its existing authority to apply the new 50 percent threshold retrospectively to the 2010 reporting year.
• The AMA supports enhancing the measures and methods used in the resource use Physician Resource Use Measurement and Reporting Program (RUR). Under this program, CMS must adequately prepare for handling additional feedback report requests and distribution techniques, and until adequate risk adjustment and attribution models are widely tested and applicable, these reports should not be publicly reportable.
• We strongly support CMS’ proposed requirements for the 2011 electronic prescribing (e-prescribing) incentive payment program, which is to require reporting on only 25 services involving electronic prescriptions.
• We strongly oppose CMS’ proposal to impose financial penalties in 2012 and 2013 against physicians based on their e-prescribing activity during the first six months of 2011. Instead, we strongly urge CMS to review 2012 and 2013 e-prescribing activity (not 2011 e-prescribing activity) in order to assess penalties in 2012 and 2013.
• We strongly recommend that CMS add more exception categories so that more physicians facing hardship will be eligible for an exemption from e-prescribing penalties in 2012 and 2013.
• We also recommend that CMS provide feedback reports to physicians and establish an appeals process to allow physicians to appeal decisions that affect their eligibility to take part in the e-prescribing program or that affect their ability to get e-prescribing incentives.
• CMS should take appropriate measures to ensure the accuracy of the list of successful e-prescribers and to provide the appropriate disclaimers for the website listing.
• The AMA strongly supports better coverage for preventive care. CMS should work through the established Current Procedural Terminology (CPT) Editorial Panel and the Relative Value System Update Committee (RUC) process to adopt existing CPT codes for the annual preventive visits rather than establishing separate Healthcare Common Procedure Coding System (HCPCS) G-Codes for these services.
• CMS should expand the availability of the primary care incentive payments by interpreting “allowed charges” as charges under the physician fee schedule, and not as all Part B charges.
• CMS should ensure that the general surgery bonus payments promote access to these important services for patients by modifying the Health Professional Shortage Area (HPSA) criteria to allow a non-HPSA hospital to be part of a HPSA if: (i) the hospital is adjacent to a HPSA; (ii) the patient resides in a HPSA; or (iii) the general surgeon maintains an office in a HPSA.
• CMS should seek input from the RUC and its Health Care Professionals Advisory Committee on the efficiencies or reduced resources involved in services provided to the same patient in the same session or on the same day rather than implementing arbitrary multiple procedural payment reductions for imaging and therapy services.
• The ACA contained a number of provisions that apply retroactively, which requires CMS to re-process claims for various physicians’ services. CMS should issue guidance to its contractors about reprocessing these claims in a manner that minimizes the burden on physicians and avoids further confusion and payment delays. CMS should also make this guidance publicly available so that physician organizations can disseminate it to our members.
On August 24, 2010 the AMA submitted a comment letter to the Centers for Medicare and Medicaid Services’ (CMS) regarding the proposed physician fee schedule rule for CY 2011. The AMA's principal recommendations are as follows:
• The AMA strongly supports the proposed comprehensive review of the Medicare Economic Index (MEI). The MEI needs to reflect the realities of medical practice in the 21st century and the AMA welcomes the proposed review. Until this review of the MEI is completed, CMS should withdraw the changes it has proposed to the MEI for CY 2011, as well as the revisions to the relative value units (RVUs) and geographic practice cost indexes (GPCIs) that arise from the proposed changes to the MEI.
• CMS should revise the Physician Quality Reporting Initiative (PQRI) feedback report proposal to ensure that this process improves successful participation in the PQRI program.
• To implement a successful informal PQRI appeals process, CMS should significantly improve the Quality Net Help Desk by adding more telephone lines and hiring more trained and experienced, qualified staff.
• The AMA applauds CMS’ decision to change the definition of group practice from 200 to 2, as it will allow more physician practices to participate in the group practice reporting option (GPRO) for 2011.
• CMS must publish detailed specifications for individual measures and measures groups for the PQRI November 15, 2010.
• The AMA applauds CMS’ decision to reduce the PQRI reporting sample requirement from 80 percent to 50 percent for FY 2011. The AMA urges CMS to also use its existing authority to apply the new 50 percent threshold retrospectively to the 2010 reporting year.
• The AMA supports enhancing the measures and methods used in the resource use Physician Resource Use Measurement and Reporting Program (RUR). Under this program, CMS must adequately prepare for handling additional feedback report requests and distribution techniques, and until adequate risk adjustment and attribution models are widely tested and applicable, these reports should not be publicly reportable.
• We strongly support CMS’ proposed requirements for the 2011 electronic prescribing (e-prescribing) incentive payment program, which is to require reporting on only 25 services involving electronic prescriptions.
• We strongly oppose CMS’ proposal to impose financial penalties in 2012 and 2013 against physicians based on their e-prescribing activity during the first six months of 2011. Instead, we strongly urge CMS to review 2012 and 2013 e-prescribing activity (not 2011 e-prescribing activity) in order to assess penalties in 2012 and 2013.
• We strongly recommend that CMS add more exception categories so that more physicians facing hardship will be eligible for an exemption from e-prescribing penalties in 2012 and 2013.
• We also recommend that CMS provide feedback reports to physicians and establish an appeals process to allow physicians to appeal decisions that affect their eligibility to take part in the e-prescribing program or that affect their ability to get e-prescribing incentives.
• CMS should take appropriate measures to ensure the accuracy of the list of successful e-prescribers and to provide the appropriate disclaimers for the website listing.
• The AMA strongly supports better coverage for preventive care. CMS should work through the established Current Procedural Terminology (CPT) Editorial Panel and the Relative Value System Update Committee (RUC) process to adopt existing CPT codes for the annual preventive visits rather than establishing separate Healthcare Common Procedure Coding System (HCPCS) G-Codes for these services.
• CMS should expand the availability of the primary care incentive payments by interpreting “allowed charges” as charges under the physician fee schedule, and not as all Part B charges.
• CMS should ensure that the general surgery bonus payments promote access to these important services for patients by modifying the Health Professional Shortage Area (HPSA) criteria to allow a non-HPSA hospital to be part of a HPSA if: (i) the hospital is adjacent to a HPSA; (ii) the patient resides in a HPSA; or (iii) the general surgeon maintains an office in a HPSA.
• CMS should seek input from the RUC and its Health Care Professionals Advisory Committee on the efficiencies or reduced resources involved in services provided to the same patient in the same session or on the same day rather than implementing arbitrary multiple procedural payment reductions for imaging and therapy services.
• The ACA contained a number of provisions that apply retroactively, which requires CMS to re-process claims for various physicians’ services. CMS should issue guidance to its contractors about reprocessing these claims in a manner that minimizes the burden on physicians and avoids further confusion and payment delays. CMS should also make this guidance publicly available so that physician organizations can disseminate it to our members.
Fee schedule calculation with example
Example of Computation of Fee Schedule Amount
The following example further clarifies the computation of a fee schedule amount.
Background Example
Nationwide, cardiovascular disease has retained its position as a primary cause of morbidity and mortality. Currently, cardiovascular disease affects approximately 61.8 million Americans. Cardiovascular disease is responsible for over 40 percent of all deaths in the United States. However, 84.3 percent of those deaths are persons age 65 and above.
Organ transplantation is one modality that has been used in the treatment of cardiovascular disease. Currently over 2,000 persons per year receive a heart transplant. However, another 2,300 persons are on the waiting list. Because of the disparity between the demand and supply of organs, mechanical heart valves are now covered under Medicare.
Sample Computation of Fee Schedule
Patients fitted with a mechanical heart valve require intensive home international normalized ratio (INR) monitoring by his/her physician. Physician services required may include instructions on demonstrations to the patient regarding the use and maintenance of the INR monitor, instructions regarding the use of a blood sample for reporting home INR test results, and full confirmation that the client can competently complete the required self-testing.
Assumptions
RVUw = 0
Given the nature of the example, the physician would, under product code G0248, not be allowed to assign work RVUs.
RVUm = .01
However, the treatment of the patient with a mechanical heart carries a level of risk.
RVUpe = 2.92
Based upon a relatively intense level of staff time for an RN/LRN, or MN, as well as a supply list that includes a relatively sophisticated home INR monitor, batteries, educational materials, test strips and other materials, the RVUpe can be assigned a value of 2.92.
The above values require modification by regionally based values for work, practice, and malpractice. If the city is assumed to be Birmingham, Alabama, the values below can be assigned based upon current data.
GPCIw = 0.994
GPCIpe = 0.912
GPCIm = 0.927
The above indices suggest that the index in Birmingham is .6 percent below the national norm for physician work intensity, 8.8 percent below the national norm for practice expenses, and 7.3 percent below the national norm for malpractice.
If the assumption is made that the nonfacility payment for a home visit is $166.52, the full fee schedule payment can be computed through substitution into the formula.
Payment = (RVUw x GPCIw + (RVUpe x GPCIpe) + RVUm + GPCIm x physician fee schedule payment.
Payment = (0 x .994) + (2.92 x .927) + (.01 x .912) x $166.52 =
Payment = (0) + (2.70684) + (.00912) x 166.52
Payment = $452.26166 or $452.26 when rounded to the nearest cent.
The above example is purely illustrative. The CMS completes all calculations and provides
carriers with final fee schedule for each locality via the Medicare Physicians'Fee Schedule Database (MPFSDB).
The following example further clarifies the computation of a fee schedule amount.
Background Example
Nationwide, cardiovascular disease has retained its position as a primary cause of morbidity and mortality. Currently, cardiovascular disease affects approximately 61.8 million Americans. Cardiovascular disease is responsible for over 40 percent of all deaths in the United States. However, 84.3 percent of those deaths are persons age 65 and above.
Organ transplantation is one modality that has been used in the treatment of cardiovascular disease. Currently over 2,000 persons per year receive a heart transplant. However, another 2,300 persons are on the waiting list. Because of the disparity between the demand and supply of organs, mechanical heart valves are now covered under Medicare.
Sample Computation of Fee Schedule
Patients fitted with a mechanical heart valve require intensive home international normalized ratio (INR) monitoring by his/her physician. Physician services required may include instructions on demonstrations to the patient regarding the use and maintenance of the INR monitor, instructions regarding the use of a blood sample for reporting home INR test results, and full confirmation that the client can competently complete the required self-testing.
Assumptions
RVUw = 0
Given the nature of the example, the physician would, under product code G0248, not be allowed to assign work RVUs.
RVUm = .01
However, the treatment of the patient with a mechanical heart carries a level of risk.
RVUpe = 2.92
Based upon a relatively intense level of staff time for an RN/LRN, or MN, as well as a supply list that includes a relatively sophisticated home INR monitor, batteries, educational materials, test strips and other materials, the RVUpe can be assigned a value of 2.92.
The above values require modification by regionally based values for work, practice, and malpractice. If the city is assumed to be Birmingham, Alabama, the values below can be assigned based upon current data.
GPCIw = 0.994
GPCIpe = 0.912
GPCIm = 0.927
The above indices suggest that the index in Birmingham is .6 percent below the national norm for physician work intensity, 8.8 percent below the national norm for practice expenses, and 7.3 percent below the national norm for malpractice.
If the assumption is made that the nonfacility payment for a home visit is $166.52, the full fee schedule payment can be computed through substitution into the formula.
Payment = (RVUw x GPCIw + (RVUpe x GPCIpe) + RVUm + GPCIm x physician fee schedule payment.
Payment = (0 x .994) + (2.92 x .927) + (.01 x .912) x $166.52 =
Payment = (0) + (2.70684) + (.00912) x 166.52
Payment = $452.26166 or $452.26 when rounded to the nearest cent.
The above example is purely illustrative. The CMS completes all calculations and provides
carriers with final fee schedule for each locality via the Medicare Physicians'Fee Schedule Database (MPFSDB).
Medicare computing fee schedule amount - how to calculate
Method for Computing Fee Schedule Amount
The CMS continually updates, refines, and alters the methods used in computing the fee schedule amount. For example, input from the American Academy of Ophthalmology has led to alterations in the supplies and equipment used in the computation of the fee schedule for selected procedures. Likewise, new research has changed the payments made for physical and occupational therapy. The CMS provides the updated fee schedules to carriers on an annual basis. The sections below introduce the formulas used for fee schedule computations.
A. Formula
The fully implemented resource-based MPFS amount for a given service can be computed by using the formula below:
MPFS Amount = [(RVUw x GPCIw) + (RVUpe x GPCIpe) + (RVUm x GPCIm)] x CF
Where:
RVUw equals a relative value for physician work,
RVUpe equals a relative value for practice expense, and
RVUm refers to a relative value for malpractice.
In order to consider geographic differences in each payment locality, three geographic
practice cost indices (GPCIs) are included in the core formula:
A GPCI for physician work (GPCIw),
A GPCI for practice expense (GPCIpe), and
A GPCI for malpractice (GPCIm).
The above variables capture the efforts and productivity of the physician, his/her
individualized costs for staff and for productivity-enhancing technology and materials.
The applicable national conversion factor (CF) is then used in the computation of every
MPFS amount.
The national conversion factors are:
2002 - $36.1992
2001 - $38.2581
2000 - $36.6137
1999 - $34.7315
1998 - $36.6873
1997 - $40.9603 (Surgical); $33.8454 (Nonsurgical); $35.7671 (Primary Care)
1996 - $40.7986 (Surgical); $34.6296 (Nonsurgical); $35.4173 (Primary Care)
1995 - $39.447 (Surgical); $34.616 (Nonsurgical); $36.382 (Primary Care)
1994 - $35.158 (Surgical); $32.905 (Nonsurgical); $33.718 (Primary Care)
1993 - $31.926 (Surgical); $31,249 (Nonsurgical);
1992 - $31.001
For the years 1999 through 2002, payments attributable to practice expenses transitioned from charge-based amounts to resource-based practice expense RVUs. The CMS used the following transition formula to calculate the practice expense RVUs.
1999 - 75 percent of charged-based RVUs and 25 percent of the resource-based RVUs.
2000 - 50 percent of the charge-based RVUs and 50 percent of the resource-based RVUs.
2001 - 25 percent of the charge-based RVUs and 75 percent of the resource-based RVUs.
2002 - 100 percent of the resource-based RVUs.
As the tabular display introduced earlier indicates, CMS has calculated separate facility
and nonfacility resource-based practice expense RVUs.
The CMS continually updates, refines, and alters the methods used in computing the fee schedule amount. For example, input from the American Academy of Ophthalmology has led to alterations in the supplies and equipment used in the computation of the fee schedule for selected procedures. Likewise, new research has changed the payments made for physical and occupational therapy. The CMS provides the updated fee schedules to carriers on an annual basis. The sections below introduce the formulas used for fee schedule computations.
A. Formula
The fully implemented resource-based MPFS amount for a given service can be computed by using the formula below:
MPFS Amount = [(RVUw x GPCIw) + (RVUpe x GPCIpe) + (RVUm x GPCIm)] x CF
Where:
RVUw equals a relative value for physician work,
RVUpe equals a relative value for practice expense, and
RVUm refers to a relative value for malpractice.
In order to consider geographic differences in each payment locality, three geographic
practice cost indices (GPCIs) are included in the core formula:
A GPCI for physician work (GPCIw),
A GPCI for practice expense (GPCIpe), and
A GPCI for malpractice (GPCIm).
The above variables capture the efforts and productivity of the physician, his/her
individualized costs for staff and for productivity-enhancing technology and materials.
The applicable national conversion factor (CF) is then used in the computation of every
MPFS amount.
The national conversion factors are:
2002 - $36.1992
2001 - $38.2581
2000 - $36.6137
1999 - $34.7315
1998 - $36.6873
1997 - $40.9603 (Surgical); $33.8454 (Nonsurgical); $35.7671 (Primary Care)
1996 - $40.7986 (Surgical); $34.6296 (Nonsurgical); $35.4173 (Primary Care)
1995 - $39.447 (Surgical); $34.616 (Nonsurgical); $36.382 (Primary Care)
1994 - $35.158 (Surgical); $32.905 (Nonsurgical); $33.718 (Primary Care)
1993 - $31.926 (Surgical); $31,249 (Nonsurgical);
1992 - $31.001
For the years 1999 through 2002, payments attributable to practice expenses transitioned from charge-based amounts to resource-based practice expense RVUs. The CMS used the following transition formula to calculate the practice expense RVUs.
1999 - 75 percent of charged-based RVUs and 25 percent of the resource-based RVUs.
2000 - 50 percent of the charge-based RVUs and 50 percent of the resource-based RVUs.
2001 - 25 percent of the charge-based RVUs and 75 percent of the resource-based RVUs.
2002 - 100 percent of the resource-based RVUs.
As the tabular display introduced earlier indicates, CMS has calculated separate facility
and nonfacility resource-based practice expense RVUs.
Fee Schedule - General Information
ZIPCODE TO CARRIER LOCALITY FILE (see files below)
This file is primarily intended to map Zip Codes to CMS carriers/Medicare Administrative Contractors and localities. This file will also map Zip Codes to their State. In addition, this file contains an urban, rural or a low density (qualified) area Zip Code indicator.
Provider Center
For a one-stop resource web page focused on the informational needs and interests of Medicare Fee-for-Service (FFS) providers, including physicians, other practitioners and suppliers, go to the Provider Center.
Clinical Laboratory Fee Schedule update from Medicade
Clinical Laboratory Fee Schedule (CLFS) – Special Instructions for Specific Test Codes (CPT Code 80100, CPT Code 80101, CPT Code 80101QW, G0430, G0430QW and G0431QW)
Provider Types Affected
This article is for clinical laboratories billing Medicare Carriers, Fiscal Intermediaries (FIs) or Part A/B Medicare Administrative Contractors (A/B MACs).
Provider Action Needed
This article is based on Change Request (CR) 6852 which provides special instructions for the proper use of Current Procedural Terminology (CPT) Code 80100, CPT Code 80101, CPT Code 80101QW, G0430, G0430QW, G0431 and G0431QW as of April 1, 2010. Be sure your billing staffs are aware of the changes outlined in this article.
Background
Each year, the Centers for Medicare & Medicaid Services (CMS) hosts an Annual Public Meeting concerning new test codes that have been established by the CPT committee and that will be covered by Medicare and paid based on the CLFS.
During calendar year (CY) 2009, effective for January 1, 2010, two new G codes were established: G0430 and G0431. It had come to CMS’ attention that some providers were incorrectly using CPT Code 80100 and CPT Code 80101. Therefore, CMS created two new G codes to operate in place of and alongside existing CPT Code 80100 and existing CPT Code 80101.
In addition, those clinical laboratories that require a Clinical Laboratory Improvement Amendments (CLIA) certificate of waiver had been utilizing CPT Code 80101 QW. In order to ensure that clinical laboratories that require a CLIA certificate of waiver are also billing correctly whether the drug screen test performed is for a single drug class or multiple drug classes, effective April 1, 2010, two additional G codes were established – G0430QW and G0431QW.
Provider Types Affected
This article is for clinical laboratories billing Medicare Carriers, Fiscal Intermediaries (FIs) or Part A/B Medicare Administrative Contractors (A/B MACs).
Provider Action Needed
This article is based on Change Request (CR) 6852 which provides special instructions for the proper use of Current Procedural Terminology (CPT) Code 80100, CPT Code 80101, CPT Code 80101QW, G0430, G0430QW, G0431 and G0431QW as of April 1, 2010. Be sure your billing staffs are aware of the changes outlined in this article.
Background
Each year, the Centers for Medicare & Medicaid Services (CMS) hosts an Annual Public Meeting concerning new test codes that have been established by the CPT committee and that will be covered by Medicare and paid based on the CLFS.
During calendar year (CY) 2009, effective for January 1, 2010, two new G codes were established: G0430 and G0431. It had come to CMS’ attention that some providers were incorrectly using CPT Code 80100 and CPT Code 80101. Therefore, CMS created two new G codes to operate in place of and alongside existing CPT Code 80100 and existing CPT Code 80101.
In addition, those clinical laboratories that require a Clinical Laboratory Improvement Amendments (CLIA) certificate of waiver had been utilizing CPT Code 80101 QW. In order to ensure that clinical laboratories that require a CLIA certificate of waiver are also billing correctly whether the drug screen test performed is for a single drug class or multiple drug classes, effective April 1, 2010, two additional G codes were established – G0430QW and G0431QW.
Medicare payment for 43200 - 46930 - Endoscopy and Colonoscopy procedure
Medicare Fee Schedule for GI - FL
| Insurance | Medicare | |
| CPT | Hospital | ASC |
| 43200 | $154.12 | $314.86 |
| 43202 | $201.91 | $314.86 |
| 43235 | $216.25 | $314.86 |
| 43239 | $251.15 | $339.71 |
| 43244 | $233.67 | $339.71 |
| 43245 | $148.87 | $339.71 |
| 43246 | $200.27 | $339.71 |
| 43247 | $158.62 | $339.71 |
| 43248 | $149.24 | $339.71 |
| 43249 | $137.62 | $339.71 |
| 43250 | $149.64 | $339.71 |
| 43251 | $172.38 | $339.71 |
| 43255 | $223.14 | $339.71 |
| 43260 | $274.63 | $722.74 |
| 43261 | $288.88 | $722.74 |
| 43262 | $338.80 | $722.74 |
| 43271 | $339.02 | $722.74 |
| 43760 | $255.50 | $98.06 |
| 44360 | $123.90 | $370.21 |
| 44376 | $241.07 | $370.21 |
| 44378 | $326.38 | $370.21 |
| 44388 | $251.02 | $324.78 |
| 44389 | $287.53 | $324.78 |
| 45330 | $97.75 | $81.96 |
| 45331 | $122.63 | $225.34 |
| 45334 | $129.06 | $328.65 |
| 45338 | $277.71 | $328.65 |
| 45339 | $241.69 | $328.65 |
| 45378 | $289.36 | $349.62 |
| 45379 | $367.68 | $349.62 |
| 45380 | $346.29 | $349.62 |
| 45381 | $335.83 | $349.62 |
| 45382 | $453.60 | $349.62 |
| 45384 | $344.18 | $349.62 |
| 45385 | $391.52 | $349.62 |
| 45386 | $474.25 | $349.62 |
| 46221 | $178.28 | $123.09 |
| 46500 | $149.28 | $116.13 |
| 46930 | $142.76 | $117.46 |
| G0121 | $281.04 | $321.61 |
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