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Volume 6, Issues 4 & 5 December 2011

CMS Publishes Final Rule for 2012
On November 1, 2011, the Centers for Medicare and Medicaid Services (CMS) released the 2012 Final Rules for the Medicare Physician Fee Schedule (MPFS) and the Hospital Outpatient Prospective Payment System (HOPPS). Both the MPFS and HOPPS rules address Medicare payment policies and rates and are effective January 1, 2012.

The issuance of these final rules follows the summer release of the proposed rules for physician offices and hospital outpatient departments (HOPDs). In the final rules, CMS addresses the comments they received on the proposed rules and finalizes the changes to Medicare payment and policies for 2012. The comment period for both the HOPPS final rule and the MPFS final rule is open until January 3, 2012. The MPFS final rule was published in the November 28, 2011 publication of the Federal Register.

MEDICARE 2012 PHYSICIAN FEE SCHEDULE FINAL RULE

Each year CMS updates their payment systems and policies to reflect changes in medical practice and the relative value of services. In 2012, the final rule also addresses provisions of the Affordable Care Act (ACA) and the Medicare Improvements for Patients and Providers Act (MIPPA) of 2008. In addition, the final rule discusses payments for Part B drugs; the Physician Quality Reporting System (PQRS); the Electronic Prescribing (eRx) Incentive Program; the Physician Resource-Use Feedback Program and the value modifier; and other Part B related issues.

Factors Influencing the Medicare Payment Rate
The payment rate for Medicare fee-for-service providers is based in large part on three key components, as described in detail in the Best Practices Review September Issue:

  • The Sustainable Growth Rate (SGR)
  • The Conversion Factor (CF)
  • Relative Value Units (RVUs)

In the proposed 2012 rule, CMS estimated the SGR formula would result in a negative 29.5% update to the physician fee schedule (PFS) for 2012. However, in the final rule CMS reports that the total reduction in MPFS rates between CY 2011 and CY 2012 under the SGR system will be 27.4%. This lower negative update results in a slightly higher estimated conversion factor of $24.6712 in 2012, down from $33.9764 in 2011. The current calculation of the calendar year 2012 PFS conversion factor is shown in Figure 1.

The PFS conversion factor will change if Congress steps in and stops the scheduled SGR cut. In fact, it is expected that Congress will take such action and the most likely scenario is they will do so through another temporary fix. Watch for updates on this evolving issue.

BREAKING NEWS ALERT
On Friday, December 23, 2011, Congress agreed on a deal that would provide a delay in the implementation of the 27.4% SGR cut to physician payments by enacting a two-month freeze on Medicare’s physician payment rates. The bill passed by Congress and signed by the President, will freeze physician payments at the 2011 level through February 29, 2012.  

CALCULATION OF THE CY 2012 PFS CF

Conversion Factor in effect in CY 2011   $33.9764
CY 2011 Conversion Factor had statutory increases not applied   $25.4999
CY 2012 Medicare Economic Index 0.6 percent (1.006)

 

CY 2012 Update Adjustment Factor -4.0 percent (0.9600)

 

CY 2012 RVU Budget Neutrality Adjustment 0.2 percent (1.0018)

 

 

CY 2012 Conversion Factor   $24.6712
Percent Change from Conversion Factor in effect in CY 2011to CY 2012 Conversion Factor   -27.4%

Figure 1: Table 34 2012 Medicare Physician Fee Schedule Final Rule

In the final rule, CMS reminds us that only Congress can act to stop the pending SGR cuts to physician payments. CMS says that a long-term solution is critical, stating, “We will continue to work with Congress to fix this untenable situation so doctors and beneficiaries no longer have to worry about the stability and adequacy of their payments from Medicare under the Physician Fee Schedule.”

Other factors affecting Medicare physician payment rates in 2012 are the continued transition to the practice expense per hour (PE/HR) data using the AMA’s Physician Practice Information Survey (PPIS), and changes to the Geographic Practice Cost Indices (GPCIs) including the expiration of the Physician Work Geographic Adjustment Floor of 1%.

In 2010, CMS updated the PE/hour (PE/HR) data that are used in the calculation of PE RVUs for most specialties using the Physician Practice Information Survey (PPIS) conducted by the AMA. Because of the significant payment reductions for some specialties resulting from the use of the PPIS data, CMS implemented a 4-year transition period from the previous PE/HR Socioeconomic Monitoring System (SMS) data to the new PPIS data. As shown in Figure 2, in 2012 we will be in the third-year of the transition using 25% of the old SMS data and 75% of the new PPIS data.

Figure 3 provides a comparison of the 2011 and 2012 national Medicare payment rates (not adjusted for location) for drug administration codes based on RVU and other changes in the 2012 physician fee schedule. The figures shown are based on the assumption that Congress stops the SGR cuts and instead freezes the conversion factor at the 2011 level. Please be aware, that even if a conversion factor freeze is the congressional action taken, the final conversion factor may actually be slightly higher or lower than 2011.

CPT codes used to bill for physician services are assigned Relative Value Units (RVUs) for the physician work, practice expense and malpractice associated with the individual service. To calculate the payment for each service these RVUs are adjusted by geographic practice cost indices (GPCIs). The GPCIs reflect the relative costs of physician work, PE, and malpractice in an area compared to the national average costs for each component. As a result, rural health care providers are paid less than urban providers are.

In an effort to protect Medicare beneficiaries access to health care in rural areas, the Medicare Modernization Act of 2003 (MMA) established a floor for the physician work GPCI of 1.0 for 2004-2006. This provision, which has been extended each year since 2006, is set to expire December 31, 2011 resulting in a decrease in payments for all services in geographic areas with a work GPCI below 1.0.

The expiration of the work GPCI floor will not affect Alaska as the MIPPA established a permanent 1.5 work GPCI for services in Alaska.

CMS is also finalizing several changes to the GPCI and how it is applied to payment for physician services including a technical change in how the GPCI applies to office rents, purchased services and employee compensation.

History of the 1.0 Work GPCI Floor

  • Established for three years 2004-2006, by passage of the Medicare Modernization Act of 2003 (MMA)
  • Extended through December 31, 2007, by passage of the Tax Relief and Health Care Act of 2006 (TRHCA)
  • Extended for six months through June 30, 2008, by passage of the Medicare, Medicaid and SCHIP Extension Act of 2007 (MMSEA)
  • Extended for eighteen months through December 31, 2009, by passage of the Medicare Improvements for Patients and Providers Act of 2008 (MIPPA)
  • Extended through December 31, 2010, by passage of the Patient Protection and Affordable Care Act (ACA)
  • Extended through December 31, 2011, by passage of the Medicare and Medicaid Extenders Act of 2010 (MMEA)

TRANSITION TO PRACTICE EXPENSE
PER HOUR (PE/HR) PPIS DATA

2010
75% SMS Data 25% New PPIS Data
arrow
2011
50% SMS Data 50% New PPIS Data
arrow
2012
25% SMS Data 75% New PPIS Data
arrow
2013
100% New PPIS Data

Figure 2 Transition to PPIS Data

COMPARISON OF DRUG ADMINISTRATION SERVICES
National Medicare Payment Rates 2011 over 2012*

CPT DESCRIPTION 2011
RATE
2012
RATE
%
CHANGE
96401 Chemo non-hormonal SQ/IM $72.71 73.05 0.47%
96402 Chemo hormonal SQ/IM $35.00 $33.64 -3.89%
96409 Chemo IVP initial $112.80 $110.76 -1.81%
96411

Chemo IVP each additional drug

$63.20 $62.18 -1.61%
96413 Chemo IV infusion initial $146.44 $138.28 -5.57%
96415

Chemo IV infusion additional hour

$31.26 $30.58 -2.18%
96416 Chemo prolonged infusion requiring pump $161.39 $137.94 -14.53%
96417

Chemo IV infusion each additional sequential

$72.37 $71.01 -1.78%
96360 Hydration; initial, 31 min to 1 hour $57.08 $57.08 0%
96361

Hydration; each additional hour

$15.29 $15.29 0%
96365 Non-chemo, IV initial, up to 1 hour $71.01 $72.37 1.92%
96366

Non-chemo, IV, each additional hour

$21.74 $21.41 -1.52%
96367 Non-chemo, IV, additional sequential inf., up to 1 hour $32.96 $32.28 -2.06%
96368

Non-chemo, IV concurrent infusion

$19.37 $19.03 -1.76%
96372 Non-chemo, SQ/IM injection $23.10 $24.12 4.42%
96374

Non-chemo, IV push, single or initial drug

$55.72 $55.72 0%
96375 Each additional sequential IV push of a new drug $22.76 $22.42 -1.49%

Figure 3 *Comparison based on 2012 Physician Fee Schedule changes and assuming Congress stops the SGR cut with a freeze on the Conversion Factor at the 2011 level

Payment Reductions
Under the current advanced imaging (CT, MRI and ultrasound) multiple procedure payment reduction (MPPR) policy, full payment is made for the technical component (TC) of the highest paid procedure, and payment is reduced by 50 percent of the TC for each additional procedure when an MPPR scenario applies.

For CY 2012, CMS proposed to expand the imaging (MPPR) policy to the professional component (PC) of the same advanced imaging services, reducing the PC of the second and subsequent advanced imaging services furnished in the same session by 50 percent.

In the proposed rule, CMS cited the July 2009 GAO report entitled, "Medicare Physician Payments: Fees Could Better Reflect Efficiencies Achieved when Services are Provided Together," which recommends that CMS:

  • Expand the existing imaging MPPR policy for certain services to the PC to reflect efficiencies in physician work for certain imaging services; and
  • Expand the MPPR to reflect PE efficiencies that occur when certain nonsurgical, non-imaging services are furnished together.

In the final rule, CMS addresses the mostly negative comments received regarding the proposal. CMS also reports that while most of the comments were opposed to the expansion of the imaging MPPR policy to the PC a few commenters, most notably MedPAC, were supportive of the proposal.

CMS reports that in response to the comments and after further analysis, they have determined that a 25 percent reduction would more appropriately capture the range of physician work efficiencies for second and subsequent imaging services furnished by the same physician (including physicians in the same group practice) to the same patient in the same session on the same day.

As a result, effective January 1, 2012, the current MPPR policy for advanced imaging services will be expanded to include a 25 percent reduction to the PC of the second and subsequent advanced imaging services furnished in the same session by the same physician (including physicians in the same group practice) to the same patient in the same session on the same day.

MEDICARE INCENTIVE PROGRAMS

The 2012 final rule also includes some minor revisions to the Physician Quality Reporting System (PQRS), the Electronic Health Record Incentive Program (EHR) and the ePrescribing Incentive Program (eRx). Additionally, CMS reiterates their intention of more closely aligning the various quality reporting programs and makes changes to some of the reporting requirements.

Physician Quality Reporting System
The PQRS incentive program was established in 2007 (originally known as PQRI) as a voluntary pay for reporting program. The PQRS program provides a combination of incentives and payment adjustments. In 2012, eligible professionals (EPs) or group practices who participate in the PQRS and satisfactorily report PQRS measures can qualify for an incentive equal to 0.5 percent of their total estimated part B allowed charges for all covered professional services furnished by the EP or group practice during the applicable reporting period.

With regard to the PQRS Group Practice Reporting Option (GPRO), CMS finalized the proposal to define a "group practice" as a physician group practice, as defined by a TIN, with 25 or more individual eligible professionals (or, as identified by NPIs) who have reassigned their billing rights to the TIN. Nevertheless, CMS states that they are interested in allowing group practices comprised of less than 25 EPs to participate in the PQRS via the GPRO in the future.

CMS also finalized their proposal to continue the claims-based, registry-based and EHR-based reporting options for 2012. In 2012, EPs will have two options for EHR-based reporting, direct submission through a PQRS certified system or through a certified (for PQRS) EHR Submission Vendor.

2012 PQRS Reporting Methodologies:

  • Claims-based reporting
  • Registry-based reporting
  • EHR-based reporting

CMS specifies a 12-month reporting period (January 1 through December 31 of the program year) for the satisfactory reporting of PQRS quality measures for claims, registry and EHR-based reporting. CMS finalized the elimination of the 6-month reporting period for all submissions except measures groups submitted through registries. Claims for service dates of January 1, 2012 - December 31, 2012 must be reported by February 22, 2013 to be included in the analysis for the PQRS incentive payment.

In keeping with their goal of better aligning the PQRS and EHR incentive programs, CMS finalized their proposal to make all 44 clinical quality measures in the Medicare EHR Incentive Program available for EHR-based reporting under the 2012 PQRS and established the Physician Quality Reporting System-Medicare EHR Incentive Pilot. For more information on this Pilot program, see the article on the EHR incentive program in this newsletter.

For those of you who missed the CMS November 8, 2011 National Provider Call, the presentation is archived on the PQRS website at www.cms.gov/PQRS/. The archived presentation contains tables illustrating the 2012 criteria for satisfactory reporting on individual and group measures (as shown in figures 4 and 5) as well as the criteria for satisfactory reporting for group practices participating in the Group Practice Reporting Option (GPRO).

2012 Criteria for Satisfactory Reporting on
Individual Measures

REPORTING PERIOD REPORTING MECHANISM REPORTING CRITERIA
Jan 1, 2012 - Dec 31, 2012 Claims Report at least three PQRS measures; OR

If less than three measures apply to the eligible professional, 1-2 measures; AND

Report each measure for at least 50% of the eligible professional's Medicare Part B FFS patients seen during the reporting period to which the measure applies.

Measures with a 0% performance rate will not be counted.
Jan 1, 2012 - Dec 31, 2012 Registry Report at least three PQRS measures, AND

Report each measure for at least 80% of the eligible professional's Medicare Part B FFS patients seen during the reporting period to which the measure applies.

Measures with a 0% performance rate will not be counted.
Jan 1, 2012 - Dec 31, 2012 EHR - Aligning with the Medicare EHR Incentive Program Report on ALL three Medicare EHR Incentive Program core measures.
If the denominator for one or more of the Medicare EHR Incentive Program core measures is 0, report on up to three Medicare EHR Incentive Program alternate core measures. AND

Report on three (of the 38) additional measures available for the Medicare EHR Incentive Program.
Jan 1, 2012 - Dec 31, 2012 EHR Report at least three PQRS measures AND

Report each measure for at least 80% of the eligible professional's Medicare Part B FFS patients seen during the reporting period to which the measure applies.

Measures with a 0% performance rate will not be counted

Figure 4 CMS November 8, 2011 National Provider Call  


2012 Criteria for Satisfactory Reporting on Measures Groups via Claims and Registry

REPORTING PERIOD

REPORTING MECHANISM

REPORTING CRITERIA

Jan 1, 2012 - Dec 31, 2012 Claims Report at least 1 PQRS measures group; AND

Report each measures group for at least 30 Medicare Part B FFS patients.

Measures groups containing a measure with a 0% performance rate will not be counted.
Jan 1, 2012 - Dec 31, 2012 Claims Report at least 1 PQRS measures group; AND

Report each measures group for at least 50% of the eligible professional's Medicare Part B FFS patients seen during the reporting period to whom the measures group applies; BUT

Report each measures group on no less than 15 Medicare Part B FFS patients seen during the reporting period to which the measures group applies.

Measures groups containing a measure with a 0% performance rate will not be counted.

Jan 1, 2012 - Dec 31, 2012

Registry

Report at least 1 PQRS measures group; AND

Report each measures group for at least 30 Medicare Part B FFS patients.

Measures groups containing a measure with a 0% performance rate will not be counted.

Jan 1, 2012 - Dec 31, 2012 Registry Report at least 1 PQRS measures group; AND

Report each measures group for at least 80% of the eligible professional's Medicare Part B FFS patients seen during the reporting period to whom the measures group applies; BUT

Report each measures group on at least 15 Medicare Part B FFS patients seen during the reporting period to which the measures group applies.

Measures groups containing a measure with a 0% performance rate will not be counted.

Jul 1, 2012 - Dec 31, 2012

Registry

Report at least 1 PQRS measures group; AND

Report each measures group for at least 80% of the eligible professional's Medicare Part B FFS patients seen during the reporting period to whom the measures group applies; BUT

Report each measures group on no less than 8 Medicare Part B FFS patients seen during the reporting period to which the measures group applies.

Measures groups containing a measure with a 0% performance rate will not be counted.

Figure 5 CMS November 8, 2011 National Provider Call

Beginning in 2015, a payment adjustment will apply under the PQRS Incentive Program if the EP does not satisfactorily report the PQRS quality measures. Although CMS finalized the proposal to use calendar year 2013 as the reporting period for the 2015 payment adjustment they also stated that they may consider additional reporting periods that are less than 12 months for the 2015 payment adjustment, so that EPs have additional opportunities to meet the requirements for the 2015 payment adjustment. Any changes will be published in future notice and comment rulemaking.

In response to commenters’ feedback, CMS addresses the need to reduce the PFS amount concurrently with claims submissions in 2015. Doing so, CMS explains, allows them to avoid having to recoup or provide added payments after the determination is made about whether the payment adjustment applies, or alternatively, to hold claims until such a determination is made. Nevertheless, CMS states they will continue to explore options for potentially using a reporting period closer to the time in which the payment adjustment is applied for future years of the payment adjustment.

The fee schedule amount for services furnished by EPs who are not successful PQRS reporters will be reduced by the following percentages:

  • 1.5% for 2015; and
  • 2.0% for 2016 and each subsequent year

Electronic Health Record Incentive Program

The Electronic Health Record (EHR) Incentive Program is a voluntary program whereby eligible professionals (EPs), eligible hospitals, and critical access hospitals (CAHs) demonstrate meaningful use of certified EHR technology through the submission of clinical quality measures (CQMs).

Created by the American Recovery and Reinvestment Act of 2009 (ARRA), which included the Health Information Technology for Economic and Clinical Health (HITECH) Act, to promote the adoption and meaningful use of health information technology, the EHR Incentive Program provides incentive payments for adoption and meaningful use of HIT and qualified EHRs.

The maximum incentive payment that a physician can receive is 75% of the professional part B allowable charges they have submitted to Medicare in the calendar year. EPs can receive up to $44,000 over five years under the Medicare EHR Incentive Program with an additional 10% incentive for eligible professionals who provide services in a Health Professional Shortage Area (HPSA).

Citing a study by the Centers for Disease Control and Prevention (CDC), Kathleen Sebelius, Secretary of Health and Human Services (HHS), says the conversion to electronic charts is proceeding rapidly with the percentage of physicians with basic EHRs doubling from 17% to 34% between 2008 and 2011. Furthermore, as of October 31, HHS has paid out more than $1.2 billion in incentive payments to physicians, hospitals, and other providers.

To get the maximum incentive payment, Medicare eligible professionals must begin participation by 2012. For 2015 and later, Medicare eligible professionals, eligible hospitals, and CAHs that do not successfully demonstrate meaningful use will have a payment adjustment applied to their Medicare reimbursement.

Medicare EHR Incentive Program Payments to Eligible Providers
           ←        Maximum Amount Paid Each Year          →
↓Year of
Eligibility
2011 2012 2013 2014 2015 2016 Total
Paid
2011

$18 K

$12 K

$8 K

$4 K $2 K 0 $44 K
2012 - $18 K $12 K $8 K $4 K $2 K $44 K
2013 - - $15 K $12 K $8 K $4 K $39 K
2014 - - - $12 K $8 K $4 K $24 K
2015 - - - - 0 0 0

Figure 6

To qualify for the incentive payment, in the first year of the program EPs must be using a certified EHR and must demonstrate meaningful use over any consecutive 90-day period within the payment year (2011 or 2012). In the second year of participation & beyond, the reporting period is for the entire calendar year.

CMS finalizes changes to the EHR Incentive Program for EPs for the 2012 payment year with respect to the reporting of CQMs for purposes of achieving meaningful use. In 2012, in addition to the attestation method of reporting CQMs, CMS will allow EPs to report CQMs through participation in the Physician Quality Reporting System-Medicare EHR Incentive Pilot.

Participation in the Pilot program will allow EPs who are participating in both the EHR and PQRS incentive programs to report their clinical quality measures once. The reporting period for EPs participating in the Pilot program is the full year, January 1-December 31, 2012.

EPs that choose to participate in the Pilot may submit CQMs via:

  • A PQRS qualified EHR data submission vendor, or
  • An EHR-based reporting option using the EP’s certified and PQRS qualified EHR technology.

EPs will be required to indicate, within the EHR Incentive Program attestation module, their intent to fulfill the Meaningful Use (MU) objective of reporting CQMs by participating in the Physician Quality Reporting System-Medicare EHR Incentive Pilot.

CMS will provide additional guidance on the process for participating in the Pilot program on the EHR Incentive Program website at www.cms.gov/ehrincentiveprograms/ and the PQRS website at www.cms.gov/PQRS/. CMS will also publish a list of EHR products that are both ‘‘qualified’’ and Certified EHR Technology and make the list available on the PQRS website.

In accordance with ARRA requirements, CMS will post the names, business addresses, and business phone numbers of all Medicare eligible professionals, eligible hospitals and critical access hospitals (CAHs) that receive EHR incentive payments. The list will be updated quarterly and may be viewed at
www.cms.gov/EHRIncentivePrograms/56_DataAndReports.asp
.

Electronic Prescribing
Authorized through the Medicare Improvements for Patients and Providers Act of 2008 (MIPPA), the Electronic Prescribing (eRx) Incentive Program began on January 1, 2009. The eRx program was established with the primary goals of improving patient safety and quality of care.

Through the eRx incentive program, eligible professionals (EPs) who are successful electronic prescribers as defined by MIPPA may earn an incentive payment while EPs who fail to meet the reporting requirements may receive an eRx payment adjustment.

The eRx incentive does not apply to an EP, if, for the EHR reporting period, the EP earns an incentive payment under the Medicare EHR Incentive Program beginning in 2011. Nonetheless, EPs who meet the eRx payment adjustment inclusion criteria, must meet the reporting requirements to avoid the eRx payment adjustment regardless of whether they qualify for the eRx payment incentive.

EPs who met the eRx payment adjustment criteria, but who failed to meet the reporting requirements in 2011, may receive the 2012 eRx payment adjustment starting January 1, 2012. The 2012 eRx payment adjustment will result in an EP, or group practice participating in eRx GPRO, receiving 99 percent of their Medicare Part B Physician Fee Schedule (PFS) amount that would otherwise apply to such services.

eRx PENALTIES
  • -1 PERCENT FOR 2012
  •  1.5 PERCENT FOR 2013
  • -2.0 PERCENT FOR 2014
eRx INCENTIVES
  • 2.0 PERCENT FOR 2010
  • 1.0 PERCENT FOR 2011
  • 1.0 PERCENT FOR 2012
  • 0.5 PERCENT FOR 2013

The electronic prescribing quality measure consists of two parts:

  1. A denominator that defines the patient population on which the eligible professional's performance is being measured; and
  2. A reporting numerator, which identifies whether or not a clinical quality action was performed.

In 2012, the eRx denominator and reporting numerators remain unchanged from 2011. There is one reporting numerator, eRx measure G8553 At least one prescription created during the encounter was generated and transmitted electronically using a qualified ERX System and fifty-six denominator codes:

90801, 90802, 90804, 90805, 90806, 90807, 90808, 90809, 90862, 92002, 92004, 92012, 92014, 96150, 96151, 96152, 99201, 99202, 99203, 99204, 99205, 99211, 99212, 99213, 99214, 99215, 99304, 99305, 99306, 99307, 99308, 99309, 99310, 99315, 99316, 99324, 99325, 99326, 99327, 99328, 99334, 99335, 99336, 99337, 99341, 99342, 99343, 99344, 99345, 99347, 99348, 99349, 99350, G0101, G0108, and G0109.

To qualify for the incentive payment in 2012, EPs must report the eRx measure G8553 for at least 25 unique visits associated with one or more denominator-eligible visits during the reporting period of January 1- December 31, 2012. Criteria for successfully reporting for the incentive program are listed in Figure 7 of this newsletter.

Individual EPs need not sign-up or pre-register to participate in the eRx Incentive Program. However, EPs must have and use a qualified eRx system and report on his or her adoption and use of the eRx system. For purposes of the eRx Incentive Program, covered professional services are those paid under the Medicare Physician Fee Schedule (PFS).

To be eligible to participate in the eRx Incentive Program:

  • EPs must have prescribing authority;
  • EPs must meet the criteria for successful electronic prescriber specified by CMS for a particular reporting period; and
  • At least 10% of the EPs Medicare Part B covered services must be made up of codes that appear in the denominator of the eRx measure.

CMS finalized their proposal to include an additional six-month reporting period for purposes of the 2013 payment adjustment as well as the ability to report the eRx measure code G8553 with any service, rather than the limited denominator codes, during the six-month period. See figures 8 and 9 for detailed criteria for avoiding the 2013 and 2014 eRx payment adjustment.

CMS also finalized the proposed significant hardship exemptions for the 2013 and 2014 eRx payment adjustments to include:

  • The eligible professional or group practice practices in a rural area with limited high-speed internet access.
  • The eligible professional or group practice practices in an area with limited available pharmacies for electronic prescribing.
  • Inability to electronically prescribe due to local, state, or Federal law or regulation.
  • Eligible professionals who prescribe fewer than 100 prescriptions during a 6-month, payment adjustment reporting period.

2012 eRx Incentive Program Authoritative Documents

  1. 2012 eRx Incentive Program Measure Specification,
  2. 2012 eRx Incentive Program Measure Specification Release Notes, and
  3. 2012 eRx Claims-Based Reporting Principles.

Available Now At:
www.cms.gov/ERxIncentive/06_E-Prescribing_Measure.asp

 

Criteria for Being a Successful Electronic Prescriber for the 2012 Incentive Individual Eligible Professionals

REPORTING PERIOD REPORTING MECHINISM REPORTING CRITERIA
Jan 1, 2012 -
Dec 31, 2012
Claims Report the electronic prescribing measure's numerator for at least 25 unique denominator-eligible visits
Jan 1, 2012 -
Dec 31, 2012
Registry Report the electronic prescribing measure's numerator for at least 25 unique denominator-eligible visits
Jan 1, 2012 -
Dec 31, 2012
EHR
(Direct EHR & EHR data submission vendor)
Report the electronic prescribing measure's numerator for at least 25 unique denominator-eligible visits

Figure 7

 

Criteria for Being a Successful Electronic Prescriber for the 2013 eRx Payment Adjustment Individual Eligible Professionals

REPORTING PERIOD REPORTING MECHINISM REPORTING CRITERIA
12-month
(Jan 1, 2011 -
Dec 31, 2011)*
Claims* Reports on the 2011 electronic prescribing measure's numerator code at least 25 times for encounters associated with at least 1 of the denominator codes (the same criteria as the 2011 eRx incentive)*
12-month
(Jan 1, 2011 -
Dec 31, 2011)*
Registry* Reports on the 2011 electronic prescribing measure's numerator code at least 25 times for encounters associated with at least 1 of the denominator codes (the same criteria as the 2011 eRx incentive)*
12-month
(Jan 1, 2011 -
Dec 31, 2011)*
EHR* Reports on the 2011 electronic prescribing measure's numerator code at least 25 times for encounters associated with at least 1 of the denominator codes (the same criteria as the 2011 eRx incentive)*
6-month
(Jan 1, 2012 -
Jun 30, 2012)
Claims Report the electronic prescribing measure's numerator code at least 10 times

Figure 8

Criteria for Being a Successful Electronic Prescriber for the 2014 eRx Payment Adjustment Individual Eligible Professionals

REPORTING PERIOD REPORTING MECHINISM REPORTING CRITERIA
12-month
(Jan 1, 2012 -
Dec 31, 2012)
Claims Reports on the electronic prescribing measure's numerator code at least 25 times for encounters associated with at least 1 of the denominator codes (the same criteria as the 2012 eRx incentive)
12-month
(Jan 1, 2012 -
Dec 31, 2012)
Registry Reports on the electronic prescribing measure's numerator code at least 25 times for encounters associated with at least 1 of the denominator codes (the same criteria as the 2012 eRx incentive)
12-month
(Jan 1, 2012 -
Dec 31, 2012)
EHR (Direct EHR & EHR data submission vendor) Reports on the electronic prescribing measure's numerator code at least 25 times for encounters associated with at least 1 of the denominator codes (the same criteria as the 2012 eRx incentive)
6-month
(Jan 1, 2013 -
Jun 30, 2013)
Claims Report the electronic prescribing measure's numerator code at least 10 times

Figure 9

 

The Medicare PQRS, EHR and eRx programs all have both a payment incentive and payment adjustment component. CMS explains that these two program elements are intended to encourage eligible providers to successfully participate in the programs.

The following article published by CMS on their FAQ website is in response to provider questions regarding when and how the eRx payment adjustment would be applied to a provider’s Medicare payment.

CMS states:
Irrespective of whether a physician is deemed participating or non-participating, the eRx payment adjustment will be applied to the allowed Medicare Physician Fee Schedule (MPFS) independently, before the beneficiary co-insurance is assessed. However, if the physician is subject to a payment adjustment due to his/her failure to be deemed a successful electronic prescriber under the eRx Incentive Program, the payment adjustment will be applied to the initial allowed MPFS.

Example:
In calendar year 2012, the MPFS amount for a particular service is $100. If the physician is not subject to a payment adjustment, the paid amount the physician will receive is $80. That is, $100 (allowed MPFS) - ($100 x 20%) (beneficiary co-pay) = $80.00. The beneficiary co-insurance is 20% of the MPFS amount, or $100 x 20% = $20.00.

However, if the physician is subject to a 1.0% payment adjustment due to his/her failure to be deemed a successful electronic prescriber under the eRx Incentive Program, the 1.0% payment adjustment will be applied to the initial allowed MPFS. As such, the reduced MPFS is $100 - ($100 x 1.0%) = $99.00. The beneficiary will pay $99.00 x 20% = $19.80. The paid amount to the physician accounting for the payment adjustment will thus be $99.00 - $19.80 = $79.20.

Note: Multiple Procedure Payment Reductions (MPPR) are calculated AFTER the application of the payment adjustment to the MPFS.

Below is a table which illustrates this example:

Participating physician NOT subject to 1.0% payment adjustment Participating physician SUBJECT to 1.0% payment adjustment

Allowed MPFS = $100

MPFS with Payment Adjustment (PA MPFS) = $100 - $0.00 = $100

Beneficiary co-pay = (Allowed MPFS) x 20% = $20

Amount Paid to Physician = $80

[Allowed MPFS ($100) - Beneficiary co-pay ($20)]

Allowed MPFS = $100

MPFS with Payment Adjustment (PA MPFS) = $100 - ($100 x 1.0%) = $99.00

Beneficiary co-pay = (PA MPFS) x 20% = $19.80

Amount Paid to Physician = $79.20

[PA MPFS ($99.00) - Beneficiary co-pay ($19.80)]

Figure 10 CMS FAQs Answer ID 10560 Updated 10/12/2011 02:16 PM https://questions.cms.hhs.gov/app/home

Formula for Calculating
2012 Physician Payment
Work RVU x Work GPCI
+
Transitioned Practice Expense RVU* x Practice Expense GPCI
+
____Malpractice RVU x Malpractice GPCI____
= Total RVUs
x
________Conversion Factor (24.6712) *_______
= Medicare Allowable

*This will be the 2012 Conversion Factor (CF) unless Congress stops the 27.4% SGR cut

Figure 12 Calculating the Medicare Allowable - CMS Final Rule CY 2012

 

Published by Rise Marie Cleland. Sponsored by Lilly Oncology

PRICE SUBSTITUTION -
DRUGS

CMS finalized the method under which they would substitute 103% of the Average Manufacturers Price (AMP) for 106% of Average Sales Price.

In 2012, price substitution of AMP +3% will be allowed when ASP exceeds Widely Available Market Price (WAMP) by 5%, or, AMP by 5%, for 2 consecutive preceding quarters, or 3 out of 4 preceding quarters.

According to statute, the Office of Inspector General (OIG) is tasked with conducting studies to determine the WAMP of Part B drugs and biologicals and to compare ASP with the WAMP and AMP for these drugs. If the OIG finds that the ASP for a drug exceeds the WAMP or AMP by a certain percentage CMS is allowed to disregard the ASP and substitute the lesser of WAMP or 103% of AMP.

 

 

 

VALUE BASED MODIFIER

The Medicare Physician Feedback/Value-Based Modifier Program is part of Medicare’s value-based purchasing (VBP) initiative. The goal of VBP is to transform Medicare from a passive payer to an active purchaser of higher quality more efficient health care.

The Medicare Physician Feedback/ Value-Based Modifier Program contains two primary components:

  • Physician Quality and Resource Use Reports (QRUR)
  • Development and implementation of a Value-based Payment Modifier

The Affordable Care Act (ACA) requires CMS to provide information to physicians and medical practice groups about the resource use and quality of care they provide to their Medicare patients, including comparisons of patterns of resource use and cost among physicians and medical practice groups.

The ACA also requires that CMS begin applying a value-based payment modifier under the Medicare Physician Fee Schedule (MPFS) for some providers in 2015 and expanding the use of the modifier to all physicians beginning in 2017.

With the value-based payment modifier, both cost and quality data are to be included in calculating payments for physicians.

 

 

 

DON’T FORGET THE
2012 CODE CHANGES

It’s time to review the new 2012 coding books for new, revised and deleted codes and to make the necessary changes in your practice management and billing systems as well as any related billing and coding documents.

This year there are several new HCPCS codes that you need to be aware of including the new J-codes for XGEVA®, Afinitor®, Jevtana®, Halavan™ and Yervoy™. The table below is not a complete list of HCPCS changes so be sure to review the complete 2012 HCPCS list on the CMS website.

NEW HCPCS EFFECTIVE
JANUARY 1, 2012

HCPCS  DESCRIPTION
C9287 INJ., BRENTUXIMAB VEDOTIN, 1 MG
J0131 INJ., ACETAMINOPHEN,
10 MG

J0490

INJ., BELIMUMAB, 10 MG

J0897

INJ., DENOSUMAB (XGEVA), 1 MG

J1557

INJ., IMMUNE GLOBULIN, (GAMMAPLEX), IV, NON-LYOPHILIZED, 500 MG

J1725

INJ., HYDROXY-PROGESTERONE CAPROATE, 1 MG

J7131

HYPERTONIC SALINE SOLUTION, 1 ML

J7180

INJ., FACTOR XIII (ANTIHEMOPHILIC FACTOR, HUMAN), 1 I.U.

J7183

VON WILLEBRAND FACTOR COMPLEX (HUMAN), WILATE, 1 I.U. VWF:RCO

J7665

MANNITOL, ADMINISTERED THROUGH AN INHALER, 5 MG

J8561

EVEROLIMUS (AFINITOR), ORAL, 0.25 MG

J9043

INJ., CABAZITAXEL (JEVTANA), 1 MG

J9179

INJ., ERIBULIN MESYLATE (HALAVEN), 0.1 MG

J9228

INJ., IPILIMUMAB (YERVOY), 1 MG

Figure 11

 

 

2010 Newsletter Archives

Volume 6, Issue 3
Volume 6, Issue 2
Volume 6, Issue 1
Volume 5, Issue 6
Volume 5, Issue 5
Volume 5, Issue 4
Volume 5, Issue 3
Volume 5, Issue 2
Volume 5, Issue 1

 

 

CONTACT US
Risë Marie Cleland
Rise@Oplinc.com

Oplinc, Inc.
113 W. 7th Street
Suite 205
Vancouver, WA 98660
360.695.1608 office
360.326.1733 fax
www.Oplinc.com
Rise@Oplinc.com

 

 

UPCOMING ISSUE
Comments and suggestions for future issues are welcome, please forward correspondence to Risë Marie Cleland by email at: Rise@Oplinc.com

 

 

PAST ISSUES
Access all of our
previous newsletters.

 

 

ABOUT THE EDITOR
Risë Marie Cleland is the Founder and CEO of Oplinc, Inc., a national organization of oncology professionals. Through Oplinc, Inc., Ms. Cleland publishes the weekly Oplinc Fast Facts focusing on the timely dissemination of information pertaining to billing, reimbursement and practice management in the oncology office and Oplinc’s Best Practices Review, which provides a more in-depth look at the issues and challenges facing oncology practices. Ms. Cleland also works as a consultant and advisor for physician practices, pharmaceutical companies and distributors.

 

 

IMPORTANT NOTICES
Please note that this newsletter is presented for informational purposes only. It is not intended to provide coding, billing or legal advice. Regulations and policies concerning Medicare reimbursement are a rapidly changing area of the law. While we have made every effort to be current as of the issue date, the information may not be as current or comprehensive when you review it. Please consult with your legal counsel for any specific reimbursement information. For Medicare regulations visit: www.cms.gov.

CPT® is a Trademark of the American Medical Association Current Procedural Terminology (CPT) is copyright 2011 American Medical Association. All Rights Reserved. No fee schedules, basic units, relative values, or related listings are included in CPT. The AMA assumes no liability for the data contained herein.

Copyright ©2011
Oplinc, Inc.
Oplinc, Inc., grants permission to distribute this newsletter without prior permission provided it is forwarded unedited and in its entirety.

 

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