On July 8, 2013, the Centers for Medicare & Medicaid Services (CMS) issued a proposed rule that would update payment policies and payment rates for services furnished under the Medicare Physician Fee Schedule (PFS) on or after January 1, 2014. The rule is available here in its entirety and appeared in the July 19, 2013, Federal Register. CMS will accept comments on the proposed rule until Sept. 6, 2013, and will respond to them in a final rule with comment period to be issued on or about Nov. 1, 2013.
In the proposed rule, in order to support primary care, CMS proposes to make a separate payment to physicians for managing select Medicare patients’ care needs beginning in 2015.
The proposed rule also proposes changes to several of the quality reporting initiatives that are associated with PFS payments – the Physician Quality Reporting System (PQRS), the Medicare Electronic Health Record (EHR) Incentive program, as well as changes to the Physician Compare tool on the Medicare.gov website.
Finally, the rule continues the phased-in implementation of the physician value-based payment modifier (Value Modifier), created by the Affordable Care Act, which would affect payments to physician groups based on the quality and cost of care they furnish to beneficiaries enrolled in the traditional Medicare fee-for-service program.
CMS released a fact sheet discussing the proposed changes to payment policies and payment rates for services furnished under the PFS. Another fact sheet discusses proposed changes to quality reporting programs, the Medicare HER Incentive program, and the proposals for implementing the Value Modifier.
PROVISIONS INCLUDED IN THE CY 2014 PFS PROPOSED RULE
CMS’s fact sheet discussing proposed changes to payment policies and payment rates for services furnished under the PFS outlines several provisions of the proposed rule.
Primary Care and Complex Chronic Care Management: CMS notes:
“In this proposed rule, we emphasize advanced primary care through our proposal to pay separately for complex chronic care management services, beginning in CY 2015. Specifically, we propose to pay for non-face-to-face complex chronic care management services for Medicare beneficiaries who have multiple, significant chronic conditions (two or more). Complex chronic care management services include regular physician development and revision of a plan of care, communication with other treating health professionals, and medication management. Medicare will make separate payment to physicians through two G-codes for establishing of a plan of care and furnishing care management over 90-day periods.”
CMS states to be eligible for these services, the agency proposes that beneficiaries must also have had an Annual Wellness Visit or an Initial Preventive Physical Examination, if applicable. CMS also proposes that a single practitioner furnish these services and that they must have the beneficiary’s consent to receiving these services over a one-year period.
In addition, the rule indicates that CMS intends to: “establish practice standards necessary to support payment for furnishing complex care coordination management services.”
The rule also: “solicits comment on the potential for CMS to recognize a patient-centered medical home (PCMH) designation by private organizations as one means for a practice to demonstrate that it has met the requisite practice standards.”
Telehealth Services: CMS proposes the modification of regulations describing eligible telehealth originating sites to include health professional shortage areas (HPSAs) located in rural census tracts of urban areas as determined by the Office of Rural Health Policy.
In addition, CMS also proposes to add transitional care management services to the list of eligible Medicare telehealth services.
Revisions To The Practice Expense Geographic Adjustment: CMS is proposing new geographic practice cost indices (GPCIs) using updated data. In addition, CMS states: “we are changing the weights assigned to each GPCI (work, PE and malpractice) consistent with the recommendations of the Medicare Economic Index (MEI) Technical Advisor Panel (see below) that increases the weight of work and reduces the weight of practice expense. These new GPCIs would be phased in over CY 2014 and CY 2015. These changes are budget neutral. The statutory work GPCI “floor” of 1.0 is scheduled to expire under current law on December 31, 2013. The proposed GPCIs reflect the elimination of the work “floor” and as a result 51 localities will have a work GPCI below 1.”
Medicare Economic Index: CMS is proposing revisions to the calculation of the MEI — the price index used to update physician payments for inflation. The proposed rule includes proposed changes in the RVU and GPCI weights assigned to work and practice expense so that the weights in the payment calculation would continue to mirror those in the MEI if the proposed revisions are adopted.
Misvalued Codes: CMS is proposing to adjust payment rates for more than 200 codes where Medicare pays more for services furnished in an office than in an outpatient hospital department or ASC. CMS states: “we are proposing to limit the PFS payment in the situation described above to the total payment that Medicare would make to the practitioner and the facility when the service is furnished in a hospital outpatient department or ASC. In addition, for CY 2014, we are proposing potentially misvalued codes that we identified with the assistance of the Contractor Medical Directors based on their personal experience in paying for Medicare services.”
Application of Therapy Caps to Critical Access Hospitals: CMS proposes: “The law applies two per beneficiary limits to outpatient therapy services—one for physical therapy and speech-language pathology services and another for occupational therapy services. Before the American Taxpayers Relief Act passed earlier this year, the caps did not previously apply in Critical Access Hospitals (CAH). We propose to apply the therapy cap limitations and related policies to outpatient therapy services furnished in a CAH beginning on January 1, 2014 to conform Medicare’s regulations to current law.”