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2010 Medicare Physician Fee Schedule Proposed Rule
作者:USMedEdu
发表时间:2009-10-08
更新时间:2009-10-08
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2010 Medicare Physician Fee Schedule Proposed Rule Summary________________________________________________________The Centers for Medicare and Medicaid Services (CMS) has proposed the Medicare physician feeschedule (MPFS) for 2010. The rule in its entirety can be found at:http://edocket.access.gpo.gov/2009/pdf/E9-15835.pdf. CMS will accept comments on the proposed ruleuntil August 31, and will respond to all comments in a final rule to be issued by November 1, 2009. Unless otherwise specified, the new payment rates and policies will apply to services furnished toMedicare beneficiaries on or after January 1, 2010. Physician Fee Schedule Update While Medicare updates most of their payment rates each year for inflation, physician services areupdated by a formula mandated in legislation known as the Sustainable Growth Rate (SGR). SGRestablishes a spending target for physician services. CMS projects a negative update of -21.5 percent forthe 2010 Medicare Physician Fee Schedule due to the application of the SGR formula. This will result ina CY 2010 conversion factor (CF) of $28.3208. This represents a decrease from the 2009 CF of$36.0666. Negative updates have been expected every year since 2002, although Congressional actionhas averted payment reductions since 2003. Congressional action will be needed again in order to avoid apayment reduction in 2010. Proposal to Remove Physician Administered Drugs from SGR FormulaVPROPOSAL: CMS is proposing to remove physician administered drugs from the calculation ofallowed and actual expenditures. While this proposal would not change the update for 2010 it wouldreduce the past discrepancy between actual and targeted expenditures and would reduce the number ofyears in which physicians are projected to experience a negative update.Specialty ImpactIncluded in the rule, is a chart showing the impact of the proposed work, practice expense (PE), andmalpractice (MP) relative value units (RVU) changes on the various Medicare recognized specialties. The analysis does not include the effect of any conversion factor change which is the same for allspecialties. For the most part, the projected impact on specialties is a function of the proposed changes topractice expense and malpractice. Based on this analysis, hematology/oncology is estimated toexperience an impact of -5 percent from the practice expense changes and – 1 percent from malpracticeRVU changes in the 2010 proposed rule. An excerpt from the chart is below and the full chart isattached.Table 39: CY 2010 Total Allowed Charge Impact for Work, Practice Expense and Malpractice (MP) ChangesSpecialtyAllowedCharges(mill)Impact ofWork RVUChangesImpact ofPE RVUChanges*Impact ofMP RVUChangesCombinedImpactTotal$77,7440%1%0%1%Hematology/Oncology$1,8880%-5%-1%-6%* Note: The law caps the MFS imaging payment amount at the comparable payment amount in thehospital outpatient payment system (OPPS cap). In the absence of the negative current law CY 2010 MFSupdate, the proposed PE change to the equipment utilization rate for expensive equipment from 50percent to 90 percent would increase expenditures by approximately 1 percent due to a loss of savingsfrom the OPPS cap.1
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Practice Expense ChangesPractice Expense Relative Value Units (RVUs) represent the resources used in furnishing supplies, officerent/lease, equipment and personnel wages (excluding malpractice expense) when providing physicianservices.AMA Physician Practice Information Survey (PPIS)Currently PE per hour (PE/HR) data is obtained from the American Medical Association’s (AMA’s)Socioeconomic Monitoring Survey (SMS) surveys from 1995-1999. For several specialties more currentsupplemental survey data was accepted and is being used by the Agency to calculate PE RVUs. Thesespecialties include cardiology, dermatology, gastroenterology, radiology, cardiothoracic surgery, vascularsurgery, physical and occupational therapy, independent laboratories, allergy/immunology, independentdiagnostic testing facilities (IDTFs), radiation oncology, medical oncology, and urology. Because theSMS data and the supplemental survey data are from different time periods, CMS has historically inflatedthem by the Medical Economic Index (MEI) to help make the data comparable.The AMA in collaboration with numerous medical specialty societies recently conducted a new survey,the Physician Practice Information Survey (PPIS) to update the specialty-specific PE per hour (PE/HR)data used to develop PE RVUs. The PPIS survey was administered in 2007 and 2008 and unlike previoussurveys included nonphysician practitioners (NPP).VPROPOSAL: CMS is proposing to update the PE/HR data based on the new PPIS survey for allMedicare recognized specialties that participated in the PPIS for payments effective January 1, 2010. ThePPIS gathered information from 3,656 respondents across 51 physician specialty and health careprofessional groups. Since IDTFs and independent labs did not participate in the PPIS survey, CMS isproposing to continue using the existing survey data for these providers. Although reproductiveendocrinology, sleep medicine, and spine surgery participated in the PPIS survey since these specialtiesare not separately recognized by Medicare, CMS is not using this data and is seeking comment on how toblend this specialty data.Impact on Medical Oncology Services: While hematology did not participate in the survey, medicaloncology did participate. Regardless of specialty designation the medical oncology data would impact alloncology services. PE RVUs are based on direct practice expense inputs (clinical labor, medical suppliesand medical equipment) and indirect costs (clerical payroll, office expense, and other expense). Key tothe determination of indirect costs is the ratio of a specialty’s indirect costs to that of all physicians. Thechart below provides the results of the new survey for medical oncology.IndirectDirectSpecialtyCurrentIndirectPE/HRPPISIndirectPE/HRCurrentIndirect%PPISIndirect%2009PE/HRPPISPE/HRAll Physicians$59.04$86.3667%74% $88.23$116.96Medical Oncology$141.84 $129.9459%56% 240.91$230.06The survey final report and other details is available on the CMS website:http://www.cms.gov/PhysicianFeeSched/Equipment Utilization Rate Assumption In allocating equipment costs for calculating PE RVUs, CMS assumes equipment is in use 25 hours perweek or 50 percent of the time a facility/office is open (a 50 hour week is assumed). A 2006 surveysponsored by the Medicare Payment Advisory Commission (MedPAC) of CT and MRI machinesindicates that the current usage rate is understated. According to the data from the survey MRI scanners2
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are used an average of 52 hours per week and CT machines are operated an average of 42 hours per week. An increase in the equipment use assumption would decrease the equipment costs allocated to theseservices and reduce PE RVUs for CT, MRI and other services associated with equipment priced at $1million or above.VPROPOSAL: Although MedPAC has concluded that their survey was not nationally representative butrepresentative of the imaging providers in the six markets included in the survey, CMS is proposing achange in the equipment utilization assumption based on this new data. CMS is proposing to change theequipment usage assumption from the current 50 percent usage rate to a 90 percent usage rate forequipment priced over $1 million. The threshold of a million is proposed since all of the equipment citedin the MedPAC study is priced at $1 million or more. CMS will continue to explore data sourcesregarding the utilization rates of equipment priced at less than $1 million but no policy changes are beingproposed at this time for this less expensive equipment.Miscellaneous PE IssuesThe proposed rule mentioned other miscellaneous PE issues including:• CMS will continue to analyze PE methodology for services which are utilized 24 hours a day/7days a week• CMS requested AMA RUC to review PE direct inputs for several high dose radiation therapy(HDRT) and placement CPT codesCPT Code ChangesConsultation ServicesA consultation service is an evaluation and management (E/M) service furnished by a physician orqualified NPP at the request of another physician or appropriate source. The payment for a consultationhas been set higher than for an initial visit because a written report must be made to the requestingprofessional.For the past several years the appropriate reporting of consultation services has been an issue of someinterest to CMS. Since 2006 CMS has had an ongoing discussion with the AMA CPT Editorial Panel forpotential changes to the consultation definition and guidance in CPT. A 2006 report published by theOffice of the Inspector General (OIG) indicated that Medicare allowed approximately $1.1 billion more in2001 than it should have for services that were billed as consultations.CMS cited two areas of disagreement that have remained unresolved with the physician communityregarding consultation codes: documentation requirements and ambiguity regarding transfer of carepolicies. EM guidelines require both the requesting physician and the consulting physician to documentthe request. CMS has heard from representatives from national physician organizations that aredissatisfied with this policy. CMS has also found that interpretation differs from one physician to anotheras whether a transfer of care should be reported as an initial E/M service or as a consultation service.VPROPOSAL: CMS proposes to budget neutrally eliminate the use of all consultation codes (inpatientand office/outpatient codes for various places of service except for the telehealth consultation G-codes) byincreasing the work RVUs for the new and established office visits, increasing the work RVUs for initialhospital and initial nursing facility visits, and incorporating the increased use of these visits into our PEand malpractice RVU calculations. CMS believes the rationale for differential payment for a consultationservice is no longer supported because documentation requirements are now similar across all E/Mservices.3
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While specific crosswalks were not provided in the rule, CMS stated that providers will bill initial visitcodes in lieu of the consultation codes. While there are five office/outpatient consultation codes and fiveoffice/outpatient new patient EM codes, the crosswalk for inpatient consultation codes is less clear sincethere are only three initial inpatient visit codes while there are five inpatient consultation codes.Because Medicare policy only allows one admitting patient of record for a particular patient, CMS willcreate a modifier to identify the admitting physician of record for hospital inpatient and nursing facilityadmissions. This will help distinguish the admitting physician who oversees the patient’s care from otherphysicians who may be furnishing specialty care.Potentially Misvalued Services Under the Physician Fee ScheduleCMS is considering several different approaches to address the issue of potentially misvalued services. AMA RUC Process – To address concerns voiced by different stakeholders, the AMA RUC reviewed anumber of potentially misvalued codes through their Five Year Review Workgroup at their February andApril 2009 meetings. Subsequently recommendations were submitted to CMS by the RUC. CMS plansto address these recommendations in the 2010 final rule.High Cost Supplies – In the CY 2009 proposed physician rule CMS proposed a process to update theprices associated with high cost supplies over $150 every two years. The Agency requesteddocumentation from the medical community. The Agency did receive input but is continuing to consideralternatives to obtain pricing information and will propose a revised process in future rulemaking. Nonsurgical Services Often Billed Together – CMS plans to analyze codes furnished together more than75 percent of the time, excluding E/M codes. Both physician work and PE inputs will be examined. Ifduplications or overlap in work or PE are found, CMS will consider whether a multiple procedurepayment reduction (MPPR) or bundling of service is most appropriate. Any proposed changes will bemade through rulemaking and open for public comment.Site of Services Anomalies – The AMA RUC Five Year Identification Workgroup reviewed a number ofcodes where there had been a shift in the site of service (site of service anomaly). These are generallyservices that historically were provided in the inpatient setting and are now typically provided in theoutpatient setting. The AMA submitted revisions to the values of these codes. After further review, CMSis proposing additional changes to several of these codes. CMS does not believe the AMA RUC-recommended values reflect the extraction of the RVUs associated with deleted or reallocated pre-serviceand post-service time, hospital days, office visits, and discharge day management services.MedPAC Recommendation– MedPAC in the past has recommended the establishment of a group of panelof experts separate from the AMA RUC to review RVUs. CMS is seeking public input on the followingquestions and other aspects of such an approach:• How could input from a group of experts best be incorporated into existing processes ofrulemaking and agency receipt of AMA RUC recommendations?• What specifically would be the roles of a group of experts (for example, identify potentiallymisvalued services, provide recommendations on valuation of specified services, review AMARUC recommendations selected by the Secretary, etc.)?• What should be the composition of a group of experts? How could such a group provide expertiseon services that clinician group members do not furnish?• How would such a group relate to the AMA RUC and existing Secretarial advisory panels such asthe Practicing Physician Advisory Committee?4
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Also of interest are comments on the resources required to establish and maintain such a group.Telehealth ServicesMedicare policy allows for coverage and payment for Medicare telehealth includes consultation, officevisits, individual psychotherapy, and pharmacologic management any additional services specified by theSecretary delivered via a telecommunications system. CMS maintains a list of eligible services. VPROPOSAL: CMS is proposing to specify that G-codes for follow-up inpatient telehealth consultations(as described by HCPCS codes G0406 through G0408) include follow-up telehealth consultationsfurnished to beneficiaries in hospitals and SNFs.CMS received a number of other requests for additions to the list of approved telehealth servicesincluding Health Behavior and Assessment Intervention (HBAI) and critical care services which wererejected.Payment for Initial Preventive Physical Examination (IPPE)MIPPA changed the initial preventive physical examination (IPPE) benefit by adding the measurement ofan individual’s body mass index and, upon an individual’s consent, end of life planning. MIPPA alsoremoved the screening electrocardiogram (EKG) as a mandatory service of IPPE. The IPPE is reportedwith code G0402 and is valued at 1.34 work RVUs in 2009.VPROPOSAL: CMS is proposing to increase the work RVUs for code G0402 to 2.30 work RVUs. Thisvalue was crosswalked from code 99204, Evaluation and management new patient, office or otheroutpatient visit. Based on analysis of the work and intensity, CMS concluded the IPPE is most similar tocode 99204.Malpractice Relative Value Units (RVUs)Revision of Resource-Based Malpractice RVUsInitial implementation of resource-based malpractice (MP) RVUs occurred in 2000. CMS is required toreview these RVUs no less than every five years. The first review of malpractice RVUs were addressedin the CY 2005 final rule.Hematology/Oncology is estimated to experience a -1% impact in 2010 due to the proposed changes tomalpractice relative value units (RVUs).VPROPOSAL: CMS is proposing to implement the second review and update of malpractice RVUs byusing specialty-specific malpractice premium data from CY 2006 and 2007. Data was collected from 49states and the District of Columbia for all physician specialties represented by major insurance providers. Thirteen specialties were crosswalked to similar specialties for which sufficient data was not available. Data for four specialties which were not crosswalked were dropped resulting in data from 44 specialtiesrepresenting 90 percent of Medicare services.The data showed that the primary determinants of malpractice liability costs continue to be physicianspecialty, level of surgical involvement, and the physician’s malpractice history. CMS proposes to use the current methodology of a specialty-weighted approach with minor modificationsto accommodate additional data gathered. The specialty-weighted approach bases the malpractice RVUsupon a weighted average of the risk factors of all specialties furnishing a given service. This approachensures that all specialties furnishing a given service are accounted for in the calculation of the finalmalpractice RVUs. 5
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Malpractice RVUs for TC Portion of Certain ServicesThe previous update of the malpractice RVUs did not update the TCs due to the lack of availablemalpractice premium data for entities providing TC services. In previous regulations CMS has requestedinformation on how technicians employed by these facilities purchase professional liability insurance(PLI) or how their professional liability is covered. Premium data recently collected by Acumen LLC from a firm that provides liability insurance to imagingcompanies indicates that medical physicists have very low malpractice premiums relative to physicians. Medical physicists are involved in complex services such as Intensity-Modulated Radiation Therapy(IMRT). VPROPOSAL: CMS is proposing to use the medical physicists’ premium data as a proxy for themalpractice premiums paid by entities providing TC services.Malpractice RVUs for Certain Codes with No Physician WorkCertain codes have no physician work RVUs. The overwhelming majority of these codes are the TC s ofthe diagnostic tests, such as x-rays and cardiac catheterization which have a distinctly separate TC (thetaking of the x-ray) and PC (the interpretation of the x-ray by the physician). VPROPOSAL: CMS proposes to set the TC malpractice RVUs equal to the difference between the globalmalpractice RVUs and the PC malpractice RVUs.Impact on the Technical Component (TC) of ServicesThe impact on the TC of these proposed changes can be dramatic. For example, code 73720, MRI lowerextremity, w/out and w/ dye, picked at random went from a 2009 MP RVU of 0.84 down to 0.01 MPRVUs. Part B DrugsStatutorily Named CompendiaMedicare has designated compendia that are authoritative sources for use n the determination of"medically-accepted indication" of drugs and biologicals used off-label in an anticancer chemotherapeuticregimen.VPROPOSAL: MIPPA requires that on or after January 1, 2010 no compendia may be included on thelist of compendia unless it has a publically transparent process for evaluating therapies and for identifyingpotential conflicts of interest.CMS proposes that this standard of publically transparent process could be met by publishing materialsused in its evaluation process on its website. The Agency proposes that assurance of a publicly transparent evaluation process is best achieved byestablishing a process that provides for public disclosure of the evidence considered and the review of thatevidence leading to the development of compendia recommendations.CMS proposes that a publicly transparent process for identifying potential conflicts of interest is bestdemonstrated by a process that requires public transparency regarding the competing financial andnonfinancial interests that may give rise to such conflicts. CMS believes that a compendium should havea process for disclosing by publication on its publicly accessible website certain information regardingpotential conflicts of interests associated with individuals who are responsible for the compendium'srecommendations as well as their immediate family members. Disclosures should remain available of aperiod of not less than 5 years.6
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Other Part B Drug IssuesThe rule also reviewed details regarding some technical issues related to the widely available market price(WAMP) and average manufacturer price (AMP).Physician Quality Reporting Initiative (PQRI)The Physician Quality Reporting Initiative (PQRI) was authorized by the Medicare, Medicaid, andSCHIP Extension Act (MMSEA) of 2007. In 2009 participating professionals were eligible for a bonusof 2.0 percent of the estimated total allowed charges for all covered professional services furnished duringthe reporting period. Providers report either individual measures or a measure group through a variety ofreporting mechanisms. 2010 PQRI ProgramIncentive Payment - The Secretary is authorized to provide an incentive payment equal to 2.0 percent ofthe estimated total allowed charges for all covered professional services during the reporting period for2010.Reporting Mechanisms – In 2009 providers could submit measures either through claims or via aqualified registry and the Agency proposes to maintain these reporting options. CMS proposes thatproviders that report measures through a registry will need to enter into and maintain an appropriate legalarrangement with a qualified 2010 PQRI registry. CMS will post on the PQRI section of the CMSwebsite a list of qualified registries for the 2010 PQRI. An initial list will be posted by December 31,2009 of registries who successfully participated in the 2009 program and a subsequent list will be postedlater in 2010 for additional registries who have indicated interest through the self nomination process. CMS is proposing additional criteria for registries to meet in 2011 that are outlined in the rule. TheAgency notes that even though a registry is listed as “qualified” CMS cannot guarantee or assumeresponsibility for the registry’s successful submission.VPROPOSAL: For 2010 CMS is proposing to add a third reporting mechanism, electronic health record(EHR) for a limited subset of measures. This proposal is contingent upon the successful completion ofthe 2009 EHR data submission testing process. This process is scheduled to conclude in 2009. EHRproducts that meet the requirements will be posted on the CMS section of the PQRI website.CMS also noted they are considering significantly limiting the claims-based mechanism of reportingclinical quality measures for PQRI after 2010. This would be contingent upon there being an adequatenumber and variety of registries available and/or an EHR reporting option.Reporting Periods –CMS proposes to establish the following reporting periods for the various reportingoptions. The incentive payment is based on the claims submitted for the reporting period.• 12 month period – January 1 to December 31, 2010o Individual measures (claims based, EHR, or registry)o Measure groups (claims, registry)• 6 month period – July 1 to December 31, 2010o Individual measures (registry)o Measure group (claims based, registry)Successful Reporting of Individual Measures – In previous years CMS had both a criteria related to thenumber of measures reported (3 measures or 1-2 measures if less than 3 measures applied) and criteriarelated to the frequency of reporting (at least 80% of the time the measure applied). 7
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VPROPOSAL: For 2010 CMS is proposing an additional requirement. CMS proposes establishing aminimum patient sample size for at least one measure to enhance the scientific validity of the eligibleprofessionals’ performance results. For 2010 CMS proposes that regardless of the reporting mechanismthat the minimum patient sample size for reporting individual quality measures be 15 Medicare Part Bpatients for the 12 month reporting period and 8 patients for the 6 month reporting period. Successful Reporting of Measure Groups – Table 15 in the rule summarizes the six different options andvarious reporting criteria available to providers when reporting measure groups. Measure groups can bereported either through a claims-based process or a registry for either 12 months or 6 months. The EHRreporting mechanism option is not available for measure groups. Similar to reporting individual measuresCMS has proposed criteria related to the number of measures reported (1 measure group) and frequencyof reporting and various minimum sample sizes that varies by the reporting option selected.Group Practice Participation Option – CMS proposes establishing an option for group practices toparticipate in the PQRI program in 2010. VPROPOSAL: A provider participating in a group practice option would not be eligible to earn aseparate individual PQRI incentive payment. A group practice is defined as at least 200 or moreindividual eligible professionals. Group practices interested in participating would be required tocomplete a self nomination process and meet certain technical and other requirements and agree to havethe performance rates at the group practice level (not individual) for each measure publically reported onposted on the CMS website. However, CMS may identify the individual professionals who wereassociated with the group during the reporting period. Final participation requirements will be posted onthe CMS website by November 15, 2009 and group practices will be required to self nominate by the endof the first quarter in 2010.Group practices would be required to report for a 12 month period and will be required to submitinformation on their measures using a data collection tool based on the data collection tool used in CMS’Medicare Care Management Performance (MCMP) demonstration and the Physician Group Practice(PGP) demonstration. Group practices would be required to report on a common set of 26 NQF-endorsedquality measures that are based on measures currently used in the MCMP and/or PGP demonstration. Similar to previous demonstration projects, the group practice will be required to report on beneficiariesassigned by Medicare to the group practice.Measures Proposed for 2010 - Legislation requires that quality measures be adopted or endorsed by aconsensus organization such as the national Quality Forum or the AQA. In January 2009 the AQAannounced that it will no longer be adopting measures. CMS proposes that any new quality measuresproposed for the 2010 PQRI must be NQF-endorsed by July 1, 2009, while any proposed 2010 PQRIquality measures selected from the 2009 PQRI quality measure set would need to have been adopted bythe AQA as of January 31, 2009 if the measure still is not endorsed by the NQF by July 1, 2009.• All Measures - For the 2010 PQRI program CMS proposes a total of 168 measures of these 22would be new individual measures. • Measure Groups - CMS is proposing to retain the 7 measure groups from 2009 and add 6 newmeasure groups for a total of 13 measure groups for 2010. The six new measure groups proposedfor 2010 PQRI are: Coronary and Artery Disease (CAD); Heart Failure (HF); Ischemic VascularDisease (IVD); Hepatitis C; Human Immunodeficiency Virus (HIV)/Acquired ImmuneDeficiency Syndrome (AIDS); and Community Acquired Pneumonia (CAP). 8
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• Registry-only Measures - Due to measure complexity a select number of measures are beingproposed to be designated as "registry-only" measures. None of the hematology/oncologymeasures were selected for this designation.• EHR Measures - Additionally, a select number of measures have been designated to be reportedthrough an EHR. None of the hematology/oncology measures were selected for this designation.• Proposed Deletion of Measures for 2010 - CMS is also proposing to delete seven measures fromthe 2009 PQRI program. None of these measures were of interest to hematology/oncology. • Hematology/Oncology Measures Proposed for 2010 - CMS is proposing the following measuresfor 2010 PQRI of potential interest to hematologists/oncologists.Proposed Measures of Interest to Hematologists/Oncologists for 2010 PQRIClaims-Based and Registry ReportingNo.Measure Title67Myelodysplastic Syndrome (MDS) and Acute Leukemias: Baseline CytogeneticTesting Performed on Bone Marrow68Myelodysplastic Syndrome (MDS): Documentation of Iron Stores in PatientsReceiving Erythropoietin Therapy69Multiple Myeloma: Treatment with Bisphosphonates70Chronic Lymphocytic Leukemia (CLL): Baseline Flow Cytometry124 Health Information Technology (HIT): Adoption/Use of Electronic Health Records (EHR)The 2010 measure specifications document, which provides guidance on the appropriate definition andreporting of the measures, will be posted on the CMS website no later than December 31, 2009.Physician Resource Use Measurement and Reporting ProgramAs required by MIPPA, in 2009 CMS established and implemented a Physician Feedback Program usingMedicare claims data and other data to provide confidential feedback to physicians that measure theresources involved in furnishing care to Medicare beneficiaries. CMS is implementing this program in a phased-in approach. Phase I which consisted of thedissemination of an approximately 50-page report on resource use related to specific conditions to a selectnumber of physicians was completed earlier this year. The resource use reports disseminated in phase Iof the program defined peer groups of physicians by focusing on one condition, one specialty, and onegeographic location. Within each peer group, the resource use reports indicated whether the individualphysician fell over the 90th percentile (high cost benchmark), below the 10th percentile (low costbenchmark), or over the 50th percentile (median cost benchmark). CMS also solicited comments on thisprogram in the 2009 final rule with comment period. 2010 Physician Resource Use Measurement Reporting ProgramBased on the experiences from phase I and input received from the 2009 final rule with comment CMS isplanning on the following changes for the 2010 program.• Costs – Based on comments received CMS will include all cost of service categories included onthe claim for the 2010 program. • Conditions - Selected conditions for Phase I were: congestive heart failure, chronic obstructivepulmonary disease, prostate cancer, cholecystitis, coronary artery disease with acute myocardial9
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infarction, hip fracture, community acquired pneumonia, and urinary tract infection. Based oncomments received CMS will add diabetes to the list of conditions for the 2010 program.• Time Period – In 2010 CMS will include three years of Medicare claims data for calculatingresource use.• Specialties – In phase I of the program the following physician specialties were included: generalinternal medicine, family practice, gastroenterology, cardiology, general surgery, infectiousdisease, neurology, orthopedic surgery, physical medicine and rehabilitation, pulmonology, andurology. CMS plans on maintaining this list of specialties for the 2010 program.• Location of physicians – For phase I of the program CMS mailed the report to physicians locatedin the following sites chosen due to their proximity to a CMS central office: Greenville, SC;Indianapolis, IN; Northern New Jersey; Orange County, CA; Seattle, WA; Syracuse, NY; Boston,MA; Cleveland, OH; East Lansing, MI; Little Rock, AR; Miami, FL; and, Phoenix, AZ. For the2010 program CMS intends to include the sites listed above and identify a limited number of newlocations.• Benchmarks – CMS intends on continuing the use of the benchmarks used in phase I reports.CMS is soliciting comments on the design and elements of the sample resource use report used in phase Iof the Program. The Agency is particularly interested in receiving comments on the usefulness of the costof service category drill down analysis. The report is available on-line at: http://rurinfo.mathematica-mpr.com/#contentPhase II of the ProgramThe Agency is proposing to expand the program in phase II.VPROPOSAL: CMS is proposing the following expansions for phase II.• Physician Groups – CMS is proposing to add reporting to groups of physicians recognizing thatphysicians practice in various arrangements. Group level reporting provides a mechanism foraddressing sample size issues that arise when individual physicians have too few Medicarebeneficiaries with specific conditions to generate statistically significant reports.• Quality measurements – CMS is proposing to add quality measurement information as context forinterpreting comparative resource use. Possible sources of quality measures include PQRI andthe Generating Medicare Physician Quality Performance Measurement Results (referred to asGEM) Project.Physician Value Based Purchasing (PVBP) ProgramCurrently, Medicare health professional payments are based on the quantity of services or proceduresprovided, without recognition of quality or efficiency. MIPPA requires the Secretary to develop a value-based purchasing (VBP) program for Medicare payment for professional services paid under thephysician fee schedule. By May 1, 2010 the Secretary shall submit a report to Congress containing theplan, together with recommendations for such legislation and administrative action as the Secretarydetermines appropriate.Examples of VBP initiatives relevant to physicians include: pay for reporting of quality measurementdata; resource use reports comparing overall costs, as well as costs for treatment across episodes of care;or, demonstration projects, including the Physician Group Practice demonstration of a shared savingsmodel.10
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CMS has created an internal VBP Workgroup to lead the development of the plan. Four subgroups wereestablished to address the major sections of the pan: measures; incentives; data strategy and infrastructure;and public reporting. The Agency has reached out to the public and various stakeholders to help informtheir work. The goals and objectives of the workgroup were outlined in an issues paper that was releasedon November 24, 2008. A listening session was held on December 9, 2008 where CMS staff heardvarious stakeholders.The workgroup has begun to develop potential recommendations for inclusion in the Report to Congress. The first step is to design various approaches for performance-based payment that will address theplanning goal and objectives for different practice arrangements. This design process will includeidentifying appropriate measures and incentive structures, considering the necessary data infrastructure,and addressing public reporting options. Consideration will be given to approaches that:• Overlay the current fee schedule such as differential fee schedule payments based on measuredperformance or for providing a medical home• Address multiple levels of accountability, including individual health professionals, as well aslarger teams or organizations• Promote more integrated care through shared savings models and bundled payment arrangements.CMS is soliciting comments particularly in the areas of the appropriate level of accountability (i.e. group,individual, region) and appropriate data submission mechanisms. The workgroup will use publiccomments to inform its development of the plan and report to Congress.E-Prescribing Incentive Program2010 will be the second year of the MIPPA authorized E-prescribing incentive program. The programuses a mix of carrots and sticks to encourage participation. Successful participants will be eligible for thefollowing bonus payments: 2% in 2010; 1% in 2011; 1% in 2012; and, 0.5% in 2013. In order to beeligible for the program, the e-prescribing quality measure must apply to at least 10 percent of theprofessional’s total Part B allowed charges. Eligible participants who are not successful or do notparticipate will face the following reductions to their Medicare payments: – 1% in 2012; – 1.5% in 2013;and -2.0% in 2014 and each subsequent year. CMS will report publicly the names of eligibleprofessionals who are successful electronic prescribers. The Recovery Act specifies that an individualprovider or group providers is not eligible to receive the incentive if, for the EHR reporting period, theeligible professional earns an incentive payment under the new Health Information Technology (HIT)incentive program authorized under the Recovery Act.2010 E-Prescribing Incentive ProgramVPROPOSAL: CMS is proposing the following for the 2010 program:• Physician group option – CMS will begin making incentive payments to group practices based onthe determination that the group practice, as a whole, is a successful electronic prescriber.• Reporting period – CMS proposes a 12 month reporting period: January 1 – December 31, 2010.• Reporting Mechanism – CMS proposes to retain the claims-based reporting mechanism that wasused in the 2009 program. In addition, CMS proposes to implement a registry-based reportingmechanism. Potentially, an EHR-based reporting mechanism will also be available in 2010. Thesame registries and EHR products that are qualified to submit PQRI data would be consideredqualified to submit e-prescribing data. 11
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• E-prescribing Measure – CMS proposes 1 measure in 2010 (G8443) to indicate that at least 1prescription in connection with the visit billed was electronically prescribed and proposes toeliminate the other two G-codes used in 2009. CMS proposes to modify the measure so that itwould apply to professional services not just in the office and outpatient setting as it had in 2009but to also include skilled nursing and home care settings.• Successful reporting - E-prescribers must report the G-codes at least 50% of the time to beconsidered successful. In 2010 CMS is proposing to add a minimum threshold that the measurewas reported at least 25 times during the 2010 reporting period.In order to be eligible the electronic quality measure must apply to at least 10 percent of the professional’stotal Part B allowed charges. Final measure specifications for the E-prescribing program will be postedby December 31, 2009 on the CMS website.Implementation of Accreditation Standards for Suppliers Furnishing theTechnical Component (TC) of Advanced Diagnostic Imaging ServicesSection 135 of MIPPA requires advanced diagnostic imaging service suppliers to be accredited by anaccreditation organization by January 1, 2012. Payment for the technical component (TC) of the serviceis contingent upon the supplier being accredited by an accreditation organization designated by theSecretary. For the purposes of this policy, advanced diagnostic imaging services include: diagnosticmagnetic resonance imaging, computed tomography, nuclear medicine, and positron emissiontomography. This rule sets forth the criteria for designating organizations to accredit suppliers. CMS expects topublish a notice to solicit applications from entities interested in becoming an accredited organization onor before November 1, 2009.Request for CommentsCMS indicated that they are interested in obtaining additional information on the role of radiologyassistants (RA) and radiology practitioner assistants (RPA), including the level of physician supervisionthat would be appropriate when RAs and RPAs are involved in the performance of the TC of advancedmedical imaging, whether the role varies by state or any other related information.Geographic Practice Cost Indices (GPCIs)The Medicare physician fee schedule pricing amounts are adjusted to reflect the variation in practice costsfrom area to area. A geographic practice cost index (GPCI) has been established for every Medicarepayment locality for each of the three components of a procedure's relative value unit (i.e., the RVUs forwork, practice expense, and malpractice).Expiration of MIPPA ProvisionThe Medicare Improvements For Patients and Providers Act, (MIPPA) extended the 1.000 work GPCIfloor from July 1, 2008 through December 31, 2009. MIPPA also established a permanent 1.500 workGPCI floor in Alaska for services furnished beginning January 1, 2009. As required by MIPPA, the 1.000work GPCI floor will be removed on January 1, 2010 but the 1.500 work GPCI floor for Alaska willremain in place.Payment LocalitiesThe current locality structure was developed and implemented in 1997. There are currently 89 localities. Any changes to the locality configuration must be made in a budget neutral manner the implication beingthat any change in localities can lead to significant redistribution in payments. CMS recently contractedwith Acumen LLC to conduct a preliminary study of several options for revising the payment localities on12
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a nationwide basis. Public comments on this interim study were accepted until November 3, 2008. CMSis continuing to review these comments and consider the impact of the proposals in the interim study.CMS is not proposing changes in the locality structure at this time.Other Miscellaneous IssuesOutpatient Mental Health TreatmentIn this rule CMS also outlined a plan to begin the implementation of the MIPPA provision to phase outthe limitation on recognition of expenses incurred for outpatient mental health treatment. Theimplementation of this provision will result in an increase in the Medicare Part B payment for outpatientand mental health services to 80 percent by CY 2014. At this time CMS is also proposing a number oftechnical corrections in order to update and clarify the services to which the limitation does not apply. The rule also addresses policy clarifications of audiology codes, Stark physician self-referral rules,changes to the Medicare anesthesia teaching program, payments and coverage improvements for patientswith chronic obstructive pulmonary disease and other conditions, coverage of kidney disease patienteducational materials, renal dialysis provisions, chiropractic services demonstration project,comprehensive outpatient rehabilitation facilities (CORF), ambulance fee schedule, and the clinical labfee schedule.13
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20092010*20092010*FrequencyCF=$36.0666CF =$36.4309CF=$36.0666CF =$36.430936430Blood transfusion service13,66336.07$ 26.96$ -25.25%NANANA36511Apheresis wbc489NANANA88.00$ 93.26$ 5.98%36512Apheresis rbc715NANANA89.45$ 93.26$ 4.27%36513Apheresis platelets358NANANA93.41$ 98.36$ 5.30%36514Apheresis plasma19,963495.19$ 450.65$ -9.00%87.28$ 91.08$ 4.35%36515Apheresis, adsorp/reinfuse2571,845.53$ 1,719.90$ -6.81%85.48$ 91.81$ 7.40%36516Apheresis, selective1,0212,089.34$ 1,771.63$ -15.21%61.67$ 64.12$ 3.96%36522Photopheresis4,0981,303.81$ 1,155.95$ -11.34%99.90$ 100.18$ 0.28%38205Harvest allogenic stem cells188NANANA78.26$ 81.61$ 4.27%38206Harvest auto stem cells2,305NANANA78.26$ 80.88$ 3.34%38220Bone marrow aspiration44,054147.15$ 130.06$ -11.62%58.79$ 60.84$ 3.49%38221Bone marrow biopsy132,778163.38$ 141.35$ -13.48%74.66$ 75.41$ 1.01%38230Bone marrow collection384NANANA304.04$ 330.79$ 8.80%38240Bone marrow/stem transplant269NANANA121.18$ 123.50$ 1.91%38241Bone marrow/stem transplant927NANANA121.91$ 124.23$ 1.91%38242Lymphocyte infuse transplant52NANANA92.33$ 95.08$ 2.98%88184Flowcytometry/ tc, 1 marker100,36678.26$ 72.86$ -6.90%NANANA88185Flowcytometry/ tc, add-on1,868,75246.53$ 44.45$ -4.47%NANANA88187Flowcytometry/read, 2-823,54464.20$ 68.85$ 7.25%64.20$ 68.85$ 7.25%88188Flowcytometry/read, 9-1529,03178.99$ 86.34$ 9.31%78.99$ 86.34$ 9.31%88189Flowcytometry/read, 16 & <127,080100.63$ 106.01$ 5.35%100.63$ 106.01$ 5.35%90760**Hydration iv infusion, init258,737 DELETEDDELETEDNANANANA90761**Hydrate iv infusion, add- on639,572 DELETEDDELETEDNANANANA90765**Ther/ proph/ diag iv inf, init1,237,103 DELETEDDELETEDNANANANA90766**Ther/ proph/ dg iv inf, add- on798,381 DELETEDDELETEDNANANANA90767**Tx/ proph/ dg addl seq iv inf2,079,889 DELETEDDELETEDNANANANA90768**Ther/ diag concurrent inf374,116 DELETEDDELETEDNANANANA90772**Ther/ proph/ diag inj, sc/ im8,500,055 DELETEDDELETEDNANANANA90773**Ther/ proph/ diag inj, ia2,414 DELETEDDELETEDNANANANA90774Ther/ proph/ diag inj, iv push346,850 DELETEDDELETEDNANANANA90775**Ther/ proph/ diag inj add- on1,931,941 DELETEDDELETEDNANANANA96360**Hydration iv infusion, initNEW56.62$ 47.36$ -16.36%NANANA96361**Hydrate iv infusion, add- onNEW16.59$ 12.75$ -23.14%NANANA96365**Ther/ proph/ diag iv inf, initNEW68.89$ 60.11$ -12.74%NANANA96366**Ther/ proph/ dg iv inf, add- onNEW22.00$ 19.31$ -12.24%NANANA96367**Tx/ proph/ dg addl seq iv infNEW34.62$ 26.96$ -22.14%NANANA96368**Ther/ diag concurrent infNEW20.56$ 16.76$ -18.48%NANANA96372**Ther/ proph/ diag inj, sc/ imNEW20.92$ 21.86$ 4.49%NANANA96373**Ther/ proph/ diag inj, iaNEW18.03$ 18.58$ 3.03%NANANA96374**Ther/ proph/ diag inj, iv pushNEW54.46$ 46.63$ -14.38%NANANA96375**Ther/ proph/ diag inj add- onNEW23.80$ 18.22$ -23.48%NANANA96401Chemotherapy, sc/im415,74267.44$ 61.93$ -8.17%NANANA96402Chemo hormon antineopl sq/ im566,92436.79$ 28.05$ -23.75%NANANA96405Intralesional chemo admin1,41584.40$ 73.59$ -12.80%28.85$ 29.87$ 3.54%96406Intralesional chemo admin401116.50$ 102.01$ -12.44%41.84$ 44.08$ 5.36%96409Chemo, iv push, sngl drug224,975111.81$ 88.53$ -20.82%NANANA96411Chemo, iv push, addl drug362,69363.84$ 50.27$ -21.25%NANANA96413Chemo, iv infusion, 1 hr2,314,555147.51$ 114.39$ -22.45%NANANA96415Chemo, iv infusion, addl hr1,652,63433.54$ 25.87$ -22.88%NANANA96416Chemo prolong infuse w/ pump114,079160.86$ 124.23$ -22.77%NANANA96417Chemo iv infus each addl seq716,10473.58$ 57.20$ -22.26%NANANA96420Chemotherapy, push technique177107.84$ 87.43$ -18.92%NANANA96422Chemotherapy,infusion method413173.84$ 137.34$ -20.99%NANANA96423Chemo, infuse method add-on1,30177.54$ 64.48$ -16.84%NANANA96425Chemotherapy,infusion method741171.32$ 144.99$ -15.36%NANANA96440Chemotherapy, intracavitary75597.98$ 784.72$ 31.23%132.36$ 140.26$ 5.96%96445Chemotherapy, intracavitary1,473285.29$ 243.36$ -14.70%116.86$ 118.76$ 1.63%96450Chemotherapy, into CNS2,667208.10$ 163.21$ -21.57%88.00$ 81.24$ -7.68%96521Port pump refill & main87,087126.95$ 108.56$ -14.49%NANANA96522Refill/ maint pump/ resvr syst25,680107.84$ 91.08$ -15.54%NANANA% CHANGE2009-2010* The 2010 CF assumes a 1.01% update from 2009. This is a proposal currently being considered in Congress.2010 Proposed Physician Fee Schedule (CMS 1413-P)Payment Rates for Medicare Physician Services - Hematology-OncologyCPTCodeModDescriptor2007NON-FACILITY (OFFICE)FACILITY (HOSPITAL)% CHANGE2009-2010** Note: CPT Codes 90760-90775 were deleted in CY 2009. The new codes assigned to these services are 96361-96375. 1
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20092010*20092010*FrequencyCF=$36.0666CF =$36.4309CF=$36.0666CF =$36.4309% CHANGE2009-2010* The 2010 CF assumes a 1.01% update from 2009. This is a proposal currently being considered in Congress.2010 Proposed Physician Fee Schedule (CMS 1413-P)Payment Rates for Medicare Physician Services - Hematology-OncologyCPTCodeModDescriptor2007NON-FACILITY (OFFICE)FACILITY (HOSPITAL)% CHANGE2009-2010** Note: CPT Codes 90760-90775 were deleted in CY 2009. The new codes assigned to these services are 96361-96375. 96523Irrig drug delivery device261,78225.25$ 20.04$ -20.63%NANANA96542Chemotherapy injection2,015134.17$ 101.28$ -24.51%45.44$ 41.53$ -8.61%99363*Anticoag mgmt, initNA118.30$ 121.68$ 2.86%81.87$ 85.25$ 4.12%99364*Anticoag mgmt, subseqNA41.12$ 41.53$ 1.01%31.74$ 32.42$ 2.16%G0364Bone marrow aspirate &biopsy68,44112.98$ 11.66$ -10.21%9.74$ 8.74$ -10.21%2
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20092010*20092010*FrequencyCF=$36.0666CF =$36.4309CF=$36.0666CF =$36.4309Evaluation and Management Services99201Office/outpatient visit, new354,65836.79$ 41.53$ 12.89%23.44$ 26.59$ 13.44%99202Office/outpatient visit, new2,432,66463.48$ 71.77$ 13.06%45.08$ 50.64$ 12.32%99203Office/outpatient visit, new5,175,28991.97$ 104.19$ 13.29%68.17$ 77.23$ 13.30%99204Office/outpatient visit, new3,232,644141.74$ 160.66$ 13.35%113.97$ 130.79$ 14.76%99205Office/outpatient visit, new1,040,042178.89$ 200.01$ 11.80%148.23$ 167.95$ 13.30%99211Office/outpatient visit, est9,345,98518.75$ 18.22$ -2.87%8.66$ 9.47$ 9.43%99212Office/outpatient visit, est21,647,31537.15$ 41.17$ 10.82%23.08$ 25.87$ 12.06%99213Office/outpatient visit, est104,328,94261.31$ 69.58$ 13.49%44.72$ 51.37$ 14.86%99214Office/outpatient visit, est65,511,13792.33$ 103.10$ 11.66%69.25$ 78.69$ 13.64%99215Office/outpatient visit, est8,060,246124.79$ 139.53$ 11.81%98.46$ 111.11$ 12.85%99221Initial hospital care425,845NANANA89.81$ 100.91$ 12.37%99222Initial hospital care3,035,525NANANA122.63$ 137.34$ 12.00%99223Initial hospital care5,631,298NANANA180.33$ 200.73$ 11.31%99231Subsequent hospital care16,329,791NANANA37.15$ 39.71$ 6.89%99232Subsequent hospital care51,080,310NANANA66.72$ 72.13$ 8.11%99233Subsequent hospital care19,596,436NANANA95.58$ 103.46$ 8.25%99241Office consultation**336,28148.69$ NANA33.18$ NANA99242Office consultation**1,503,72490.89$ NANA69.97$ NANA99243Office consultation**4,951,902124.79$ NANA97.38$ NANA99244Office consultation**6,025,404184.30$ NANA154.00$ NANA99245Office consultation**2,256,828226.50$ NANA192.23$ NANA99251Initial inpatient consult**267,653NANANA48.69$ NANA99252Initial inpatient consult**929,556NANANA75.74$ NANA99253Initial inpatient consult**3,093,064NANANA114.69$ NANA99254Initial inpatient consult**5,692,509NANANA165.55$ NANA99255Initial inpatient consult**2,832,048NANANA201.97$ NANA99291Critical care, first hour3,799,317253.91$ 265.95$ 4.74%212.07$ 223.69$ 5.48%99292Critical care, add&#298;l 30 min376,489114.69$ 120.59$ 5.14%106.04$ 111.84$ 5.48%99471Ped critical care, initial65NANANA777.96$ 800.39$ 2.88%99472Ped critical care, subseq198NANANA384.11$ 405.11$ 5.47%NON-FACILITY (OFFICE)FACILITY (HOSPITAL)% CHANGE2009-2010% CHANGE2009-2010CPTCodeDescriptor20072010 Proposed Physician Fee Schedule (CMS 1413-P)Payment Rates for Medicare Physician Services - Evaluation & Management Services* The 2010 CF assumes a 1.01% update from 2009. This is a proposal currently being considered in Congress.** In 2010 CMS proposes to budget neutrally eliminate the use of all consultation codes by increasing work RVUs for the new and established officevisits, initial hospital visits and initial nursing facility visits. Providers will bill initial visit codes in lieu of the consultation codes.

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