On July 1, 2011, CMS released the 2012 Physician Fee Schedule proposed rule for Medicare. What follows is a detailed summary of the lengthy document focusing on the issues with the most relevance to cardiology. CMS will accept comments from the public on the proposed rule during a 60 day public comment period and will publish a final rule on or about Nov. 1. The ACC will comment on the provisions of the rule of concern to cardiologists and their patients. The College has also developed a spreadsheet with the list of common cardiology services with payment changes.
Conversion Factor: The proposed rule includes provisions for next year’s conversion factor that determines overall physician payment. CMS proposes a conversion factor of $23.96, a 29.5 percent reduction from 2011, mandated by the Sustainable Growth Rate factor. Congressional intervention is once again required to avoid this cut. ACC continues to lobby Congress to permanently eliminate the SGR and provide for sustainable updates for physicians.
Overall impact on cardiology: Setting aside the impact of the mandated SGR cuts, CMS estimates that the provisions of this year’s proposed rule will result in a 1 percent reduction in payments for cardiologists. This is an aggregate number, so the impact will be very different for practices depending on their mix of services. The primary reason for this reduction is the third year of implantation of changes in practice expense relative value units (RVUs) as a result of the AMA Physician Practice Information Survey (PPIS). There are no new provisions with significant impact on cardiology. Because this proposed rule does not account for changes in payments to codes revised through the CPT/RUC process, the eventual impact of this year’s regulatory changes in the final rule this November could be very different than included in this proposal.
Potentially Misvalued Codes: Medicare proposes to continue to ask the AMA Relative Value Resource Use Committee (RUC) to examine existing services to determine if they are properly valued. CMS has targeted services using a variety of screens and is now focusing on services with high volumes that have not been reviewed in recent years. For cardiology, this means that the values for 12 lead EKG codes, cardiovascular stress tests, and extracranial ultrasound tests will be examined for potential payment changes in the coming year. In addition, CMS has indicated that it would like all evaluation and management services codes to be reviewed as well. Many cardiology services have been reviewed in recent years on the basis of these screens. In many cases, payment for the services has remained the same but in other cases this review has led to reductions in payment. ACC continues to work with the RUC and CMS to demonstrate the value of the services provided by cardiologists as review of existing codes continues.
Ultrasound Equipment: CMS proposes that all services that include ultrasound equipment, including echocardiography, be reviewed to ensure that the payments reflect consistent practice expense inputs. This may or may not change the payment for services that include echocardiography equipment in 2013.
Expansion of Payment Reductions for Multiple Imaging Studies – For many years, Medicare has reduced the payment for the technical component of certain imaging services provided to the same patient by the same provider at the same session when paid under the physician fee schedule. In this rule, CMS proposes to expand this reduction to the professional component of these imaging services. Common cardiology imaging services such as echocardiography, SPECT, and vascular ultrasound are not included on the list of codes which would be reduced. However, CMS requests comments on whether this reduction should be expanded to all diagnostic services provided together. An expansion of this policy would have a significant impact on cardiology services but would require a new proposal from CMS in the future.
Preventive Visits: In 2011, Medicare begin to pay for annual wellness visits for comprehensive prevention planning. In this rule, CMS proposes that these visits be changed to include a systematic health risk assessment. This annual wellness visit would most likely be provided by primary care.
Physician Quality Reporting System – CMS proposes the details of the Physician Quality Reporting System that has been in place since 2007. In 2012, successful participants in the PQRS program will receive a bonus of 0.5 percent of physician fee schedule allowed charges, a reduction from the 1 percent bonus available for 2011. As in 2011, CMS proposes that physicians be given multiple participation options, including claims-based submission, registry submission, and electronic health record submission. There are also special methods for physicians in practices with more than 25 physicians. CMS proposes that physicians who wish to participate in the program must report on quality for a full year – previous years had allowed for a six month reporting option. CMS proposes to maintain the opportunity for physicians to report on measures groups, allowing reporting on 30 patients to qualify for a full year. There are measures groups available for coronary artery disease and congestive heart failure. CMS proposes that cardiologists be required to report certain core measures with the intention of using these measures in the future for comparative purposes. Because none of these core measures are contained within the measures groups commonly reported by cardiologists, this would increase the reporting burden for many cardiologists.
PQRS and Maintenance Of Certification: CMS proposes that physicians who are successful participants in PQRS may receive an additional 0.5 percent bonus for completing any practice assessment associated with maintenance of board certification. However, the practice assessment must be completed more frequently than is required for maintenance of that board certification. For cardiologists, the American Board of Internal Medicine would have to indicate whether or not a physician did so “more frequently” than is required. In 2011, CMS had required that physicians complete all elements of maintenance of certification to receive this additional bonus, so few if any participated. CMS proposed this change partially as a result of ACC and others criticizing the implementation in 2011.
PQRS and payment adjustments: Congress has mandated that the bonus payments that had been associated with the PQRS be phased out in favor of penalties starting in 2015. In this rule, CMS proposes that it will determine whether a physician will be penalized in 2015 based on successful participation during 2013. This is similar to how CMS has implemented a payment adjustment for electronic prescribing, in which physicians who did not e-prescribe during the first six months of 2011 will receive penalties in 2012.
Electronic Prescribing Penalties: By law, CMS is required to reduce Medicare payments to those practitioners who do not electronically prescribe and for whom at least 10 percent of their Medicare payments are associated with certain types of office visits. As part of the 2011 Medicare Physician Fee Schedule, CMS determined that practitioners who reported the e-prescribing measure at least 25 times in conjunction with those office visits between January 1 and December 31, 2011 would avoid the payment adjustment in 2013. As part of the 2012 proposed rule, CMS is considering providing practitioners with an additional opportunity to avoid the penalty. If practitioners prescribe electronically at least 10 times in conjunction with any Medicare service billable under the Physician Fee Schedule between January 1 and June 30, 2012, they would also avoid the 2013 penalty under the proposal.
Physician Compare Website: In 2011, CMS rebranded its existing Medicare provider directory into a website called “Physician Compare.” Modeled after a similar website available for hospitals, this website intends to allow consumers to determine quality information about physicians. In 2011, Medicare added information that indicated whether a provider had been a successful participant in PQRS. In 2012, CMS proposes to indicate if a physician was a successful electronic prescriber on this site. CMS indicates that it intends to include much more quality information on this site, including the performance results on individual PQRS measures.
Value-Based Purchasing: CMS is required to begin adjusting payments to physicians based on quality of care and resources used starting in 2015. In this rule, CMS proposes the foundation for creating this new program. First, CMS will begin with a wider distribution of physician feedback reports. These confidential feedback reports will show physicians their scores on certain quality reporting measures as well as the per-capita Medicare resources consumed by their patients. The reports will also include the results of certain claims-based quality measures, including a number that track cardiovascular disease, such as persistence of beta blocker treatment after a heart attack. These reports have been distributed on a limited pilot basis in previous years but have contained limited or no quality information. CMS also proposes measures that will be used to assess quality as part of the value-based purchasing initiative. Physicians will be assessed on the basis of core measures from the electronic health record incentive program as well as the PQRS program. CMS’s proposal covers fewer details on the issue of resource use, but indicates that it is exploring multiple attribution methodologies in order to assign patient resource use to the appropriate physicians. Because of the lead time required to implement the value adjustment, CMS proposes that it will adjust payment on the basis of data from 2013 for the 2015 adjustment.
Hospital Owned Physician Practices: CMS proposes that hospital-owned physician practices not be paid separately for the technical component of any service provided in the three days prior to an admission to that hospital. For services that do not have a technical/professional split, the physician would be paid the facility rate which is lower than the non-facility rate. This had been a long-standing policy in relation to diagnostic services but is proposed to be expanded to include all services, including office visits. ACC opposed this expansion when it was included in the inpatient prospective payment system rule released earlier in 2011.