Heads Up, Family Physicians

AAFP Summarizes Final 2015 Medicare Fee Schedule for Your Convenience

November 05, 2014 09:58 pm News Staff

On Oct. 31, CMS released the final version of its 2015 Medicare physician fee schedule(www.ofr.gov). And now, just a few days later, the AAFP has posted a summary(16 page PDF) of the rule so family physicians can read the highlights that pertain to them without having to slog through the particulars of the nearly 1,200-page document.

[Document Regulations binder, calculator, glasses, pencil]

In addition, AAFP President Robert Wergin, M.D., of Milford, Neb., released a statement on Nov. 4 that highlighted wins for family medicine and primary care that are included in the rule while also pointing to areas that still need to be addressed.

Advancing the Chronic Care Management Fee, Telemedicine

"Family physicians applaud the planned payment of a new chronic care management (CCM) code," said Wergin in the statement, "because it is a step toward recognizing the value of the often complicated clinical oversight that -- although needed by many Medicare beneficiaries -- requires significant clinical time outside the exam room."

Wergin referred to the fact that, beginning in 2015, CMS will pay $42.60 for a "one-per-month, per-patient CCM code." And rather than using its proposed "G" code to report CCM services, the agency changed course in the final rule to allow physicians to utilize CPT code 99490 for CCM reporting purposes.

"As a result of implementing payment for this code, elderly and disabled patients will have better access to the care they need to reduce and avoid complications of their conditions and expenses that come with treating such complications," said Wergin.

Story Highlights
  • On Oct. 31, CMS released the final version of its 2015 Medicare physician fee schedule.
  • The final rule is nearly 1,200 pages long, and, as a service to members, the AAFP created a summary document of important points.
  • The summary highlights portions of the fee schedule that are particularly relevant to primary care, such as implementation of the new chronic care management fee, handling of misvalued CPT codes, and addressing CMS' Open Payments program regulations.

CMS also nixed its initial proposal that would have required physicians to use 2014 certified technology to bill for CCM services. Instead, physicians will be able to use whatever certified EHR version they were using on Dec. 31 of the previous calendar year to do so.

Regarding telemedicine, the AAFP noted in its summary -- prepared with the Academy's August 24 comment letter(16 page PDF) close at hand -- that it fully supported CMS' expansion of a list of services that could be furnished to patients as part of the Medicare "telehealth benefit."

In fact, in addition to the three services that had been listed in the proposed rule -- psychotherapy, prolonged evaluation and management services in the outpatient setting, and the annual wellness visit -- CMS added psychoanalysis to the services that could be delivered via telemedicine and for which Medicare would pay.

Tracking Progress in Handling Misvalued Codes

Also noted in the AAFP's response to CMS when the proposed fee schedule was released in August was the fact that the Academy places a high priority on efforts to identify and review potentially misvalued CPT codes.

Although CMS failed to take action in the final rule on reviewing 67 codes previously identified as "high expenditure," the agency did render decisions on misvalued codes for services such as hip and knee replacement, radiation therapy, and epidural pain injections.

In addition, the Academy's summary noted, CMS "revised the process used for establishing fee schedule payment rates by allowing for public comments to be made on changes before they become effective."

In August, the AAFP also had urged CMS to fix site-of-service payment discrepancies in part by identifying services provided in an off-campus, provider-based setting based on receipt of a corresponding claim for a facility fee from the provider. The Academy was anxious to "prevent new documentation requirements for providers," said the AAFP summary.

In the final rule, CMS signaled it would begin collecting data on services furnished in "off-campus provider-based departments." Hospitals will be required to report a CPT code modifier for any services provided in such departments. In addition, the final rule requires physicians to report such services using a new "place of service" code on claims.

The new code will not be available for use before Jan. 1, 2016.

Addressing SGR Repeal, Open Payments Intricacies

Of issues as yet unresolved, payment reductions mandated by the sustainable growth rate (SGR) remain at the top of the list. Although years of advocacy by the AAFP and other physician groups have raised awareness of -- and commitment to -- the need to repeal and replace the fatally flawed SGR formula, legislators have stopped short of taking definitive action to safeguard the health of America's seniors.

"Current law requires CMS to slash Medicare physician payment by 21.2 percent on April 1," said Wergin in his statement. "Without Congressional action to permanently repeal the sustainable growth rate formula that requires this devastating cut, Medicare patients will continue to struggle with insecure access to health care."

To that end, the AAFP has made it easy for members to reach out to their lawmakers directly and urge them to enact permanent SGR repeal legislation. Using the Academy's Speak Out feature, members can simply fill in their contact information online, customize a pre-written letter if they wish, and send it off to their congressional representatives.

Another key issue for the AAFP -- so important that it required a separate comment letter to CMS in August -- is CMS' Open Payments transparency program, created to implement provisions of the Physician Payments Sunshine Act.

The AAFP noted in its summary document that in the 2015 proposed rule, CMS "unexpectedly suggested four changes to the Open Payments program." From the Academy's point of view, the most problematic of these was the agency's proposal to delete the clause outlining the program's CME exemption.

In its proposed rule, CMS contended that eliminating the exemption for payments to speakers at accredited or certified CME events would create a more consistent reporting requirement for industry, as well as greater uniformity for consumers who accessed reported data.

CMS finalized this deletion in the final rule despite the AAFP's strong objection, in which the Academy reiterated its position that deletion of the section would not remove redundancy from the final rule nor would it expand the range of educational events exempt from reporting.

Noting Other Issues Important to Primary Care

Wergin encouraged family physicians to take a few minutes to read through the entire summary document to stay up-to-date on fee schedule details most important to primary care.

For example, other areas of interest the summary addresses include

  • Physician Quality Reporting System,
  • Medicare Shared Savings Program,
  • Physician Compare website,
  • the physician value payment modifier and
  • the global surgical package.

Wergin promised in his statement that the AAFP would "monitor the documentation requirements related to the (CCM) codes to ensure they are not overly burdensome for practicing physicians." He also said the AAFP would continue "to urge CMS to review undervalued codes and ensure appropriate payment for primary care services."

Moreover, said Wergin, "The complexity and intensity of primary medical care justifies creating separate, outpatient, primary care evaluation and management codes, and codes to recognize the medical expertise required to provide this comprehensive care."

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