Academy comments on the revision of form CMS-484, "Attending Physician's Certification of Medical Necessity for Home Oxygen Therapy and Supporting Regulations"

Mr. Christopher Martin
Office of Management and Budget
Human Resources and Housing Branch
New Executive Office Building
Room 10235
Washington, DC 20503

Dear Mr. Martin:

I am writing on behalf of the American Academy of Family Physicians, which represents more than 94,000 physician and medical students nationwide. I am writing to offer our comments on the revision of the form CMS-484, "Attending Physician's Certification of Medical Necessity for Home Oxygen Therapy and Supporting Regulations," as referenced in the Federal Register on January 25, 2005.

Oxygen and oxygen equipment is the largest single total charge of all items paid under Medicare's durable medical equipment coverage authority. Family physicians are responsible for a significant number of the estimated 1.2 million certificates of medical necessity (CMNs) required for oxygen and oxygen equipment.

From our perspective, the two proposed revisions to the physician sections of the CMN are a welcomed change. First, CMS proposes to eliminate the current question that asks for the name and address of the physician/provider performing the most recent arterial blood gas PO2 and/or oxygen saturation test referenced in Question 1 of the CMN. We agree that this question may be safely eliminated without adversely affecting Medicare's oversight of this benefit, and its elimination will reduce the burden on the certifying physician. Second, CMS proposes to eliminate the current statement in Section D of the CMN which states, "(signature and date stamps are not acceptable)." Again, we agree with this proposal and believe it will facilitate the physician's certification of the CMN without adversely affecting Medicare's oversight of the benefit.

While supportive of the proposed changes to the CMN, we believe that CMS has significantly underestimated the burden of the CMN to physician offices. According to the supporting documentation, CMS estimates that cost to respondents involves 10 minutes of a clerk's time (presumably at the supplier's office) and up to 2 minutes of the certifying physician's time, as well as copying, postage, and administrative costs. CMS values 2 minutes of the physician's time at $2.50 (i.e., $75 per hour), and it estimates total cost to respondents (i.e., suppliers plus physicians) as between $4.50 and $8.00 per CMN.

We believe CMS has significantly underestimated the burden and cost to physicians in several ways. First, it is not clear that they have accounted for the administrative staff time and cost in the physician's office required to do such things as pull the patient's chart, retrieve and return the CMN to the supplier, etc.

Also, Medicare values a physician's time at substantially greater than $75 per hour. For instance, under the 2005 Medicare physician fee schedule, Medicare values 15 minutes of a physician's time in evaluation and management at $25.39 (work relative value for 99213 x 2005 Medicare conversion factor). That translates into a per hour value of $101.57, rather than the $75 per hour referenced above.

Finally, there is no acknowledgement of the opportunity cost to physicians for completing CMNs. Since Medicare does not compensate physicians for completion of the CMN, they lose not only the estimated cost of the 2 minutes spent reviewing and signing the CMN but also the potential income that could have been garnered if they had been otherwise employed during that time. While 2 minutes may not seem like much, when multiplied 1.2 million times, it becomes 40,000 hours of unproductive, uncompensated physician hours. Thus, the burden of this CMN to physicians is much greater than implied by CMS.

Thank you for the opportunity to comment on this revision to the CMN for home oxygen therapy. If you have any questions about this matter, please contact Mr. Kent Moore at the American Academy of Family Physicians at 1-800-274-2237, extension 4170, or at kmoore@aafp.org.

Sincerely,

Michael Fleming, M.D.