Academy Sends Strong Message to Agency

CMS Is Still Undervaluing Primary Care in Physician Fee Schedule

January 12, 2011 06:00 pm News Staff

Although CMS has taken steps to reward some primary care services in its rule-making process for the 2011 Medicare Physician Fee Schedule, the AAFP says the agency still is undervaluing primary care services.

"We do want to recognize and thank CMS for its ongoing effort to address primary care issues within the parameters permitted by the current (health care reform law)," said AAFP Board Chair Lori Heim, M.D., of Vass, N.C. in a recent letter(8 page PDF) to CMS Administrator Donald Berwick, M.D. For example, noted Heim, CMS made significant adjustments to the Primary Care Incentive Program that will help ensure more primary care physicians qualify for a 10 percent bonus called for in the Patient Protection and Affordable Care Act.

But Heim urged the agency to continue its efforts. "Millions of Americans will become eligible for Medicare in the near future, and implementation of health care reform will provide greater access to health care for millions more Americans during the same time frame," said Heim. Primary care physicians will be essential to ensure that the nation's health care needs are met, she added.

CPT Codes

Heim also addressed CPT codes for immunization administration, hospital observation care and maternity care. In each instance, she criticized the agency for disregarding the recommendations of the AMA/Specialty Society Relative Value Scale Update Committee, or RUC, by adopting relative value units, or RVUs, that were less than what the RUC recommended.

Regarding immunizations, Heim pointed out that previous immunization administration codes did not allow physicians to accurately report the considerable work involved in counseling patients regarding combination vaccines. The revised immunization codes "represent a substantial structural revision from their predecessor codes in that they allow reporting of counseling per vaccine component rather than per administration," said Heim.

However, she noted, it was inappropriate of CMS to "crosswalk values from predecessor codes to new codes given the underlying structural differences between the two sets of codes." Moreover, CMS' crosswalk valuation for the new codes would make the relative value of physician work equivalent to other immunization administration codes, which do not have the requirement of physician counseling as part of their descriptors.

Heim also noted that CMS and HHS took out an advertisement in many of the nation's leading newspapers in early December extolling the benefits and necessity of obtaining the seasonal influenza vaccine. More than 40 medical and medically associated organizations prominently signed on as supporters of this effort, said Heim.

"It is therefore both somewhat ironic and very disappointing that at the same time you are promoting immunizations with the very public support of those organizations that actually provide this service, you have taken such an approach in valuing these services," Heim said. "Unfortunately, it is action such as this that contributes to a sense among our members that CMS continues to underappreciate and, therefore, undervalue the work that primary care physicians in general and family physicians in particular provide.

Work Values

Heim also disagreed with CMS' valuation of codes to report subsequent observation services in a facility -- CPT codes 99224-99226. According to Heim, in the final rule, CMS said "in only rare and exceptional cases would reasonable and necessary outpatient observation services span more than 48 hours." But that ignores the significant increase from 2006 to 2008 in observation services extending beyond 48 hours, Heim said.

CMS also said in the final rule that "the acuity level of that typical patient receiving outpatient observation services would generally be lower than that of the inpatient level. But, Heim asserted, "that is an assumption, not a documented fact."

"In fact, hospital inpatient and outpatient status is often as much a function of payment policy as it is patient acuity," said Heim. "That is, hospitals not infrequently declare a patient's status as 'inpatient' or 'outpatient' based on what they calculate will be most financially advantageous." And that does not necessarily equate to patient acuity, she pointed out.

Maternity Care

CMS' determination of CPT codes that define maternity care also sparked AAFP objections. In spite of a RUC recommendation to significantly increase these work values, CMS reduced the RVUs for each code in this family of codes by approximately 11 percent, according to Heim.

Most physicians agree that the RVUs for maternity care services currently are undervalued, she noted. "We encourage CMS to accept the RUC recommendations without either adjusting the postpartum work or applying a budget neutrality adjustment to the family (of codes)," said Heim. "The RUC-recommended values accurately reflect the physician work required to provide those services.