AAFP Works to Fine-tune 2015 Proposed Medicare Physician Fee Schedule

August 27, 2014 04:13 pm News Staff

The AAFP went to bat for family physicians this week in a detailed response to CMS' 2015 proposed Medicare physician fee schedule.

[Gov't Regulations Books stacked with pencil and magnifying glass]

After the Academy's careful review of the proposed schedule -- published in the July 11 Federal Register(www.federalregister.gov) -- AAFP Board Chair Jeff Cain, M.D., of Denver, sent a detailed response to CMS Administrator Marilyn Tavenner, M.A.

In that Aug. 26 letter, Cain highlighted AAFP concerns with portions of the 2015 proposed fee schedule most likely to affect family physicians and their patients.

Cain prefaced his remarks by noting the AAFP appreciates CMS' efforts to implement short-term payment strategies "that recognize primary care and care coordination as critical components in achieving better care for individuals and reduced expenditure growth."

However, Cain expressed frustration that the 2015 fee schedule proposed by CMS once again included a pay cut for America's physicians. He cited the estimated 20.9 percent reduction that physicians face because of the flawed sustainable growth rate formula used to determine Medicare physician payments.

Story Highlights
  • The AAFP has responded to CMS' proposed 2015 Medicare physician fee schedule with a detailed comment letter to CMS Administrator Marilyn Tavenner, M.A.
  • The AAFP addressed issues important to family physicians, such as chronic care management fees, misvalued services and site-of-service payment discrepancies.
  • The 16-page letter also covered telehealth services, health IT requirements, the Physician Compare website and the Physician Quality Reporting System.

"The AAFP encourages CMS and Congress to work together and avert this devastating cut and replace it with a formula that includes better payment for primary care," said Cain.

He then went on to outline some specific AAFP suggestions for improving the 2015 fee schedule.

Tweaking Chronic Care Management Fee Proposal

Cain commended CMS for its commitment to supporting primary care and for its proposal to pay for chronic care management services in 2015 but said the proposal needed more work.

Noting that the agency is exploring efforts to reimburse for chronic care and transitional care management services both in fee-for-service and through its Comprehensive Primary Care initiative, the AAFP urged CMS first and foremost to "move quickly and create a risk-adjusted, per-patient per-month (PPPM) care management fee approach and then phase out this initial and proposed fee-for-service approach." For more details, Cain urged CMS to review a care management fee policy recently adopted by the AAFP Board of Directors.

That policy outlines seven core elements that should be covered by a PPPM care management fee within the context of the patient-centered medical home. Those elements are

  • nonphysician staff time dedicated to care management,
  • patient education,
  • advanced technology to support care management,
  • physician time dedicated to care management,
  • medication management for each patient who receives services,
  • population risk stratification and management, and
  • integrated coordinated care across the health care system.

"If CMS is not willing or yet able to pay a PPPM fee, then the AAFP advocates that CMS recognize and pay the existing CPT codes 99487 and 99489," said Cain. "The CPT codes allow for add-on codes, so primary care physicians can bill for outliers in terms of beneficiaries that require significantly more than the typical time per month," he added.

Should CMS resist utilizing either the PPPM fee or the existing CPT codes, then the agency should at the very least make adjustments to the "G" code proposal, said Cain. First, CMS should more specifically describe the "20 minutes or more" time element as "clinical staff time."

Secondly, CMS should include more than 20 minutes of clinical staff in the direct practice expense inputs for the code. Otherwise, "CMS will be underpaying on practice expense for every patient who receives more than 20 minutes" of chronic care management, said Cain.

Addressing Potentially Misvalued Services

The AAFP again asked CMS to increase its efforts to identify and review potentially misvalued codes. "More can be done to ensure that Medicare is paying appropriately for primary care physicians' services rather than paying based on biased data that further exacerbates the undervaluation of primary care services," said Cain.

Read Summary of AAFP's 2015 Proposed Fee Schedule Comments

Save yourself the time of reading the Academy's full 16-page letter commenting on CMS' proposed 2015 Medicare physician fee schedule; AAFP staff have created a document(1 page PDF) that summarizes the key messages delivered on behalf of the nation's family physicians.

"We continue to argue that the complexity of the ambulatory evaluation and management (E/M) services that primary care physicians must fit into the time available for the typical patient visit is sufficiently distinct to merit dedicated codes and higher relative values than are currently assigned to existing office or other outpatient E/M codes," he continued.

Cain specifically directed Tavenner to the Academy's response to the 2014 fee schedule proposal, in which the AAFP spelled out some innovative payment recommendations -- including the creation of separate primary care E/M codes for office or other outpatient services provided to patients.

CMS' adoption of the primary care physician payment recommendations would help address the current and future shortage of primary care physicians, improve the delivery of health care services, and encourage medical students to choose family medicine and other primary care specialties, said Cain.

Regarding improvements in the valuation and coding of the global surgical package, the AAFP expressed full support for CMS' proposal to transform all 10- and 90-day global periods to zero-day global periods beginning in 2017 with a transitional period.

Fixing Site-of-Service Payment Discrepancies

The AAFP asked CMS to "create incentives" that would encourage the provision of health care services in locations that keep costs to a minimum, such as physician offices, rather than hospitals or ambulatory surgical centers.

The Academy took issue with CMS' approach to the issue -- namely, requiring that a Healthcare Common Procedure Coding System (HCPCS) modifier be reported with every CMS-1500 claim form for physicians' services "and the corresponding form for hospital outpatient claims for services furnished in an off-campus provider-based department of a hospital beginning in 2015."

Cain noted that many family physicians work in practices that are owned by hospitals or health systems "yet are still providing services in the least costly location." He expressed concern that the proposed coding requirement would cause confusion among physicians and asked CMS to scrap its proposal and instead simply identify services provided in off-campus provider-based settings "based on receipt of a corresponding claim for a facility fee from the provider."

Highlighting Other Issues Crucial to Primary Care

  • The AAFP's 16-page letter covered a plethora of payment issues important to family physicians, and indeed, all primary care physicians. In addition to the items mentioned above, Cain addressed other topics of interest, including: support for an expanded list of Medicare-approved telehealth services,
  • concern about the health IT requirement related to chronic care management services that would requires physicians to use at least 2014 certified electronic health record technology and an electronic care plan,
  • support for the concept of the Physician Compare website but concern that the data published by CMS might not be helpful to consumers, and
  • agreement with CMS' proposal to allow more frequent submissions of data for the Physician Quality Reporting System.

The AAFP also reviewed details about CMS' proposed establishment of a value-based modifier that would provide differential payment to a physician or group of physicians based on the quality of care furnished to Medicare patients compared to the cost of that care during a performance period.

For the most part, the Academy found the proposal reasonable; however, Cain offered suggestions to improve the application of the value-based modifier to physicians and nonphysician providers.

Finally, Cain offered the Academy's support as CMS reworks the proposed fee schedule to make it more acceptable to family physicians. Comments on the proposal are due to CMS by Sept. 2.