Data Show Upward Trend in Medicare CPT Codes Key to Primary Care

Primary Care Physicians Gained From 2006 to 2011

December 01, 2010 06:10 pm Sheri Porter

Family physicians hungry for some good economic news should be heartened to learn that during the course of the past six years, Medicare allowances for CPT codes 99213 and 99214 -- most FPs' bread and butter -- have seen a slow but steady cumulative rise of 42 percent and 35 percent, respectively.

In real dollars, that means Medicare's allowed amount for CPT code 99213 -- which was $52.68 in 2006 -- will be $74.85 in 2011, assuming the Medicare conversion factor remains at the 2010 level. Similarly, Medicare's allowance for CPT code 99214, which stood at $82.62 in 2006, will increase to $111.36 in 2011, again assuming no change in the conversion factor. (Payment allowances may vary slightly across the nearly 80 Medicare payment localities because figures have not been geographically adjusted as required by CMS.)

The increase in payment for these two particular CPT codes is critically important to family physicians, according to AAFP Director Thomas Felger, M.D., of Granger, Ind.

"These codes represent basic office visits. It's what we as family physicians do," said Felger, who was the Academy's representative on the AMA's Relative Value Scale Update Committee, also known as the RUC, from 2004-2009 and served on a RUC subcommittee before that.

The RUC is the sole committee that examines the valuation of codes in the Medicare physician fee schedule and makes recommendations to CMS.

For many years, Felger taught physician colleagues the nuances of CPT coding. That background compelled this self-confessed number cruncher to create a chart titled Medicare Physician Fee Schedule: 2006-2011 that compares Medicare physician fee schedule allowances for 99213 and 99214 for each year from 2006 through 2011.

"After playing with the numbers, I liked them a lot," said Felger. "The war is not won, but we've succeeded in a darned good forward advance. These little victories add up over time."

Felger pointed out that family physicians take care of a majority of the country's older patients. He estimated that Medicare patients account for 20 percent to 30 percent of the average family physician's patient panel. "We use 99214 fairly frequently in the Medicare population because those patients often have multiple chronic diseases," said Felger.

"If these payment increases flow over into the private sector -- and that's what usually happens -- that means family physicians will see better payment across the board for the cognitive work that we're doing," said Felger.

In addition, as many as 80 percent of Academy members could qualify for an additional 10 percent primary care bonus beginning in 2011 and running through 2015 as mandated by the Patient Protection and Affordable Care Act.

The Academy's assessment of payment gains for family physicians is especially timely in light of CMS' publication of its final 2011 Medicare Physician Fee Schedule in the Nov. 29 ( Register. The Academy currently is working on written comments in response to the final fee schedule. The 2011 schedule goes into effect Jan. 1, and the deadline for public comments is Jan. 3.

"The final rule is a done deal. CMS won't change the relative value units (RVUs) for 2011," said Kent Moore, AAFP's manager of health care financing and delivery systems.

Moore explained the formula by which Medicare calculates payment allowances. He said RVUs are divided into what he called "three buckets." Those buckets could be labeled "Physician Work RVUs," "Practice Expense RVUs" and "Professional Liability Insurance RVUs." The three RVU categories are added together, and the total RVU number is multiplied by the Medicare conversion factor, which currently is set at $36.87, to arrive at the actual dollar amount Medicare will allow for each CPT code.

"By law, CMS must review the RVUs every five years," said Moore. "In 2006, the AAFP lobbied very hard and argued that the physician work RVUs for evaluation and management, or E/M, services, like 99213 and 99214, were way too low. That effort resulted in a significant bump in work values for E/M services in 2007," said Moore.

Moore also pointed out that in 2010 -- again with encouragement from the AAFP -- CMS eliminated payment for consultation codes and put more money into other E/M services, such as office visits and hospital visits, which is work typically done by FPs and other primary care physicians.

Felger put the series of successes for family medicine into perspective. "This is a system change that has been influenced by the Academy's hard work. My colleagues should be encouraged by this good news," said Felger. He added that better pay for family physicians would help draw more medical students to the specialty at a time when a shortage of primary care physicians threatens America's health care delivery system.