Basic facts:
- Released on www.cms.gov on Friday, June 25, 2010.
- Scheduled to be released in the Federal Register on July 13, 2010.
- Commentary period open until August 24, 2010.
- Final rule will be published in November 2010.
- Final CY 2011 Physician Fee Schedule will become effective January 1, 2011.
- The proposed CY2011 Conversion Factor = $26.6574.
- This is a proposed -6.1% reduction under the Sustainable Growth Rate (SGR) formula that has been averted by legislative action since CY2003.
- This will change! Stay tuned, heated debate and controversy will continue.
- The majority of this 1,250 page proposed rule explains how the CY2011 Physician Work, Practice Expense & Malpractice Relative Value Units (RVUs) were determined:
- For the surgical CPT codes we routinely monitor in cardiac, orthopedic, neurosurgery, GYN and Urology, the Physician Work RVUs are unchanged; BUT the Practice Expense & Malpractice RVUs are higher across the board.
- Radiology is taking the hardest hit with an overall -12% reduction.
- Primary care is seeing an increase in reimbursement.
- Overall “winners” Primary Care & Surgeons in underserved areas:
- CMS proposes 10% incentive payment to primary care practitioners for primary care services furnished on or after January 1, 2011 and before January 1, 2016.
- 10% incentive payment program for major surgical procedures furnished in health professional shortage areas (HPSA) for services furnished on or after January 1, 2011 and before January 1, 2016.
- Overall “losers” include interventional radiology (-9%); radiology (-12%) and diagnostic testing facility (-20%) (Table 73, page 679).
Specific topics of interest:
- There is a section entitled, “Revised Malpractice RVUs for Selected Disc Arthroplasty Services”. The preamble begins on page 94 and concerns CPT 22856 Cervical Disc Arthroplasty. In this CY2011 proposed rule, Physician Work RVUs remain 24.05; while the Practice Expense RVUs increases to 17.70 (from 15.31) and Malpractice RVUs increase to 7.56 (from 5.26).
- There is a lengthy preamble about “Potentially Misvalued Codes”. It begins on page 97.
- Over the last several years, CMS, in conjunction with the AMA RUC, has identified and reviewed numerous potentially misvalued codes. Since CY 2009, CMS and AMA RUC have identified over 700 potentially misvalued codes. In CY2009, CMS identified over 100 codes designated as the “fastest growth” (aka Table 25) and requested that the AMA RUC review the codes on this list.
- Over the past 2 years, the CPT Editorial Panel has established new bundled codes to describe comprehensive services for certain combinations of these existing services that are commonly furnished together, and the AMA RUC has recommended work values and direct PE inputs to CMS for these comprehensive service codes that recognize the associated efficiencies.
- Be aware- CMS and AMA RUC will continue to bundle common combinations.
- CMS is also examining shifts in site-of-service anomalies, as well as codes that qualify as "23-hour stay" outpatient services.
- Medicare proposes to create 2 new HCPCS G-codes for Apligraf and Dermagraft to report application of tissue-cultured skin substitutes applied to the lower extremities.
- GXXX1 (Application of tissue cultured allogeneic skin substitute for dermal substitute; for use on lower limb, includes the site preparation and debridement if performed; first 25 sq cm or less).
- GXXX2 (Application of tissue cultured allogeneic skin or dermal substitute; for use on lower limb, includes the site preparation and debridement if performed; each additional 25 sq cm).
- These codes would not allow separate reporting of CPT codes for site preparation or debridement. CMS expects that these will be temporary codes, while stakeholders work through the usual channels to establish appropriate coding for these services that reflects the current common clinical scenarios in which the skin substitutes are applied.
- This proposed rule expands primary care and prevention incentives. The following preventive services will be fully covered:
- Pneumococcal, influenza, and hepatitis B vaccine and administration.
- Screening mammography.
- Screening pap smear and screening pelvic exam.
- Prostate cancer screening tests.
- Colorectal cancer screening tests.
- Outpatient diabetes self-management training (DSMT).
- Bone mass measurement.
- Screening for glaucoma.
- Medical nutrition therapy (MNT) services.
- Cardiovascular screening blood tests.
- Diabetes screening tests.
- Ultrasound screening for abdominal aortic aneurysm (AAA).
- Additional preventive services will be identified for coverage through the national coverage determination (NCD) process.
- There are new disclosure requirements for MRI, CT, and PET services.
- New incentive payment adjustments for Quality Reporting and electronic prescribing.
Upon review, please do not hesitate to call (203.271.3366) or email me for additional information.
Kathryn Barry is a healthcare marketing executive with a unique background in hospital administration, nursing, education and medical devices. A former Vice President of Strategic Marketing at U.S. Surgical and Vice President of Marketing Communications at Tyco International, she is a principal at Medical Educational Training Associates LLC in Wallingford, Conn. Visit META online at www.metallc.com.