All eyes are on the new physician fee schedule proposed by the Centers for Medicare & Medicaid Services (CMS), which will be finalized this year and go into effect Jan. 1. The ACR is reviewing the proposal and will be providing comments and recommendations to CMS. And many rheumatologists have payment and coding questions: Will fees increase or decrease? Will stiff requirements be attached to specific codes?
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Although there are no clear answers, healthcare experts believe physicians may recognize payment reductions for some services and increases for others. Meanwhile, rheumatologists should be focused on developing strategies to improve quality and decrease overall costs, which will be rewarded under the new schedule, according to Lucy Zielinski, vice president at GE Healthcare Camden Group, a national healthcare business advisory and activation firm in Chicago.
The main focus of the 856-page fee schedule document is to improve the value of primary care services and health outcomes. CMS is also proposing an increase in payments for several care management services, such as those rendered to patients with mobility-related disabilities or complex-care management services.
Some of the service and billing requirements for the chronic management code (99490) may also be eased, says Ms. Zielinski. “Before, some of the requirements [for certain codes] were pretty intense and too difficult for physicians to observe. Last year, Medicare anticipated that a higher volume [of codes with strict requirements] would be submitted, but that was not the case. So CMS is now loosening up some of these requirements and expanding CCM [chronic-care management] coding.”
As an example of restrictions being relaxed, she points to electronic sharing of care plan information. Instead of making this information electronically available 24/7 to other practitioners, the proposed rule would require care plans to be made available in a “timely” fashion to other practitioners, remove the requirement to document the provision of the care plan to the beneficiary using EHR technology and no longer requires physicians to obtain written agreement and patient consent.
Good News for Rheumatologists
Ms. Zielinski says the rule proposes that CMS pay for services for patients with chronic conditions who require complex CCM services (99487 and 99489)—good news for rheumatologists who often treat patients with comorbid, complex conditions. The agency is not, however, proposing to change the requirement that CCM services may be billed only by the one provider who assumes the care management role for a particular patient.
CMS is even considering payment for prolonged services (99358 and 99359) before or after direct patient care. Rheumatologists may now be paid for extra time spent caring for individual patient needs beyond the office visit.
“Introduction of these codes is reasonable and shouldn’t be a problem for those rheumatologists who work with coordinated care teams and have the technology infrastructure and resources to manage patients with multiple conditions,” says Ms. Zielinski. She further notes that CMS is continuing to take steps to move from a more traditional healthcare delivery model to a more coordinated and integrated healthcare delivery system.
At this point, she believes the proposed rules don’t necessarily cut overall reimbursements for rheumatologists. Although the conversion factor—a scaling factor that converts the geographically adjusted number of relative value units (RVUs) for each service in the Medicare physician payment schedule into a dollar payment amount—is expected to drop by almost three cents, from $35.8043 to nearly $35.7751, she explains that CMS is projecting a 2% overall impact in the relative values—work and practice expenses—for rheumatologists. This could result in possible increases for rheumatologists, depending on the services provided.
Ms. Zielinski adds that CMS is also reviewing misvalued 0-day global services typically billed with an evaluation and management code with Modifier 25. This includes injections or aspirations (20600, 20605, 20610, 20550) or trigger-point injections (20552 and 20553). Although the physician fee schedule is far from ideal, Ms. Zielinski points out that, overall, it should still be viewed as positive.
Besides slight changes in the physician fee schedule next year, all physicians will have opportunities to receive additional payment incentives from Medicare over the next several years.
Starting in January 2017, MACRA (Medicare Access and CHIP Reauthorization Act) reporting begins, although there is a possibility it will be postponed. Depending on their performance, rheumatologists may receive an increase of up to 4% in Medicare payments in 2019 for improving quality care and reducing healthcare costs. However, if their performance is calculated to be poor, physicians could face up to 4% in penalties. Medicare has allocated additional dollars for high performers.
“One of the levers rheumatologists can use to increase CMS reimbursements is working with their hospitals, an ACO or clinically integrated network, and providers in their community to integrate systems and take care of patient populations,” Ms. Zieliniski says. “That’s really the ticket.”
Carol Patton is a freelance writer based in Las Vegas.