Posts tagged with cms

[Note: Since this post, there are have been major changes to the RVUs. Check more recent posts in this blog, like this one.  You may also want to go directly to PCC's on-line RVU tools.]

First, a sincere thank you to Linda Walsh at the AAP for this update. Linda is like a sharp dagger who cuts through all of the baloney for me when I get confused about some CPT or RVU issue. She must get a dozen questions (or more) a day from AAP folks and always answers them quickly, graciously, and - most importantly - correctly. And she even responds that way to me!

So...race to the URLs below to see the latest information from the AAP about 2008 RVUs, etc.:

• http://www.aap.org/visit/coding.htm
  (AAP public site)
• http://www.aap.org/moc/reimburse/codingrbrvsresources.htm
  (AAP Member Center)
• http://www.aap.org/visit/rbrvsbrochure.pdf
  (direct link to RBRVS Brochure)
• http://www.aap.org/visit/RBRVSConversionSpreadsheet.xls
  (direct link to RBRVS Conversion Spreadsheet)

Here's the most important section from the brochure:

2008 Medicare Conversion Factor = $34.0682 (Note that this is an 11% reduction!)
Additional components of the Medicare RBRVS physician fee schedule factored into the payment structure include the following:

MEI: The allocation of RVUs to pools for physician work, practice expense, and professional liability insurance, have been revised to correspond with the Medicare Economic Index. Work is now allocated 52% of the total RVUs, practice expense is 44%, and professional liability insurance is 4%.

HPSA: Incentive payments for physician services provided to patients in Health Professional Shortage Areas (HPSAs), which are medically underserved communities, urban and rural locations that have a documented shortage of medical professionals.

Non-Par Physician: Reduced payments for physicians, called “non-participating” physicians, who do not accept “assignment,” the Medicare approved amount that consists of the 80% Medicare payment and the 20% patient co-payment, as payment in full for services rendered to Medicare recipients.

Budget Neutrality: Statutory guidelines indicate that revisions to the RVUs for physician services may not alter physician expenditures within the Medicare RBRVS physician fee schedule by more than $20 million from the principal expenditures that would have resulted if the RVU adjustments were never initiated. CMS normally maintains Medicare budget neutrality exclusively via annual adjustments to the Medicare Conversion Factor. However, in 2008 the Medicare program will additionally apply a separate budget neutrality adjustment factor to the physician work RVUs to ensure Medicare budget neutrality in light of work RVU increases tied to the 2005 Five-Year Review.

First, I have to be clear: my knowledge of the arcane RBRVS system, the RUC committees, CMS, etc., is all driven by my work for pediatricians. Thus, I have a very skewed view of how it works. Almost all of the changes to the CMS budget affect my clients indirectly and I have very little understanding of the big picture/politics of it all. Often, when I read through the RVU content, I gloss over big sections of important-looking information because it doesn't seem to apply to pediatrics. I don't know why I'm offering this caveat today, perhaps it's the GI bug I picked up from my kids speaking.

Anyway, the interesting news.

• There is language on the table to remove the scheduled 10.1% reduction and replace it with a .5% increase. However, there may be a related relationship to an expansion of the physician quality reporting system. No idea yet.
• There will be an extension of the 1.0 floor to the work geographic adjustment (the effects of the loss of which were heroically outlined par moi).
• Both of these changes last only until June, 2008, at which point the original proposals will be enacted. I think. We don't know, yet.

You can seem some other reactions to this news in obvious places, such as the WSJ. One thing I find interesting is that it looks like the language to make the changes above may be knowingly vetoed by GWB, but there are enough votes to override the veto. [This is a good example of what I talked about above.]

As the world turns!

All the RVU drama makes it hard for me to get to other things, but here is the latest from my generous and favorite inside source (instead of using an inappropriate 70s adult film nickname, we'll use "Siouxsie"):

1) The new CF for 1/1/08 through 6/30/08 will be $38.0870 [= 0.5% increase from the current CF of $37.8975; what happens after that point is anyone's guess] 2) The work GPCI floor (1.000) will be maintained through 6/30/08 [again, what happens after that point is unknown] 3) The bill did NOT include provisions to "alter or supplant the role" of the RUC

Attached with this cogent explanation was a memo straight from Michael Maves, the E-VP and CEO of the AMA. Now, let's all be tense for six months. Ready? Go! [I can actually update the RVU calculators, now.] Wow, Siouxsie kicks butt and sends me this important AMA Memo about the changes 2 minutes after I post this.

I am feeling a little like the Winooski River, when it freezes over and then dams up, causing the water to overflow the banks and wreak havoc locally.

It's not too soon to look ahead to 2009 to see what's in store for pediatricians as a result of the CMS machinations. I've ignored, as you can see, the drama over the last few weeks related to the scheduled Medicare fee cuts - there are plenty of places you can find that news. However, I have the opportunity to share some notes to the AAP's Coding and Nomenclature Committee about what they are seeing. I've edited or reduced the information and highlighted some important (to me) points, so please blame just me for any miscommunication, etc.

• "...CMS is proposing to exclude the clinical staff times when calculating the 2009 PE RVUs for the immunization administration codes...the potential increase in PE RVUs that we had been expecting will be negligible, if anything."

  The clinical staff time in question includes time spent entering data into an immunization registry, logging temps, etc. Given that this time demand has exploded for some offices, it's pathetic that CMS doesn't understand what these practices are going through.

• CPT 99174 (Ocular Photoscreening) should get PE and PLI RVUs.
• There is a scheduled 5.4% fee cut. My bet is that is sticks - things are going to get worse before they get better.
• The 1.000 GPCI floor will be removed. It's been threatened before, but I also think it will stick. This is a big deal that will add up to an additional 5-10% cut, iirc, for some places.
• "Per CPT copyright release restrictions, new codes are not able to be included in the proposed rule (since its publication pre-dates the AMA's release of new codes via its CPT manual). Therefore, we will not know how CMS proposes to value the new expanded age PICU codes or the ESRD codes until the final rule comes out in November."

  I want to see if I have this right: because the AMA wants to protect its ridiculous CPT copyright (including the non-copyrightable RVU values), its own members - and the affected public - cannot actually learn what our government is going to do with some federally mandated codes until the AMA has time to publish its book. I can't believe that this was in the spirit of the copyright law when it was written and I have a hard time believing it's actually in the letter of the law, either. Someone lend my the $500K+ it would take to fight that lawsuit and I'll get right on it. The money the AMA receives from their licenses ($70m/annually, when they last told me) is worth more to them than doing the right thing.

Enough of my ranting. I have to go prep for CCHIT. What can a lowly pediatrician do? Make sure your contracts are locked into a specific year of the RVUs. I prefer 2005->2007, myself.

Get your letter writing implements out, spread the word, tell everyone you know.

Really. I can't over-dramatize this issue.

I reported the expected pediatric-focused changes to the 2009 RVUs two weeks ago and pointed out how CMS is not planning to add the appropriate value to the PE elements of immunization administration. IIRC - and of course, I do, because I went back and checked - I called this pathetic. Now the AAP agrees, but they are far more mature and constructive in their language.

Here is copy from a draft letter that the AAP plans to send to CMS before the 08/29/08 comment deadline. I have been asked to share this with as many practicing physicians as I can and encourage you to send your comments to CMS in an effort to get them to recognize the significant and growing cost of providing immunizations in this country. You are welcome to use and adopt the points made below.

From the letter, which is not official nor approved by the AAP, yet:

Immunization Administration: Practice Expense Inputs

In February 2008, the RUC Practice Expense (PE) Subcommittee approved the movement of some of the indirect PE into the pool of direct PE inputs for the immunization administration (IA) codes. During that meeting, the RUC approved moving the following, additional PE inputs into the existing pool of direct PE inputs for the IA codes:

For the "initial" codes (90465, 90467, 90471, 90473):

• 4 minutes RN/LPN/MA ($0.37 per minute) for:

  • Vaccine registry input

  • Refrigerator/freezer temperature log monitoring/documentation [2 times per day; logs kept for 3 years]

  • Refrigerator/freezer alarm monitoring/documentation

• 17 minutes for dedicated full size vaccine refrigerator with alarm/lock [commercial grade]

• 17 minutes for refrigerator/freezer vaccine temperature monitor/alarm

For the "each additional" codes (90466, 90468, 90472, 90474):

• 1 minute RN/LPN/MA ($0.37 per minute) for:

  • Vaccine registry input

  • Refrigerator/freezer temperature log monitoring/documentation [2 times per day; logs kept for 3 years]

  • Refrigerator/freezer alarm monitoring/documentation

• 8 minutes for dedicated full size vaccine refrigerator with alarm/lock [commercial grade]

• 8 minutes for refrigerator/freezer vaccine temperature monitor/alarm

In the 2009 RBRVS proposed rule, however, CMS states,"...we are in agreement with the RUC (PE) recommendations...except for inclusion of the clinical staff time related to quality activities for the following immunization administration codes: CPT codes 90465-90474. While we allow this time for mammography services due to the specific regulatory requirements required by the Mammography Quality Standards Act (MQSA) of 1992, such MQSA time is not required for immunization services."

This means that CMS is proposing to exclude the clinical staff times (as listed above) when calculating the 2009 PE RVUs for the IA codes. The Academy strongly urges CMS to reconsider this decision for the following reasons:

1) During the course of RUC deliberations, it was noted that in August 2003, the Practice Expense Advisory Committee refined code 77057 (screening mammography, bilateral (2-view film study of each breast), allotting clinical staff time for "quality services" based on MQSA regulatory requirements. This, however, was not the basis of the RUC's recommendations with regard to IA. It was simply recognition of a precedent for moving practice expenses previously designated as "indirect" into the pool of direct PE inputs.

2) While MQSA does not apply to the provision of vaccines, there are several federal/state programs that require quality assessment for the following immunization services

• • Vaccine registry input

    • Thirty states have laws authorizing a vaccine registry. Of those 30 states, 14 mandate reporting (Source: Unpublished data, Immunization Information Systems Support Branch, Immunization Services Division, Centers for Disease Control and Prevention)

    • One of the objectives of Healthy People 2010 is to increase to 95 percent the proportion of children younger than 6 years of age who are enrolled in fully operational, population-based immunization registries (http://www.healthypeople.gov/Document/HTML/Volume1/14Immunization.htm)

• • Refrigerator/freezer temperature log monitoring/documentation and refrigerator/freezer alarm monitoring/documentation

    • The Vaccines For Children (VFC) program requires providers to participate in an annual Assessment, Feedback, Incentives, and eXchange (AFIX) program, where clinical staff visit offices to conduct quality checks, including vaccine temperature monitoring (http://www.cdc.gov/vaccines/programs/afix/default.htm)

    • The Centers for Disease Control and Prevention has "Recommendations and Guidelines for Vaccine Storage and Handling" (http://www.immunize.org/catg.d/p3035chk.pdf), which include the following:

      • A designated person in charge of the handling and storage of vaccines

      • A back-up person in charge of the handling and storage of vaccines

      • A vaccine inventory log

      • Maintenance of a refrigerator temperature between 35-46°F

      • Maintenance of a freezer temperature of +5°F or colder

      • A posted temperature log on the refrigerator door where the refrigerator and freezer temperatures are recorded twice a day, as well as notation as whom to call if either temperature goes out of range

      • A contingency plan in the event of refrigerator/freezer failure

The aforementioned federal/state requirements and guidelines provide compelling evidence for the RUC-recommended clinical staff times for "quality activities" to be included in the 2009 PE RVUs for the immunization administration codes.

All letters must be sent to:

Acting Administrator Kerry Weems

Centers for Medicare and Medicaid Services

Department of Health and Human Services

Room 443-G

Hubert H. Humphrey Building

200 Independence Avenue, SW

Washington, DC 20201

Re:Medicare Program; Revisions to Payment Policies Under the Physician Fee Schedule and Other Revisions to Part B for CY 2009; Proposed Rule; CMS- 1403-P

Those of you who have had to pay for immunization registry interfaces (not our clients, but the rest of you), those of you who - as outlined nicely above - are dealing with fridge management (and I know three practices, personally, who have had this process fail spectacularly leading to $thousands$ lost), or are simply paying to double-enter your registry data should feel obligated to write to Acting Administrator Weems and give CMS an understanding of your daily chores.

Wow, that was long-winded. Sorry. Just send a letter! The deadline for commentary is August 29.

Thanks to my new bf at the AAP (to whom I am significantly indebted), here is a copy of the AAP's response to the proposed RVU changes for 2009. I wrote about this a few weeks ago and would like to remind you all that you have one more day to get your comments in about the immunization admin disappointment. Copy the language in my previous post or here, it doesn't matter. Just get that letter in - pediatrics will continue to get the short end of the stick until we all stand up to be heard. I received some excellent examples of letters our clients sent...keep up the good work.

Some good data coming shortly about overdue physicals.

Yesterday, I asked if anyone knows how the awkward RBRVS GPCI system is developed.  Siouxsie, of course, had the answer.  In fact, more than answer.  Those of you who are dinged by the GPCI breakdown should head Reed Tinsley’s quick review of it and then check out CMS’s PDF…and get in touch with CMS! Remember, it worked with the imms admin for 2009, why not for GPCIs as well?

I’ve said more than once that the AAP is the first place pediatricians should go to learn about RVUs.  They have updated it and you can now find their 2009 RBRVS Conversion Spreadsheet on-line.  I got to help out by making a little change to the sheet (now the GPCI piece is just a pull down and not something you need to do manually).  Cool.  After reading through the AAP’s materials, I encourage you to check out PCC’s free RVU Calculators (this one and this one).

Today, I share a memo from the Federal Affairs desk of the AAP that pediatricians and their staff should consider.   Normally, I gloss over stuff like this (admit it, you do, too), but the comments Obama has made about child health are important and I think this is the time to make your voices heard.  We saw CMS make some changes as the result of private pediatric feedback promoted on this blog, so we know that input is valuable.

Questions?   Contact info is at the bottom.

MEMORANDUM

July 24, 2009

To:       AAP Chapter Presidents
            AAP Chapter Vice Presidents
            AAP Chapter Executive Directors

Fr:        AAP Department of Federal Affairs

Re:       Federal Health Care Reform Update

FEDERAL UPDATE:

After a weekend of meetings with the conservative Blue Dog Democrats, the House Energy and Commerce Committee reconvened late Monday to debate and vote on amendments to the America's Affordable Health Choices Act (HR 3200). Even though Energy and Commerce was scheduled to continue debate through Tuesday and Wednesday of this week, the Blue Dogs succeeded in postponing the Committee's action to negotiate with Democratic leaders on cost savings, mandates on small businesses and the proposed public option. President Obama invited the Energy and Commerce Blue Dogs to the White House Tuesday afternoon to listen to their concerns and forge agreement on how to move forward.

Late Tuesday, Chairman Waxman (D-CA) announced that negotiations among Democrats may have reached a "turning point" with the agreement to create an independent board to evaluate and influence payment rates in Medicare similar to the existing Medicare Payment Advisory Commission (MedPAC). President Obama has endorsed a proposal by Senator John D. Rockefeller IV (D-WV) to strengthen MedPAC and make its recommendations law unless rejected by Congress. Despite support from members of the Energy and Commerce Committee, those committees with jurisdiction over Medicare (Senate Finance Committee and House Ways and Means Committee) have opposed to the idea for fear that the board could impose cuts that result in reduced services.

Republicans and Democrats in both chambers have expressed concerns regarding provisions in the bill as well as the speed with which President Obama and Democratic leadership are moving forward. On Friday six senators sent a letter to Senate leadership voicing their concerns over the timetable for floor action in the Senate. The six senators, Senators Snowe (R-ME), Collins (R-ME), Lieberman (I-CT), Ben Nelson (D-NE), Landrieu (D-LA) and Wyden (D-OR), represent some of the centrist/moderate Democrats and Republicans in the Senate. If health reform is to succeed it is imperative that these moderate members, especially the four Democrats that signed the letter, support the final health reform package.

The contention amongst Democrats in both chambers is causing party leaders to soften timelines for the legislation. Speaker Pelosi announced Wednesday that while she has no doubt that she has the votes in the House to pass legislation, whether or not they vote before they adjourn for the summer recess on July 31st remains to be seen. Due to ongoing negotiations in the Senate Finance Committee, Senator Durbin (D-IL), Majority Whip, stated late Wednesday that the Senate would postpone the vote until after the August recess. Chairman Baucus continues to meet with three Republicans, Senators Snowe, Ranking Member Grassley and Enzi to craft a bipartisan bill. Senator Hatch (D-UT) was a regular participant in the negotiations, but announced Wednesday that he has stopped attending the sessions.

 

On Monday, President Obama addressed a small group of pediatricians, nurses and a physician's assistant at Children's National Medical Center in Washington, DC. One of the points he raised during his remarks was the steady increase in the volume of visits to emergency departments (ED), specifically the impact these increases have on pediatric emergency visits, shrinking access and under-insurance, and the added burden and expense that unnecessary pediatric ED visits represent. Additionally President Obama spoke to the strains our health care system places on parents with sick children. Many families, even those with health insurance, can't afford routine visits for their children. Mr. Obama also mentioned that poor payment rates for pediatricians and primary care doctors contribute to barriers to care.

On Wednesday, to rally public support for overhauling the nation's health care system, President Obama convened a primetime press conference at the White House. Following days of reports regarding the divisiveness in Congress, Mr. Obama used the news conference to take his message out of Congress and straight to the public. He said for the first time that he would be willing to help pay for the plan by raising income taxes on families earning more than $1 million a year, and is opposed to taxing middle-class families. Additionally he signaled that he was also receptive to another idea under consideration in the Senate: taxing employer-provided health benefits, as long as the tax did not fall on the middle class. During his speech Mr. Obama reaffirmed several key points:

·       Overhauling the nation's health care system would benefit Americans and strengthen the economy.
·       A new health care system would be a necessary improvement, and will implement reforms that work for the American people.
·       American's that have insurance that they like will be able to keep it.

WHAT CAN YOU DO?

We must continue to act on behalf of our nation's children. Even though your members are working hard in Washington, they need to hear from you. Over the next weeks members of Congress and advocates in DC will be working to hammer out legislation and as a result we need to regularly reaffirm the importance of providing children with the services they need and deserve in health reform.

ACTION STEPS:
   1. Call you local district offices to schedule a meeting during the August recess. Even though the recess is still a month away, schedules fill up quickly.
   2. Call your member of Congress and tell them that children need comprehensive health care reform, and the time to pass health care reform is NOW!
   3. Submit an Op-Ed to Your Local Newspaper. You can find suggested talking points and suggested tips on submitting an Op-Ed by logging into the AAP Members Center and clicking the Health Care Reform.
   4. Forward this memo to other AAP Members!

Learn more about the issues in health care reform! Log on to the AAP Members Center Federal Advocacy Page to get the latest background information and tools you need to make a difference!

    * AAP Health Care Reform backgrounder
    * AAP Access Principles
    * AAP Priorities on Health Care Reform
    * Talking Points
    * Chapter sign-on letter
    * Specific Senate and House legislation and official AAP responses
    * Kaiser Family Foundation side-by-side of the Senate and House legislation

Become a Key Contact! Unlike regular FAAN emails, Key Contacts receive regular, more specific emails from the Department of Federal Affairs, keeping them informed about the latest developments and ways to get involved.

Key Contacts are AAP members who have agreed to take their advocacy to the next level. By becoming a Key Contact, you will receive important assignments and can provide critical information to AAP based on your results. In the coming months, we will be calling on Key Contacts with specific requests to make an impact on the health care reform debate. Being a Key Contact requires a very small time commitment but can yield big results! Join today by logging into the AAP Members Center and going to the Federal Advocacy page.

The Department of Federal Affairs is here to support you, and we are more than willing to answer any questions you may have. Please contact Claire Bornstein (cbornstein@aap.org) or Erin Howard (ehoward@aap.org) if you have any questions.