Updated 2012 Medicare Physician Fee Schedule Now Available
Section 301 of the Temporary Payroll Tax Cut Continuation Act of 2011 (TPTCCA) prevents a payment cut for physicians that would have taken effect January 1, 2012. An update of zero percent is effective for claims with dates of service January 1, 2012, through February 29, 2012.
Video: Medicare Fee Schedule
Codingahead: 2012 Medicare Fee Schedule
prevents a payment cut for physicians that would have taken effect on January 1, 2012. An update of zero percent is effective for claims with dates of service January 1, 2012, through February 29, 2012. While the physician fee schedule update will be zero percent, other changes to the relative value units used to calculate the fee schedule rates must be budget neutral. To make those changes budget neutral, the conversion factor must be adjusted for 2012. CMS is currently developing the 2012 Medicare Physician Fee Schedule (MPFS) to implement the zero percent update. As previously advised, Medicare claims administration contractors will be holding new, January 2012 claims for up to 10 business days in order to effectively test and implement the new 2012 MPFS. These claims to be released into processing no later than January 18, 2012. Claims with dates of service prior to January 1, 2012, are unaffected. Finally, Medicare contractors will be posting the new rates on their websites no later than January 11, 2012.
Medicare Payment Schedule for 2012 and Claims Processing Hold
While Congress delayed the 27.4% Medicare fee cut that was to have gone into effect on January 1, 2012, it is important to understand that other payment factors from the Medicare physician payment final rule will affect the 2012 fee schedule. In other words, even though the SGR-driven fee cut was averted for two months the 2012 fee schedule is not the same as the 2011 fee schedule. For example, the conversion factor was changed from $33.9764 to $34.0376. Other changes include: an extension of the floor on the work geographic practice cost index (GPCI); multiple procedure payment logic; electronic prescribing and quality reporting; and corrected relative values for certain services. Therefore, the 2011 schedule is not the schedule that will be implemented in 2012 and the currently posted 2012 schedule (that includes the 27.4% fee cut) is not the schedule that will be implemented.
DXA Reimbursement Slated to Plummet March 1
The original Medicare program has two parts: Part A (Hospital Insurance), and Part B (Medical Insurance). Only a few special cases exist where prescription drugs are covered by original Medicare, but as of January 2006, Medicare Part D provides more comprehensive drug coverage. Medicare Advantage plans, also known as Medicare Part C, are another way for beneficiaries to receive their Part A, B and D benefits. All Medicare benefits are subject to medical necessity. Part A: Hospital Insurance Part A covers inpatient hospital stays (at least overnight), including semiprivate room, food, tests, and doctor’s fees. Part A covers brief stays for convalescence in a skilled nursing facility if certain criteria are met: 1. A preceding hospital stay must be at least three days, three midnights, not counting the discharge date. 2. The nursing home stay must be for something diagnosed during the hospital stay or for the main cause of hospital stay. 3. If the patient is not receiving rehabilitation but has some other ailment that requires skilled nursing supervision then the nursing home stay would be covered. 4. The care being rendered by the nursing home must be skilled. Medicare part A does not pay for custodial, non-skilled, or long-term care activities, including activities of daily living (ADL) such as personal hygiene, cooking, cleaning, etc. The maximum length of stay that Medicare Part A will cover in a skilled nursing facility per ailment is 100 days. The first 20 days would be paid for in full by Medicare with the remaining 80 days requiring a co-payment (as of 2009, $133.50 per day). Many insurance companies have a provision for skilled nursing care in the policies they sell. If a beneficiary uses some portion of their Part A benefit and then goes at least 60 days without receiving facility-based skilled services, the 100-day clock is reset and the person qualifies for a new 100-day benefit period. Part B: Medical Insurance Part B medical insurance helps pay for some services and products not covered by Part A, generally on an outpatient basis. Part B is optional and may be deferred if the beneficiary or their spouse is still actively working. There is a lifetime penalty (10% per year) imposed for not enrolling in Part B unless actively working. Part B coverage includes physician and nursing services, x-rays, laboratory and diagnostic tests, influenza and pneumonia vaccinations, blood transfusions, renal dialysis, outpatient hospital procedures, limited ambulance transportation, immunosuppressive drugs for organ transplant recipients, chemotherapy, hormonal treatments such as Lupron, and other outpatient medical treatments administered in a doctor’s office. Medication administration is covered under Part B only if it is administered by the physician during an office visit. Part B also helps with durable medical equipment (DME), including canes, walkers, wheelchairs, and mobility scooters for those with mobility impairments. Prosthetic devices such as artificial limbs and breast prosthesis following mastectomy, as well as one pair of eyeglasses following cataract surgery, and oxygen for home use is also covered. Complex rules are used to manage the benefit, and advisories are periodically issued which describe coverage criteria. On the national level these advisories are issued by CMS, and are known as National Coverage Determinations (NCD). Local Coverage Determinations (LCD) only apply within the multi-state area managed by a specific regional Medicare Part B contractor, and Local Medical Review Policies (LMRP) were superseded by LCDs in 2003. Coverage information is also located in the CMS Internet-Only Manuals (IOM), the Code of Federal Regulations (CFR), the Social Security Act, and the Federal Register. Part C: Medicare Advantage plans With the passage of the Balanced Budget Act of 1997, Medicare beneficiaries were given the option to receive their Medicare benefits through private health insurance plans, instead of through the original Medicare plan (Parts A and B). These programs were known as “Medicare+Choice” or “Part C” plans. Pursuant to the Medicare Prescription Drug, Improvement, and Modernization Act of 2003, “Medicare+Choice” plans were made more attractive to Medicare beneficiaries by the addition of prescription drug coverage and became known as “Medicare Advantage” (MA) plans. Traditional or “fee-for-service” Medicare has a standard benefit package that covers medically necessary care members can receive from nearly any hospital or doctor in the country. For people who choose to enroll in a Medicare Advantage health plan, Medicare pays the private health plan a capitated rate, or a set amount, every month for each member. Members typically also pay a monthly premium in addition to the Medicare Part B premium to cover items not covered by traditional Medicare (Parts A & B), such as prescription drugs, dental care, vision care and gym or health club memberships. In exchange for these extra benefits, enrollees may be limited in the providers they can receive services from without paying extra. Typically, the plans have a “network” of providers that patients can use. Going outside that network may require permission or extra fees. Medicare Advantage plans are required to offer coverage that meets or exceeds the standards set by the original Medicare program, but they do not have to cover every benefit in the same way. If a plan chooses to pay less than Medicare for some benefits, like skilled nursing facility care, the savings may be passed along to consumers by offering lower copayments for doctor visits. Medicare Advantage plans use a portion of the payments they receive from the government for each enrollee to offer supplemental benefits. Some plans limit their members’ annual out-of-pocket spending on medical care, providing insurance against catastrophic costs over $5,000, for example. Many plans offer dental coverage, vision coverage and other services not covered by Medicare Parts A or B, which makes them a good value for the health care dollar, if you want to use the provider included in the plan’s network or “panel” of providers. Because the 2003 payment formulas overpay plans by 12 percent or more compared to traditional Medicare, in 2006 enrollees in Medicare Advantage Private Fee-for-Service plans were offered a net extra benefit value (the value of the additional benefits minus any additional premium) of $55.92 a month more than the traditional Medicare benefit package; enrollees in other Medicare Advantage plans were offered a net extra benefit value of $71.22 a month more. However, Medicare Advantage members receive additional coverage and medical benefits not enjoyed by traditional Medicare members, and savings generated by Medicare Advantage plans may be passed on to beneficiaries to lower their overall health care costs. Other important distinctions between Medicare Advantage and traditional Medicare are that Medicare Advantage health plans encourage preventive care and wellness and closely coordinate patient care. Medicare Advantage Plans that also include Part D prescription drug benefits are known as a Medicare Advantage Prescription Drug plan or a MA-PD. Enrollment in Medicare Advantage plans grew from 5.4 million in 2005 to 8.2 million in 2007. Enrollment grew by an additional 800,000 during the first four months of 2008. This represents 19% of Medicare beneficiaries. A third of beneficiaries with Part D coverage are enrolled in a Medicare Advantage plan. Medicare Advantage enrollment is higher in urban areas; the enrollment rate in urban counties is twice that in rural counties (22% vs. 10%). Almost all Medicare beneficiaries have access to at least two Medicare Advantage plans; most have access to three or more. Because of the 2003 law’s overpayments, the number of organizations offering Fee-for-Service plans has increased dramatically, from 11 in 2006 to almost 50 in 2008. Eight out of ten beneficiaries (82%) now have access to six or more Private Fee-for-Service plans. Each year many individuals disenroll from MA plans. A recent study noted that about 20 percent of enrollees report that “their most important reason for leaving was due to problems getting care.” There is some evidence that disabled beneficiaries “are more likely to experience multiple problems in managed care.” Some studies have reported that the older, poorer, and sicker persons have been less satisfied with the care they have received in MA plans. On the other hand, an analysis of the Agency for Healthcare Research and Quality data published by America’s Health Insurance Plans found that Medicare Advantage enrollees spent fewer days in the hospital than Fee-for-Service enrollees, were less likely to have “potentially avoidable” admissions, and had fewer re-admissions. These comparisons adjusted for age, sex and health status using the risk score used in the Medicare Advantage risk adjustment mechanism. In December 2009 the Kaiser Family Foundation published a report that rated Medicare Advantage organizations on a five star scale. The ratings were based on data from CMS, the Consumer Assessment of Healthcare Providers and Systems (CAHPS), Healthcare Effectiveness Data and Information Set (HEDIS) data, and the Health Outcomes Survey (HOS). New plans did not receive ratings, because data were not available. Almost six out of ten (59%) of MA plans did receive ratings, and these plans represented 85% of the enrollment for 2009. The average rating was 3.29 stars. Twenty-three percent of enrollees were in a plan with four or more stars; 20% were in a plan with fewer than three stars. Twenty percent of African-American and 32 percent of Hispanic Medicare Beneficiaries were enrolled in Medicare Advantage plans in 2006. Almost half (48%) of Medicare Advantage enrollees had incomes below $20,000, including 71% of minority enrollees. Others have reported that minority enrollment is not particularly above average. Another study has raised questions about the quality of care received by minorities in MA plans. The Government Accountability Office reported that in 2006, the plans earned profits of 6.6 percent, had overhead (sales, etc.) of 10.1 percent, and provided 83.3 percent of the revenue dollar in medical benefits. These administrative costs are far higher than traditional fee-for-service Medicare.  Part D: Prescription Drug plans Main articles: Medicare Part D and Medicare Part D coverage gap Medicare Part D went into effect on January 1, 2006. Anyone with Part A or B is eligible for Part D. It was made possible by the passage of the Medicare Prescription Drug, Improvement, and Modernization Act. In order to receive this benefit, a person with Medicare must enroll in a stand-alone Prescription Drug Plan (PDP) or Medicare Advantage plan with prescription drug coverage (MA-PD). These plans are approved and regulated by the Medicare program, but are actually designed and administered by private health insurance companies. Unlike Original Medicare (Part A and B), Part D coverage is not standardized. Plans choose which drugs (or even classes of drugs) they wish to cover, at what level (or tier) they wish to cover it, and are free to choose not to cover some drugs at all. The exception to this is drugs that Medicare specifically excludes from coverage, including but not limited to benzodiazepines, cough suppressant and barbiturates. Plans that cover excluded drugs are not allowed to pass those costs on to Medicare, and plans are required to repay CMS if they are found to have billed Medicare in these cases. It should be noted again for beneficiaries who are dual-eligible (Medicare and Medicaid eligible) Medicaid may pay for drugs not covered by part D of Medicare, such as benzodiazepines, and other restricted controlled substances.
What the 2012 Medicare Physician Fee Schedule tells us about the future : Getting Paid
The final rule for the 2012 Medicare Physician Fee Schedule went on display this week. Of course it includes the all-too-familiar fee cut (27.4 percent) – the result of the Centers for Medicare & Medicaid Services’ (CMS) flawed formula for calculating physician payment that Congress has been patching annually since 2002 but which needs a permanent fix. This year’s fee schedule is notable for another reason as well. The PDF file is 1,235 pages long, and that’s without the appendices that will be included when the final rule is published in the Federal Register later this month. The fact that it requires so many pages to describe one year’s changes to one part of one government program is mind-boggling, but the additional bulk is partly because this year the rule also provides a forecast for how CMS plans to carry out government mandates for the program over the next five to 10 years. It is not a crystal ball, but the rule leaves no doubt that Medicare payment to physicians will be changing and that today’s initiatives and incentives are intended as the basis for tomorrow’s payment.
2012 Medicare Physician Fee Schedule Final Rule Important for Telemedicine
Christina Thielst is a hospital administrator, consultant, educator and author who has experienced the evolution of healthcare over the last 30 years. She consults with innovative healthcare organizations that seek to improve the delivery of healthcare by addressing administrative and governance issues, including those integral to the execution of health information technology solutions. Her firsthand experience with the challenges and barriers to effective communication and collaboration has shaped her vision for health information and social media technologies, as reflected in her writings. She is author of the book Social Media in Healthcare: Connect, Communicate, Collaborate and its accompanying self-study course, as well as, editor of the HIMSS Guide to Establishing a Regional Health Information Organization. Her work has been published in magazines and journals including, Healthcare Executive, Journal of Healthcare Management, World Hospitals and Health Services Journal, Frontiers of Health Services Management, HIMSS HIElights, HITExchange and others. Her blog posts are syndicated by several blogging and news sites. Christina received a Bachelors degree in Social Science/Management from Louisiana State University and a Masters of Health Administration from Tulane University, School of Public Health and Tropical Medicine. She is a Fellow in the American College of Healthcare Executives and a member of Health Care Executives of Southern California, Health Information Management Systems Society (HIMSS) and the American Telemedicine Association.
Revised Medicare fee schedule for January 1, to February 29, 2012 is up on
Again, as you should know, CONGRESS voted on at least five (5) separate Medicare Physician Fee Schedules for calendar year 2010. This caused the Medicare contractors to reprocess physicians’ claims for the first 5 months of the 2010 year and resulted in some peculiar recovery actions. Please use the following link to locate your elected officials and contact them to urge that 2010 not be repeated: http://www.mssny.org/mssnyip.cfm?c=s&nm=Grassroots_Action The Medicare fee schedule needs to be properly addressed. Fixing the flawed Medicare payment system and protecting Medicare beneficiaries’ access to doctors is vital. Congress must pass legislation permanently reforming the SGR and address this issue once and for all. The pattern of threatened SGR cuts and last-minute Congressional rescues is in itself not a sustainable solution and must be remedied.
The Medicare Gordian Knot
In May 2011, Rep. Tom Price, MD (R), GA, introduced HR-1700, the “Medicare Patient Empowerment Act” (MPEA), and Sen. Lisa Murkosky (R), AK, introduced a companion bill in the Senate, SB-1042. This legislation would change the physician participation restrictions, allowing docs to independently and privately contract with any Medicare patient for a mutually agreed to fee, specifically for non-emergent services, which might differ from the fixed-fee allowed by Medicare. The reason this bill is called the Medicare Patient Empowerment Act is quite simple. Should the system be allowed to go on as is, Medicare patients will soon find themselves unable to find a physician willing to work for what Medicare pays. Then, if the patient decides to go to an ‘opted-out” physician they will lose the benefits they have paid into for many years. This is quite simply unfair. This bill would solve the problem by “empowering” each patient to use their Medicare benefits however they see fit when seeking the care they need and desire.
Medicare 2011 Fee Schedules
AdvancedMD provides copies of the most current fee schedule from Medicare for your state(s), carrier # and locality. You may use this fee schedule to add a new version to your own Medicare fee schedule. The fee schedules provided by AdvancedMD will appear in your fee schedule grid as #MCR [State] [Carrier]-[Locality]. For example, #MCR11 UT 03502-09. The default Medicare (#MCR) fee schedules that appear in your grid are determined by the state(s) tied to your Practice, Group, Provider and Alternate Provider master files.
- What the 2012 Medicare Physician Fee Schedule tells us about the future : Getting Paid
- CMS Issues Final Medicare Physician Fee Schedule Rule for 2012 : Health Industry Washington Watch
- MHA’s Executive Briefing: AHA Regulatory Advisory: Medicare Physician Fee Schedule
- The Official Medicare Set Aside Blog And Information Resource: Maryland Drug Fee Schedule, Take 2
- Medicare Fee Schedule, Payment and Reimbursement Benefit Guideline, CPT Code Billing: Chest X