November 9, 2009
As expected, Medicare physician payments are set to drop by one-fifth beginning on January 1, 2010. More precisely, the “Final Rule” on the Physician Fee Schedule released by the Centers for Medicare and Medicaid Services (CMS) on October 30th calculates the reduction at 21.2 percent. The good news is that Congress will most likely stop the Sustainable Growth Rate (SGR), the gross-domestic-product based formula that has required CMS to announce conversion factor cuts year after year, from having a negative impact in 2010. A bill that is now expected to come before the full House of Representatives next week, the Medicare Physician Payment Reform Act of 2009 (H.R. 3961), would avert the 21.2 percent cut and create a framework for future positive updates to the Medicare Fee Schedule. A similar bill, S. 1776, failed to win the 60 Senate votes needed for fast-tracking on October 21st, but the 47 votes in favor are grounds for hope. Even without eliminating the SGR for good, the odds are that Congress will at least prevent a cut from taking effect on January 1, as it has done each year since 2003.
The American Society of Anesthesiologists continues to lobby Congress vigorously to avoid cuts and to bring the anesthesia conversion factor up to a reasonable level. We at ABC urge each of you to participate in ASA’s grassroots network (http://www.asahq.org/Washington/grassroots.htm) and help make the specialty’s voice heard resoundingly on the Hill.
Conversion Factor
Until legislation blocking the 21.2 percent decrease passes, though, the anesthesia conversion will drop to $16.62 and the general conversion factor (which applies to pain medicine, invasive monitoring line placement and other non-anesthesia services) to $28.41.
The anesthesia conversion factor of $16.62 is a national average. Every Medicare “locality” has a variant, determined pursuant to the Geographic Practice Cost Indices (GPCIs, pronounced “gypsies”). The statute requires CMS to review the GPCI localities at least every three years. . A 1.0 GPCI floor., implemented for 2006, will expire on December 31, 2009. The GPCIs in 54 out of 89 localities will decrease. CMS is engaged in a major study of alternative locality structures. For the time being, the Agency has decided not to pursue any of the alternative configurations.
Several other changes will have a positive, if slight, impact on the anesthesia conversion factor. First, CMS has updated practice expense relative values using new survey data, i.e., the results of the Physician Practice Information Survey (PPIS), sponsored by the American Medical Association and 72 specialty societies (including ASA) and health professional organizations. The new practice expense values are being phased in over a four-year period starting in 2010. During the initial year, the change will have a one percent positive impact on the anesthesia conversion factor; if it were fully phased in immediately, the impact -- on $1.744 billion in 2010 Medicare payments for anesthesia services – would be four percent.
Future updates to the anesthesia and general conversion factors will also benefit from CMS’s decision to remove, once and for all, physician-administered drugs from the definition of “physician services” for purposes of computing the physician update formula. Spending on such medications will not be scored as part of Medicare’s spending on physicians’ professional services. This action will restore $122 billion to funding for physician services over 10 years.
Anesthesia Teaching Rule
ASA and academic anesthesiology programs are to be congratulated for achieving their goal of eliminating the 50 percent payment reduction for concurrent resident cases. The new regulation (42 C.F.R. Section 415.178), which becomes effective on January 1, 2010, will allow the full fee schedule payment for the teaching anesthesiologist’s involvement in each of two concurrent resident cases or “in one resident case that is concurrent to another case paid under medical direction payment rules,” i.e., a nurse anesthetist or anesthesiologists assistant case. The new regulatory language provides, in pertinent part,
- (a)(2) For services furnished on or after January 1, 2010, payment made under §414.46(e) of this chapter if the teaching anesthesiologist (or different teaching anesthesiologists in the same anesthesia group practice) is present during all critical or key portions of the anesthesia service or procedure involved; and the teaching anesthesiologist (or another anesthesiologist with whom the teaching anesthesiologist has entered into an arrangement) is immediately available to furnish anesthesia services during the entire procedure.
- b) Documentation. Documentation must indicate the teaching physician's presence during all critical or key portions of the anesthesia procedure and the immediate availability of another teaching anesthesiologist.
CMS is thus implementing the 2008 federal MIPPA legislation (Medicare Improvements for Patients and Providers Act) that gives teaching anesthesiologists parity with teaching surgeons. Last summer’s proposed teaching rule, which would have limited severely the ability of attending anesthesiologists to hand off resident cases to each other, is not part of the final rule. CMS does suggest, however, that it may in the future revisit the handoff issue in the context of “quality” rather than payment.
On a practical note, CMS instructs anesthesiologists to bill concurrent teaching cases that meet the conditions of the regulation above, using the AA (“personally performed”) and GC (case involves a resident) modifiers. The anesthesia record “must indicate the teaching physician's presence during all critical or key portions of the anesthesia procedure and the immediate availability of another teaching anesthesiologist.”
Consultation Codes
CMS has finalized its proposal to eliminate the use of all consultation codes (inpatient and office/outpatient codes for various places of service except for telehealth consultation G-codes) on a budget-neutral basis. The Work relative value units (RVUs) for the consultation codes have been redistributed to new and established office visits, as well as initial hospital and initial nursing facility visits. The 2 to 6 percent increase in Work RVUs for new/established patient codes will not offset the 12 to 40 percent differential Medicare now pays for consultations for most anesthesiologists or pain physicians.
Physician Quality Reporting Initiative (PQRI)
The Perioperative Temperature Management measure is about to become the third PQRI measure available to anesthesiologists. This measure was approved by the AMA-Physician Consortium for Performance Improvement in 2007 and endorsed by the National Quality Forum in 2008 but was omitted without explanation from the 2009 PQRI.
Many anesthesiologists have raised questions about the number of measures that they must successfully report in order to qualify for the PQRI incentive payment. In general CMS requires that a physician report on at least three measures, unless two or fewer apply to that physician’s practice. With only two applicable measures, anesthesiologists have been able to report Measure #30 (timely administration of antibiotic prophylaxis) and/or Measure #76 (prevention of catheter-related bloodstream infections – central venous catheter insertion protocol). By reporting either #30 or #76 at all, they declare that measure applicable to their practice must submit the appropriate PQRI code in at least 80 percent of their eligible cases.
In the final rule for 2010, CMS states that it is considering defining “clusters” of measures that anesthesiologists will have to report in order to earn the PQRI bonus:
- If you report Measure #30, you must also report Measure #76 (the eligible cases will not inevitably overlap).
- If you report the new Perioperative Temperature Management measure, which has not yet been numbered, you must also report Measure #76.
- If, however, you only report Measure #76 and do not report either the antibiotic or the normothermia measure at all, you will still qualify for the PQRI payment. This is because multiple specialties, not just anesthesiology, can report the catheter insertion protocol.
CMS’ final decisions and particulars will appear on its website, http://www.cms.hhs.gov, no later than December 31, 2009.
As in 2009, the PQRI incentive payment will be 2 percent of all Medicare allowed charges.
There are a number of changes to the methods of reporting the PQRI measures. We will address these changes in an announcement later this year, together with the conditions and specifications for the new Perioperative Temperature Management Measure, which CMS has undertaken to publish between November 15 and December 31.
We very much hope that this communication has been useful to you.
Sincerely,
Tony Mira
President and CEO
Anesthesia Business Consultants, LLC
