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Tony Mira, Chairman and Chief Executive Officer of MiraMed

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Two Important Updates on Medicare Payments for Anesthesia Services: SGR Repealed At Last CMS Instructions Reaffirming Modifier – PT for Screening Colonoscopies

1. Senate Passes SGR Repeal Bill

We are very happy to advise you that late last night, the Senate passed the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) 92-8 and did away with the Sustainable Growth Rate (SGR) formula at long last.  Had the Senate not acted, Medicare payments to physicians would have been reduced by 21.2 percent, effective April 1.  Instead, Medicare payments will increase by 0.5 percent for the next five years beginning on July 1, 2015.

Claims that Medicare held for services provided between April 1 and April 14, pending Senate action, will now be processed and paid at the rates that were in place during the first quarter.

Other changes in the legislation include an extension of the Children's Health Insurance Program by two years as well as a consolidation of Medicare’s quality reporting programs into a single merit-based incentive payment system (MIPS).  The MIPS and the schedule of payment updates established in MACRA were reviewed in our March 30 Alert (Getting What You Ask For: Will Anesthesiologists and Other Physicians See Repeal of the SGR, Finally?) in which we described MACRA as it had just been passed by the House of Representatives as H.R. 2.  For further details, see also the AMA’s Frequently Asked Questions about H.R. 2.

MACRA now awaits the President’s signature in the very near future—and President Obama has been a strong supporter of SGR repeal.  With his signature, the very problematic SGR will finally pass into history.  We congratulate all of the physicians, and their organizations, whose tireless efforts have been translated into this major milestone.

2.  CMS Has Instructed the Carriers to Recognize Modifier PT for Screening Colonoscopies

In the notice accompanying the final fee schedule rule for 2015, CMS announced that it would start paying for anesthesia for screening colonoscopies (CPT®/HCPCS code 00810) as preventive care, meaning that patients would not be liable for cost-sharing from January 1, 2015 on.  Because of the structure of the statute, diagnostic and therapeutic colonoscopies would still be subject to co-payments and deductibles, however, and colonoscopies that began as purely preventive but during which the endoscopist ended up removing a polyp or tissue for biopsy would incur a co-payment but not a deductible.  CMS indicated that anesthesiologists were to identify the applicable payment rule by reporting “pure” screening colonoscopies with modifier 33 and screening colonoscopies that were converted to therapeutic or diagnostic procedures with modifier PT.

The original instructions to the Medicare Administrative Contractors (MACs) did not mention modifier PT, however, and claims for anesthesia for screening colonoscopies that included modifier PT were rejected.  There were also reports of difficulties in getting paid for claims with modifier 33.

On April 3rd, CMS issued new instructions stating unequivocally that:

Effective for claims with dates of service on or after January 1, 2015, contractors shall not apply deductible and coinsurance to claim lines for HCPCS 00810 services when billed with modifier 33 and shall not apply the deductible when HCPCS anesthesia code 00810 is submitted with the PT modifier.
We hope that the policy is now clear to all the MACs and that they will process claims for screening colonoscopies reported with both the 33 and the PT modifiers correctly going forward.  Anesthesiologists who have followed their MACs’ directions and submitted claims for colonoscopies that began as screening but that ended with the removal of polyp(s) or other tissue without modifier PT should start reporting the modifier again.  Any denials should be appealed.

CMS has indicated that it will be providing further guidance on the correction of previously denied claims.  We will update you again when we learn what that process will be.

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