On Nov. 1, 2012, the Centers for Medicare and Medicaid Services (CMS) released the 2013 Medicare Physician Fee Schedule final rule. The fee schedule sets the rates at which healthcare professionals are reimbursed for services provided to Medicare beneficiaries for the upcoming year. While the fee schedule reflects a 26.5 percent payment reduction caused by the flawed sustainable growth rate formula, it is expected that Congress will pass a short-term patch to prevent the cuts from taking eff ect. In the absence of the overall reduction, payments to endocrinologists are projected to increase by one percent.
In September 2012, The Endocrine Society submitted comments to CMS that advocated streamlined requirements for quality improvement programs and that supported payments for care coordination services. In the final rule, CMS addressed the numerous and often overlapping requirements of the various quality improvement programs and approved payment for transitional care management services.
PQRS and EHR
In the proposed rule, CMS recommended the inclusion of 264 individual measures and 26 measure groups in the 2013 Physician Quality Reporting System (PQRS) and the alignment of PQRS electronic health record (EHR)-based reporting measures with measures under the EHR incentive program. The Society supported alignment of the PQRS and EHR incentive programs, which would reduce the administrative burden that physicians and staff face in reporting quality measures to multiple programs. CMS finalized the proposed individual measures and measures groups for PQRS, along with proposals to reduce the administrative burdens of meeting the PQRS and EHR program requirements by aligning the reporting criteria for the programs. Eligible professionals who meet the program requirements will receive a 0.5 percent incentive payment in 2013 and avoid a 1.5 percent penalty in 2015.
CMS proposed to expand the e-prescribing group reporting option to include practices with 2-24 eligible professionals. To meet the e-prescribing requirements, practices would need to report 225 electronic prescriptions. Th e Society argued that this requirement was too arduous for smaller practices and recommended a tiered approach. In the final rule, CMS instead reduced the reporting threshold from 225 electronic prescriptions to 75, stating that a tiered approach would add unnecessary complexity to the program. Th e Society supports this compromise measure.
In the proposed rule, CMS recommended coverage for transitional care management services for the coordination of a patient’s care in the 30 days post-discharge from a hospital or nursing facility. Over the last year, the Society worked with 15 other specialty societies to develop, define, and value the transitional care management codes (99495 and 99496) and met with the CMS Deputy Administrator and Director of Medicare to advocate for coverage. In the final rule, CMS supported the societies’ proposal, which was also recommended by the American Medical Association’s Resource-based Relative Value Scale Update Committee, and agreed to cover these services under Medicare.
In order to bill the transitional care management codes, physicians or staff must contact the patient within two days post-discharge and a face-to-face visit must occur within seven days for highly complex patients (99496) or within 14 days for moderately complex patients (99495). The initial face-to-face visit is included in the payment for the codes, provided the visit includes certain specified care coordination services, such as medication reconciliation and coordination of physician referrals.
The Society supports payment for transitional care management services and is pleased that CMS has taken steps to reimburse appropriately for such services. The Society encourages CMS to consider additional coverage for care coordination, like chronic care management and inter-professional telephone consultations.