The 2009 Medicare Physician Fee Schedule (MPFS) will update the fee schedule conversion by 1.1 percent, reduce the wage index floor from 0.75 to 0.70 in 2009, and initiate an e-prescribing initiative to provide incentive payments to e-prescribers. This Medicare Improvements for Patients and Providers Act of 2008 (MIPPA) (PubLNo 110-275) update supersedes the update specified by the formula in the Medicare law, which includes application of a sustainable growth rate (SGR).
The final rule adopts the requirement in section 149 of MIPPA that three new facility types be added to the authorized telehealth originating sites. The three new facility types are the following: hospital-based or CAH-based renal dialysis center (including satellites), skilled nursing facilities (SNFs), and community mental health centers (CMHCs). The requirement will be effective for services furnished on or after January 1, 2009.
Under the final rule, new HCPCS codes specific to telehealth delivery of follow up inpatient consultations will be adopted. These new codes are for use by practitioners or non-physician practitioners (NPPs) when an inpatient consultation is requested from a patient's attending physician. The codes may not be used for billing of ongoing evaluation and management of a hospital inpatient.
E-prescribing initiative
The 2009 final rule also implements the Electronic Prescribing (E-Prescribing) Incentive program, which was authorized under MIPPA. The first reporting period for the program begins on January 1, 2009, and provides incentive payments to successful e-prescribers. To earn an incentive payment, the e-prescribing measure's denominator codes for professional offices and outpatient services must be at least 10 percent of the total allowed charges for all covered services provided.
Successful e-prescribers are defined as eligible providers who report the e-prescribing measure in at least 50 percent of applicable cases. For the reporting years 2009 and 2010, the incentive amount is two percent; for 2011 and 2012, the incentive amount is one percent; and in 2013 the incentive amount is .5 percent.
Beginning in 2012, Medicare eligible providers will be subject to a payment differential if they do not adopt e-prescribing. In 2012, the provider's fee schedule payments will be reduced by 1 percent; in 2013, payments will be reduced by 1.5 percent; in 2014 and each subsequent year, the fee schedule payment will be reduced by 2 percent.
A qualified e-prescribing system is one that generates a medication list; allows eligible professionals to select medications, print prescriptions, and transmit prescriptions electronically. The system must also conduct safety checks that include automated prompts that offer information on the drug being prescribed, potential inappropriate dose or problems with the route of administration. The system must also provide information on lower cost alternatives, formulary or tiered formulary medications, patient eligibility, and authorization requirements that are received electronically from the patient's drug plan. The E-Prescribing program is separate from the Physician Quality Reporting Initiative progam.
Wage index changes
CMS' reduction of the wage index floor from 0.75 to 0.70 will complete the four-year transition to a wage index based on core-based statistical areas. Section 153(a) of MIPPA required a one percent increase to the end stage renal disease (ESRD) composite rate component of the payment system and established a site neutral base composite rate for both hospital-based and independent dialysis facilities that will reflect the labor share, when the geographic index is applied.
CMS is also finalizing a zero percent update to the drug add-on payment, which coupled with the drug add-on payment and implementation of the one percent MIPPA increase, will revise the drug add-on adjustment from 15.5 percent to 15.2 percent. Total drug expenditures are expected to decline by 1.8 percent in 2009.
Enrollment and billing rules
The effective date of billing for physicians and non-physician practitioners (NPPs) as the later of the following: 1) the date of filing of a Medicare enrollment application that was subsequently approved by a Medicare contractor; or 2) the date an enrolled physician or NPP first started furnishing services at a new practice location. If physicians and NPPs meet all program requirements, then they may bill retrospectively: (1) for services furnished up to 30 days prior to the effective date, rather than the 23 months allowed under current regulations; and (2) for services furnished up to 90 days prior to the effective date if the President has declared an emergency under the Robert T. Stafford Disaster Relief and Emergency Assistance Act.
A physician or NPP is not allowed to bill for services furnished after certain reportable events, including a federal exclusion, debarment, felony conviction, state license suspension or revocation, or a practice location determined not to be operational by CMS or its contractor. With respect to other revocation actions, individual practitioners will be required to submit all outstanding claims within 60 days of the effective date of revocation.
Under the new rule, physicians, NPPs, physician organizations, and NPP organizations will be required to notify their Medicare contractor of a change of ownership, final adverse action, or change of location within 30 days of the reportable event. Failure to notify the contractor of any resulting change may result in an overpayment from the date of the reportable event. Also, if no individual is available and authorized to sign a non-emergency ambulance transport claim on behalf of a beneficiary who is physically or mentally incapable of signing, the ambulance provider or supplier may submit a claim without the beneficiary's signature if specified documentation requirements are met.
Physician payment locality options
CMS is also accepting recommendations regarding reconfiguration of the geographic practice cost indices (GPCIs) until November 3, 2008. The comments may be submitted electronically to: MPFS@cms.hhs.gov. The current final rule does not change the existing physician payment localities, but revisions may result as CMS continues to study the issue. CMS also conducted an interim report that analyzed potential options.
Other CMS changes and proposals
The Medicare, Medicaid, and SCHIP Extension Act of 2007 (MMSEA) also altered the calculation used to compute payment under the average sales price methodology for Part B covered drugs and established a special payment rule for certain inhalation drugs administered through a piece of durable medical equipment (DME). The provisions became effective on April 1, 2008, and were incorporated into the Medicare regulatory language. CMS will need additional information about a targeted exception to the physician self-referral law that would have permitted certain types of incentive payments or shared savings programs before it allows such an exception. CMS will also continue to review other proposals made for the 2009 final rule, including a proposal to update every two years the cost of supplies currently priced at over $150, and a proposal to improve the Competitive Acquisition for Part B Drugs program.
Advance notice of the final rule was issued October 30, 2008. The final rule will be published in the Federal Register on November 19, 2008. The advance text is available.
Source: CCH Chicago Bureau, Oct. 30, 2008.
For more information on this and related topics, consult the CCH® Medicare and Medicaid Guide.
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