Medicare Compliance & Reimbursement

Family practitioners, internists, and independent laboratories see a payment boost, while ophthalmologists and radiologists can expect cuts in 2015.

Even if the expected overhaul to the sustainable growth rate formula did not materialize, physicians still have something to cheer about in the proposed 2015 Medicare Physician Fee Schedule. 

No Negative Conversion Factor — Yet

When it comes to the conversion factor, the proposed fee schedule had some optimistic news. Because the Protecting Access to Medicare Act won’t allow any cuts in the conversion factor through March 31, 2015, the Centers for Medicare & Medicaid Services (CMS) is projecting a conversion factor of $35.7977 through that date. Even better, CMS calculated the figures in the proposed rule based on the assumption that the same conversion factor will be applicable throughout the year, the agency says on page 544 of the document.

Of course, if Congress doesn’t step in, the conversion factor will be cut by 20.9 percent. Other specialties, however, may see cuts whether or not Congress votes to avert that deep discount. Radiation oncology practices are projected to face a 4 percent cut, while ophthalmologists and radiologists are expected to see a 2 percent cut.

Specialties that could see a positive turn include family practitioners and internists, who are expected to enjoy a 2 percent raise, as well as independent laboratories, which could get a 3 percent payment boost if the proposed rule is finalized.

Chronic Care Pay Could Offer Extra Reimbursement

It makes sense that the primary care specialists would see payment increases, since CMS appears to be following through on its promise to offer separate payment for chronic care management (CCM) services starting in 2015. CMS is proposing a $41.92 payment rate for a CCM code that can be billed once a month for qualified patients. “We also propose to allow greater flexibility in the supervision of clinical staff providing CCM services,” the agency adds.

Of particular surprise, CMS also appears to be interested in severely cutting global periods from surgical procedures, although the proposal doesn’t suggest taking this step until 2017. “We are proposing to transform all 10- and 90-day global codes to 0-day global codes beginning in CY 2017,” CMS says in a fact sheet about the fee schedule proposal. “The OIG has identified a number of surgical procedures that include more visits in the global period than are being furnished.”

Because CMS seems to believe that Medicare is wasting cash by paying doctors for global periods that include visits the doctors don’t actually perform, CMS is proposing to include “all services provided on the day of surgery, and to pay separately for visits and services actually furnished after the day of the procedure beginning in CY 2017,” CMS says in its fact sheet.

This would mean that any postoperative services you perform would be billable on an a la carte basis, which for most physicians would be a welcome change — unless CMS decides to grossly undervalue the surgical codes once the agency removes the global periods from the value units.

The global period proposal is part of CMS’s larger plan to identify and revise “potentially mis-valued codes” over a multi-year effort. The proposed rule adds another 80 codes to the list of services for which CMS intends to adjust payment levels.

To read the 609-page proposed rule, visit https://s3.amazonaws.com/public-inspection.federalregister.gov/2014-15948.pdf, where you can also learn how to comment in advance of the Final Rule, which will be released this fall.