Thursday, December 12, 2013

Release of Final 2014 Medicare Physician Fee Schedule Elicits AAFP Summary

December 11, 2013 02:42 pm News Staff – CMS has released its final 2014 Medicare physician fee schedule(, a massive 1,000-plus page document filled with details about regulations
that will guide Medicare payment to family physicians and other health care professionals as of
Jan. 1.
In the final rule, CMS said it is committed to supporting primary care. "We have increasingly recognized care management as one of the
 critical components of primary care that contributes to better health for individuals and reduced
expenditure growth," said the agency.
In addition, CMS noted that in the final rule it had "prioritized the development and implementation
of a series of initiatives designed to improve payment for, and encourage long-term investment in,
 care management services."
In response to the final rule's release, the AAFP issued a statement from AAFP
President Reid Blackwelder, M.D., of Kingsport, Tenn., that said the 2014 fee schedule
indicated the country might "slowly be moving in the right direction in establishing
a health care system that meets patients' needs for a usual source of care
and a continuous relationship with a primary care physician."

However, Blackwelder also pointed out that the sustainable growth rate formula calls for a
 more than 24 percent cut in Medicare payments to physicians as of Jan. 1. "That formula
 must be repealed, and the AAFP urges Congress to act quickly to do so," said Blackwelder.
 "Congress has begun to appreciate the dire shortages of primary care physicians and other 
professionals. We again call on Congress to repeal the flawed sustainable growth rate formula."
The AAFP has reviewed the CMS final rule and summarized areas of the fee schedule that 
most affect family physicians. The resulting 27-page document(27 page PDF) is designed
 to make the changes more easily understood and to help family physicians save time.
Chronic Care Management Code
In the proposed rule, which was released in early July, CMS added a chronic care management
 code (CCM) beginning in 2015, and the AAFP was pleased to see that the final rule included
 that code. The CCM code will apply to services provided to patients who have two or more 
chronic conditions that are expected to last at least 12 months or until the patient dies. CMS 
specifies that to qualify for the new code, a chronic condition must put the patient at significant 
risk of death or functional decline.
According to the final rule, CCM services provided by a physician can include, among other
 things, development of a care plan; medication management; and communication with the
 patient, caregivers and other health care professionals.
In addition, CMS abandoned its originally proposed 90-day billing interval and instead 
adopted a 30-day billing interval for CCM services -- as recommended by the AAFP. 
The agency also finalized a code that corresponds to 20 minutes of service during that 
30-day period.
The final rule states that patients must give advance consent to a practice where they
 are receiving care before the CCM code can be applied, and that consent must be 
reaffirmed at least every 12 months.
According to the Academy's summary document, "The AAFP will continue working with
 CMS and other payers to properly structure and value CCM services and will provide
 members with further guidance prior to the service becoming payable in 2015."
Telehealth Services
Telehealth services first were defined by CMS in 2001 as services including consultations
 or office visits delivered via an interactive telecommunications system that, at a minimum,
 include the use of audio and video equipment to allow two-way, real-time communication
 between the physician and patient.
The AAFP supported changes made in the final 2014 fee schedule whereby CMS modified
 the geographic criteria for eligible telehealth originating sites to include health professional
 shortage areas located in rural census tracts of urban areas.
According to the AAFP summary, CMS also "established a policy to determine geographic
 eligibility for an originating site on an annual basis," and updated its list of eligible Medicare
 telehealth services to include transitional care management services. The AAFP 
supported both changes.
Value-based Payment Modifier
The Patient Protection and Affordable Care Act mandates that CMS establish a 
value-based modifier aimed at providing differential payment to physicians based on
 the quality of care provided to Medicare beneficiaries compared to the cost of that care
 during a specific performance period.
The Affordable Care Act requires that CMS begin using this value-based modifier with
 certain physicians in 2015 and apply the modifier to all physicians by Jan. 1, 2017.
 Furthermore, the value-based modifier must be implemented in a budget-neutral manner.
Currently, CMS is using 2013 performance data for groups with 100 or more eligible
 professionals to determine value-based modifier payments for 2015. In the final 2014
 fee schedule, CMS lowers the threshold to groups of physicians with 10 or more eligible
 professionals. The agency will use this 2014 performance data to determine value-based
modifier payments for 2016.
"CMS estimates that this change in policy would cause approximately 17,000 groups and
 nearly 60 percent of physicians to be included in the value-based payment modifier 
program in 2016," wrote the AAFP in its summary.
Furthermore, in its review of the schedule during the earlier comment period, the AAFP
 called CMS' proposal to implement the value-based payment modifier "reasonable" and
 commended CMS for its restraint in not initially subjecting practices with 10-99 physicians
 to pay cuts.
Regarding CMS' physician feedback program, the agency has, since 2010, provided annual 
reports -- dubbed "quality and resource use reports" -- to physicians as a means of offering
 feedback on the quality of care and the cost of health care services given to Medicare patients.
 In the 2014 final rule, CMS noted its intention to provide such reports to all physician groups
 and solo physicians.
PQRS Changes
Also of interest to family physicians are changes to the Physician Quality Reporting System
 (PQRS) that first was instituted by CMS in 2011, with gradually increasing incentive payments
 made to physicians who could show successful participation in the program.
2014 is the final year that incentive payments may be earned under PQRS, and, in 2014, 
physicians can meet PQRS requirements by successfully participating in a qualified clinical
 data registry. Beginning in 2015, physicians will be penalized for not successfully reporting 
PQRS data on quality measures for covered services in 2013.
According to the AAFP summary, in the 2014 rule, "CMS added 57 new individual measures
 and two measures groups to fill existing gaps and plans to retire a number of claims-based
 measures to encourage reporting via registry and EHRs (electronic health records)."
 Specifically, for certain reporting criteria in 2014, CMS increased from three to nine 
the number of measures required to be reported via claims and registry-based mechanisms.

Prior to the release of the final rule, the AAFP repeatedly questioned CMS' intention to 
increase the number of reported PQRS measures from three to nine and expressed concern
 that the burden of reporting multiple quality measures falls disproportionately on primary
 care physicians.