2009 MPFS Final Rule

The Centers for Medicare & Medicaid Services (CMS) released the Medicare Physician Fee Schedule (MPFS) final rule for calendar year (CY) 2009 for public display on October 30, 2008. [View the final rule on CMS's website] The rates and policies adopted in the final rule will apply to services furnished on or after January 1, 2009. The final rule will appear in the November 19, 2008 edition of the Federal Register. The comment period closes on December 29, 2008, and a final rule responding to the comments will be published at a later date.

Highlights of the Final Rule ·

Total Medicare spending under the 2009 Physician Fee Schedule is projected at $61.9 billion, up 4 percent from the $59.5 billion projected for 2008
Payment rates for physician fee schedule services will be increased by 1.1 percent in 2009 as required by the Medicare Improvements for Patients and Providers Act of 2008 (MIPPA) which became law on July 15, 2008, rather than being reduced by 5.4 percent as projected
The conversion factor for the 2009 MPFS will be $36.066, a 5.3 percent decrease from the 2008 conversion factor of $38.087. MIPPA also requires that CMS revise the way it applies the budget neutrality adjustment related to the most recent five-year review of physician work RVUs. Instead, the adjustment will be applied to the conversion factor for 2009
CMS will continue using the “bottom-up” methodology to calculate Practice Expense RVUs. This is the third year of the four year transition using the new methodology. Practice Expense RVUs are calculated on the basis of a blend of RVUs weighted by 25 percent during CY 2007, 50 percent during CY 2008, 75 percent during CY 2009, and 100 percent thereafter
CMS also adopted several payment changes recommended by the RUC for certain potentially misvalued services, specifically review of (1) the fastest growing procedure codes; (2) Harvard-valued codes; and (3) direct inputs for Practice Expense (PE) RVUs
CMS agreed with the majority of the RUC recommended values for the new cardiac device monitoring codes (PDF, 60K), but questioned the recommended values of the increments between some codes within and across families of pacemakers, ICDs, ILRs, and ICM systems, specifically CPT codes 93283, 93289, 93295, 93229 and 93299
For CY 2009, CMS will finalize their proposal to use the standard 50 percent utilization rate for cardiac event monitoring services (CPT codes 93012 and 93271), which the Society supported
CMS will implement the proposed changes to the PE database for Microvolt T-wave alternans (CPT code 93025) to make the clinical labor staff type consistent with the other cardiac stress tests (CPT codes 93015 and 93017), as well as add the specific Microvolt T-wave testing equipment in place of the cardiac stress testing treadmill devices, and revise the time-in-use for the equipment to reflect the service period
CMS is deferring the implementation of their proposal to apply the IDTF requirement to all diagnostic testing services furnished in physicians’ offices and will continue to review public comments received on this provision, and will consider finalizing it a future rulemaking effort if deemed necessary
CMS is not finalizing their proposal to include a targeted exception to the physician self-referral law that would have permitted certain types of incentive payments or shared savings programs
CMS will modify the anti-markup rules and adopt a more flexible approach that incorporates both proposed alternatives for determining when a physician shares a practice with another provider
CMS will implement a five-year program of incentive payments for eligible professionals who are successful electronic prescribers.
CMS will make several onerous changes to the rules for Medicare enrollment and billing
The final rule will extend the work GPCI floor through December 31, 2009

Download national payment rates for heart rhythm services and procedures (PDF, 16K). The final rule is available for viewing or downloading on CMS's website .

2009 PQRI

CMS finalized 2009 Physician Quality Reporting Initiative (2009 PQRI) with no new cardiology measures. 2009 PQRI allows for a 2 percent bonus payment through claims-based submission and registry-based submission. No electronic health record system passed criteria to be eligible for 2009 PQRI; however, testing will continue for candidates. Detailed measure specifications for measures new or revised for 2009 PQRI will be posted on the Measures/Codes tab of the PQRI section of the CMS website no later than December 31, 2008 and likely earlier.

Note that Measure # 125 HIT: Adoption/Use of Medication e-Prescribing is not included in the final set of 2009 PQRI quality measures. This measure will instead be used for the new e-prescribing incentive program authorized by MIPPA legislation which is detailed below. View the final 2008 PQRI Measures selected for 2009 (PDF, 320K).

Claims-based reporting
CMS requires year round reporting without the six month option as in 2007 PQRI. Download the table( PDF, 20 K)

Measure Groups
CMS decided to continue allow reporting through Measure Groups for 30 consecutive patients for a series of related measures, but none of these measures groups are organized for cardiovascular disease. CMS noted that the problems with Coronary Artery Disease (CAD) Measure Group revealed difficulty with determining a common denominator and that two of the four quality measures within this proposed measures group would require additional diagnosis codes in order to be applicable for the Measure Group. Unlike 2008 PQRI, CMS discontinued the 15 consecutive patients option from July-December citing the recently completed Better Quality Information for Medicare Beneficiaries pilot project (BQI pilot) that indicates that minimum patient sample sizes between 30 through 50 patients per physician are needed for reliable distinction between comparable physician’s performances. Download the table (PDF, 40K)

Registry-Based Reporting
For registry-based reporting, 32 registries have been announced as eligible to report PQRI measures. ACC’s IC3 registry was approved as a registry that may submit quality measures to allow physicians to qualify for PQRI bonus payments in 2008. Other registries are available and allow for electrophysiologists to report through this option. Download the table (PDF, 60K)

Electronic Health Record Reporting
As indicated above, CMS indicates that testing is incomplete and unlikely for 2009 PQRI. Download the table (PDF, 25K)

Physician Compare
Because of legislative requirements, CMS will begin posting the names of successful PQRI participants on a “Physician Compare” website in 2010 from 2009 PQRI. CMS indicates that 2007 PQRI and 2008 PQRI participants will not be included on Physician Compare website citing that CMS is prohibited to make public data prior to MIPPA legislation. CMS will consider the following issues from comment letters submitted to the agency:

Lack of program stability;
Lack of evidence demonstrating that compliance with pay-for-reporting programs increases quality;
Lack of evidence to demonstrate the validity of some of the PQRI quality measures;
Successful participation demonstrates only an eligible professional’s ability to implement a process and is not a measure of quality;
Publicly reporting PQRI participation information may give beneficiaries or others who visit the website the false impression that eligible professionals who participated are practicing higher quality medicine than those who do not participate;
Not clear how information on an individual’s participation in the PQRI would be helpful or meaningful;
The analysis of physician performance on some measures will be based on small numbers;
CMS’ data on PQRI participation may be an inaccurate representation of the number of eligible professionals participating or making a good faith effort to participate in PQRI since clearinghouses inappropriately removed NPI information from claims submissions;
Major improvements are needed to the Physician and Other Healthcare Professional Directory before it can form the basis for a Physician Compare Web site because there are accuracy issues associated with the data on the Physician and Other Healthcare Professional Directory;
It would be unfair to eligible professionals to publish PQRI information since no interim feedback reports are provided to help participants determine if they are reporting correctly; It would be especially unfair to publicly report 2007 and 2008 data because eligible professionals were not informed in advance that such information would be publicly reported;
Publicly reporting 2007 PQRI participation information may be perceived by physicians as reneging on prior commitments that CMS made to physicians in which we indicated that we would not publicly report PQRI information at this time;
While other providers, such as hospitals, home health agencies, and nursing homes had many months of advance notice that CMS would be launching public reporting programs for those provider settings, eligible professionals were given no advance notice that PQRI information would be made public until very recently;
CMS does not have the authority to publicly report PQRI performance information since the Congress only gave CMS the authority to publicly report the names of successful participants;
The PQRI program is too new and is a voluntary program;
Many eligible professionals cannot participate in PQRI due to the lack of applicable measures;
Experience with PQRI is limited and individual eligible professionals are still trying to determine how to integrate PQRI into their office billing processes; and
There are numerous barriers, some of which are described above, that make it difficult for physicians and other eligible professionals to participate in the PQRI.

Electronic Prescribing Bonus
CMS includes the detail on physicians getting a 2 percent bonus for successful electronic prescribing in 2009. Physicians will be required to report a CPT Category II code (like those used in PQRI) that attests that the physician used electronic prescribing during an office visit or consultation. If a physician successfully e-prescribes in 50 percent of office encounters at which a prescription is provided, he or she will receive a 2 percent bonus payment on allowed charges for 2009 services (i.e., includes services performed beyond office visit and consultations). Physicians who have less than 10 percent of their Medicare payments from office visits or consultations will not be eligible receive the bonus payment.

To participate in the e-prescribing incentive program, physicians will need to have a qualified e-prescribing system with certain required capabilities. Qualified systems must be able to:

Communicate with the patient’s pharmacy;
Help the physician identify appropriate drugs and provide information on lower cost alternatives for the patient;
Provide information on formulary and tiered formulary meZdications; and
Generate alerts about possible adverse events, such as improper dosing, drug-to-drug interactions, or allergy concerns.

To earn the incentive payment, physicians must successfully report one of three codes for the e-prescribing measure when submitting claims for specified types of medical visits, indicating that they either:

did not prescribe any medications during the visit
used e-prescribing for any medications prescribed during the visit, or
did not use e-prescribing for a prescription because the law prohibits electronic prescribing for the specific type of drug, such as a controlled substance.

Financial incentives are available for the years 2009 through 2013, and payment differentials apply starting 2012 and for all subsequent years. Incentive payments for successful electronic prescribers for future years are authorized as follows:

2.0 percent for 2010
1.0 percent for 2011
1.0 percent for 2012
0.5 percent for 2013

Note that MPFS payment differential applies beginning in 2012 to those who are not successful electronic prescribers. Specifically, for 2012 and any subsequent year, if the eligible professional is not a successful electronic prescriber for the reporting period for the year, the fee schedule amount for covered professional services furnished by such professionals during the year shall be less than the fee schedule that would otherwise apply by:

1.0 percent for 2012
1.5 percent for 2013
2.0 percent for 2014 and each subsequent years

Final specifications for the e-prescribing measure for purposes of the 2009 e-prescribing incentive program should be available no later than December 31, 2008.