2009 Medicare Physician Fee Schedule Proposed Rules

On June 30, 2008, the Centers for Medicare and Medicaid Services (CMS) released the Medicare Part B Physician Fee Schedule (PFS) proposed rule for calendar year (CY) 2009 for public view. Publication of the proposed rule in the Federal Register is scheduled for July 7, 2008. In the interim, the ruling is available for download from the CMS website. CMS will accept comments on the proposed rule until August 29, 2008, and will respond to those comments in a final rule to be issued by November 1, 2008. The revised policies and payment rates will become effective January 1, 2009.

The Society is evaluating the impact on EP services and will prepare comments by the August deadline. We welcome your written feedback — please e-mail Isabelle LeBlanc at ileblanc@HRSonline.org.

Highlights of the Proposed Rule

Total Medicare spending under the 2009 Physician Fee Schedule is projected at $54 billion, down 5% from the $57 billion projected for 2008.
The proposed rule includes a projected update to the fee schedule conversion factor of negative 5.4% under a formula specified in the Medicare law. When applied to the 10.6% reduction scheduled to take effect July 1, 2008, the estimated conversion factor for 2009 will be $32.2285. The update will be revised in the final rule to reflect the law in effect at that time.
CMS is proposing the following approaches for the RUC to undertake in identifying potentially misvalued services including: (1) Review of the Fastest Growing Procedure Codes; (2) Review of Harvard-Valued Codes; and (3) Review of PE RVUs. The following heart rhythm services have been identified as fast growing procedures and are subject to review: 33213, 93613, 93652 and 93743.
CMS is proposing changes to practice expense inputs for Microvolt T-Wave Alternanans (93025) to better align them with the direct inputs of other cardiac stress tests, specifically 93015 and 93017.
CMS is proposing to continue using the “bottom-up” methodology to calculate Practice Expense RVUs. This is the third year of the 4-year transition using the new methodology. Practice Expense RVUs are calculated on the basis of a blend of RVUs weighted by 25% during CY 2007, 50% during CY 2008, 75% during CY 2009, and 100% thereafter.
CMS is proposing to maintain the budget neutrality adjustor at 0.8806, since there is no additional work RVU changes associated with the 5-Year Review of Work RVUs.
CMS is also proposing to create a process to update the prices for high cost supply items that are paid under the practice expense methodology.
New HCPCS codes would allow practitioners to bill for telehealth delivery of follow-up inpatient consultations.
CMS has awarded a contract to Acumen, LLC to analyze potential options for reconfiguring the geographic practice cost indices (GPCIs ) for different localities, though, CMS is not proposing a change in the localities at this time.
The proposed rule includes a number of changes in enrollment and billing requirements for establishing the effective date for Medicare billing privileges for physician and non-physician organizations and for individual practitioners.
This rule proposes an exception to the prohibition on physician self-referral that would permit remuneration provided by a hospital to physicians on its medical staff under incentive payment or shared savings programs, provided that specified conditions are satisfied.
This proposed rule proposes two alternatives to revising the anti-markup rule that would not require application of the anti-markup rule to diagnostic testing services provided by a physician who shares a practice with a single physician or physician organization, and would clarify anti-markup provisions that were finalized in the MPFS CY 2008 final rule by providing guidance pertaining to various terms of the rule, including what would constitute the “office of the billing physician or other supplier” and other concepts such as “outside supplier.”

Overview: Physician Quality Reporting Initiative (PQRI)

In the Tax Relief and Health Care Act of 2006 (TRHCA), Congress authorized CMS for the first time to provide an incentive payment to eligible professionals who satisfactorily report certain quality data under the Physician Quality Reporting Initiative (PQRI). While providing a financial incentive in certain years to eligible professionals to be aware of the quality measures during treatment decisions, this program will also provide valuable information as Medicare moves toward paying for quality of care, not just quantity of services. The program has been expanded and streamlined for services furnished on or after July 1, 2008, based on provisions in the Medicare, Medicaid and SCHIP Extension Act of 2007 (MMSEA). The proposed rule includes proposals for additional improvements to the program for purposes of reporting data on quality measures in 2009 PQRI.

Updates: 2007 PQRI and 2008 PQRI

For 2007 PQRI, CMS announces that incentive payments and access to confidential reports on measures reporting rates and measures performance rates for 2007 are scheduled to begin in mid-July, 2008. Physicians must establish an account through a secure website in order to receive incentive payment and feedback reports. CMS noted that only 16% of the eligible professionals attempted to participate in 2007 PQRI. Learn more»
For 2008 PQRI, CMS anticipates that participation rates should grow based on expanded number of quality measures (117 quality measures, 2 structural measures), new reporting options (including the introduction of Measure Groups), and alternative reporting periods (six-month or 12-month reporting period). Learn more»

Measures, Eligibility and Participation Requirements for 2009 PQRI

The MMSEA amended the statute to require CMS to use a rulemaking process to select quality measures for the 2009 PQRI. In addition, the MMSEA amendments require CMS to establish for 2009 alternative reporting criteria and alternative reporting periods for reporting of measures groups and for registry-based reporting. Current law does not authorize an incentive payment for the satisfactory reporting of data on quality measures for services furnished on or after January 1, 2009.

CMS proposes that the 2009 PQRI will be structured in a similar manner to the 2008 PQRI with regard to:

Eligible professionals: all professionals who are paid under the Medicare physician fee schedule
Type and unit of analysis: individual reporting by a physician with a National Provider Identifier (NPI)
Changes to measures: 2009 PQRI will include up to 175 quality measures. Electrophysiologists are eligible to continue to report on the same four cardiology measures and the two perioperative care measures in 2007 PQRI and 2008 PQRI. Electrophysiologists who have adopted or use structural measures can participate in 2009 PQRI:
(1) Measure #124 (PDF, 1.43M) — Adoption/Use of Health Information Technology (Electronic Health Records), and
(2) Measure #125 (PDF, 1.43M)— Adoption/Use of E-Prescribing.

CMS proposes that the differences between the 2009 PQRI and 2008 PQRI include:

Submission of measures: reporting options expand to include claims-based, registry-based, and electronic health record-based mechanisms. Registry-based reporting through the ICD Registry will not occur for 2009 PQRI
Standards for satisfactory reporting: For individual measures, CMS is proposing to require reporting a minimum of three quality measures on at least 80% of the cases for which that quality measure is reportable (same as 2008 PQRI). For Measure Groups, CMS is proposing to require physicians who report for the full calendar year to report measures for 30 consecutive patients. For those that elect to report during the July 1-2009 – December 31, 2009 reporting period, CMS is proposing to require reporting on 80% of applicable patients, with a minimum of 15 patients.
Measure Group reporting. CMS expands Measure Groups from four to six different measure groups, including the 2009 Perioperative Care Measure Group and the 2009 Coronary Artery Disease Measure Group. For measure groups, each physician electing to report a group of measures must report all measures in the group that are applicable to each patient or encounter at least up to the minimum number of patients required by the applicable reporting criteria. If reporting through registry-based or electronic health record-based mechanism, CMS is proposing that 30 consecutive patients include Medicare and Non-Medicare patients. Electrophysiologists may have the opportunity to report on two separate Measure Groups:
- Measures Proposed for 2009 Perioperative Care Measure Group
  Measure #20 — Perioperative Care: Timing of Antibiotic Prophylaxis — Ordering Physician
  Measure #21 — Perioperative Care: Selection of Prophylactic Antibiotic — First OR Second Generation Cephalosporin
  Measure #22 - Perioperative Care: Discontinuation of Prophylactic Antibiotics (Non-cardiac procedures)
  Measure #23 — Venous Thromboembolism (VTE) Prophylaxis (When Indicated in All Patients)
- Measures Proposed for 2009 Coronary Artery Disease Measure Group
  Measure #6 — Coronary Artery Disease (CAD): Oral Antiplatelet Therapy Prescribed for Patients with CA
  Measure # 7 — Coronary Artery Disease (CAD): Beta-Blocker Therapy for CAD Patients with Prior Myocardial Infarction
  Measure #118 — Coronary Artery Disease (CAD): Angiotensin-Converting Enzyme (ACE) Inhibitor or Angiotensin Receptor Blocker (ARB) Therapy for Patients with CAD and Diabetes and/or Left Ventricular Systolic Dysfunction (LSVD)
  Measure # unspecified — Lipid Screening
Reporting period: one calendar year (Jan.1—Dec. 31, 2009) or an alternative six-month reporting period (July 1 — December 31, 2009)
Bonus payment calculation: The 2009 bonus payment percentage will likely be between 1.5% and 2.0% (for 2008, it is 1.5%). The exact percentage will not be determined until pending legislation is passed by Congress and signed by the President of the United States. Incentive payment will continue to represent a percentage of total-allowed charges for covered Medicare services.
Physician-Level Public Reporting Concept: CMS seeks comments on a “Physician Compare” initiative that is intended to make individual physician-level performance measurement results available to Medicare beneficiaries. The “Physician Compare” website is intended to be linked to CMS’ Physician Directory search engine on Medicare.gov website. The Agency seeks comments on:
     (1) the best forum to effectively engage physicians in the development and evaluation of a valid and reliable public reporting program
     (2) the level at which PQRI information should be publicly reported (i.e., individual level or at the facility level)
     (3) type of data that would be most useful to consumers and physicians
     (4) recommendations on a system that would allow physicians to review their data prior to being publicly reported, among other topics