PPAC Recommends CMS Delay Policy to Eliminate Consultation Services

The Practicing Physicians Advisory Council (PPAC) held its quarterly meeting on December 7, 2009 in Washington, DC to discuss final provisions of the 2010 Medicare Physician Fee Schedule, including the Physician Resource Use Measurement and Reporting Program and updates to the PQRI and e-Prescribing incentive programs.

During the meeting, several Council members made recommendations to CMS regarding its decision to eliminate consultation codes in all settings (except telehealth). Effective January 1, 2010, physicians will be required to report new or established patient office visit or initial hospital care codes in place of the consultation codes. PPAC repeated its recommendation that CMS delay for at least one year implementation of its regulatory policy that prohibits paying for consultation services, which will allow time for education about clarification of the changes.

In addition, PPAC recommended that CMS rapidly clarify the procedures for using E/M codes in a clinical setting involving the appropriate use of a consultation code when Medicare is the secondary payer. PPAC also recommended that CMS avoid the 21.2 percent cut and advise Congress to reform the seriously flawed Sustainable Growth Rate (SGR) formula and provide physicians with reimbursement that is consistent with the costs of practicing medicine.

 Physician Resource Use Measurement and Reporting Program

CMS staff charged with overseeing the Physician Resource Use Measurement and Reporting Program updated Council members on Phase II program regulations that were finalized in the 2010 final rule, which included reporting of quality measures from PQRI and the Generating Medicare Physician Quality Performance Measurement (GEM) Results Project. The ruling also finalized reporting to groups of physicians, specifically formally established single or multi-specialty group practices, physicians practicing within a defined geographic region, and physicians practicing within facilities or larger systems of care. Diabetes was also added to the list of episodes of care. Other methodologies for benchmarking, attribution, risk adjustment, minimum case size and price standardization are being considered, as well as episode groupers.

PPAC recommended that CMS revise its 10 percent threshold multiple attribution method for resource use reports so that providers who supply E/M services to a patient before or after a hospitalization split no more than 20 percent of the total cost of care for that patient and that the other 80 percent of the costs be attributed to the attending physicians and surgeons involved in the patient’s care.

PPAC also recommended that CMS reconsider its presentation of numerical data to accurately reflect the statistical validity of that data. CMS also reported that they are looking to build an episode grouper more specific to the Medicare population that will recognize patients with multiple co-morbidities. PPAC recommended that CMS include in the reporting, those factors that affect the costs of patient care, such as patient complexity and co-morbidity, local practices costs, setting of care, and similar factors, and that CMS propose to Congress to increase the PQRI bonus to at least 5 percent of total Medicare charges