• Insight
  • Medicare Coverage Gap Discount Program Guidance Beginning in 2011
  • CMS Proposed 2011 Policies and Payment Rates for Inpatient Services
  • CMS Issues Final 2011 Payment Policies for Medicare Advantage and Prescription Drug Plans
  • OPPS 2010 Rule Update
  • MPFS 2010 Rule Update
  • OIG releases CY 2010 Work Plan – Is your brand at risk?
  • Medicare Administrative Contractor Protest Update
  • Health Economics and Reimbursement
  • The Impact of ICD-10 on MS-DRGs

MPFS 2010 Rule Update

On Friday, October 30, 2009, the Centers for Medicare & Medicaid Services (CMS) released a display copy of the Medicare Physician Fee Schedule (MPFS) final rule for calendar year (CY) 2010.   This rule impacts over 1 million physicians and nonphysician practitioners who are paid under the MPFS and sets payment rates for more than 7,000 types of services in various sites of service including physician offices.  Some major topics discussed in the rule include:

A Negative 21.2 Percent Conversion Factor Update

In the 2010 MPFS final rule, CMS finalizes a negative 21.2 percent update in the MPFS conversation factor instead of the negative 21.5 update stated in the proposed rule.  The new conversion factor is $28.4061.

Note: Congress has prevented negative updates from being implemented since 2002. While not guaranteed, it is likely that Congress will intervene once again before the 2010 negative update takes hold.

Elimination of Consultation CPT Codes

CMS will deny coverage and payment for all consultation codes except G-code telehealth consultation services in 2010.  Physicians will be required to report evaluation and management (E/M) codes in place of the eliminated consultation codes.  To compensate for the consultation payment elimination, CMS will redistribute the resulting savings to E/M service codes.

2 Percent Incentive Payment for PQRI and E-Prescribing Incentive Program Participation

CMS will continue providing a 2 percent incentive payment to eligible professionals that satisfactorily report data on quality measures for covered FFS services furnished to Medicare Part B FFS beneficiaries during the CY 2010 reporting period.  CMS will add 30 individual PQRI measures and 6 measures groups on which individual eligible professionals may report.  In addition, CMS will add an electronic health record (EHR)-based reporting mechanism to promote the adoption and use of EHRs.

An additional 2 percent incentive payment will also continue to be paid to eligible professionals who comply with the E-prescribing program guidelines.

Competitive Acquisition Program (CAP)

The 2010 MPFS final rule does not state a time frame for the next CAP bidding period but finalizes a list of changes to the program.  Some of the major changes include:

• CAP drug payment rates are to be updated on a quarterly basis instead of annually
• CAP drug sales are to be permanently excluded from the ASP calculation
• CAP vendor(s) may request to exclude drugs that are not available for the market
• Participating CAP physicians may request the CAP vendor(s) to add drugs that are not currently available on the CAP list directly 
• Eases restrictions on transporting CAP drugs between a participating CAP physicians’ offices

Other topics of interest

• ASP Drug Payments – CMS does not discuss a change to the reimbursement methodology for physician administered drugs that are acquired through the buy & bill process.  As such, these drugs will continue to be paid at ASP plus 6 percent in the physician office setting.
• Compendia – CMS finalizes the revision to the statutory definition of Medicare recognized compendia to include the requirement for a transparent review process
• Drug add-on payment to the composite rate for end stage renal disease (ESRD) – CMS finalizes a zero percent update to maintain the $20.33 per treatment drug add-on amount for CY 2010.

The CY2010 MPFS proposed rule will be published in the Federal Register by November 25, 2009.  CMS is now accepting comments on the final rule until December 29, 2009.  Unless otherwise specified, the new payment rates and policies published in the final rule will apply to services furnished to Medicare beneficiaries beginning January 1, 2010.

For more information, or an in-depth look at how these rule changes may impact your product, contact The Aequitas Group today.