CMS Releases Proposed 2013 Medicare Physician Fee Schedule

Following the release of the proposed 2013 Medicare Physician Fee Schedule by the Centers for Medicare and Medicaid Services (CMS) in July, the ACC weighed in on the proposal by submitting comments on Sept. 4, 2012.  This wide-ranging proposal, which sets payment levels and other associated policies for next year, covers a number of issues of importance to the cardiovascular community. As required by current law, physicians will receive a 27 percent cut in overall Medicare payments, barring any Congressional action. Outside of the legally mandated cuts associated with the SGR, the rule, if adopted as proposed, is estimated by CMS to have a negative three percent impact on payments to cardiologists, partially as a result of the fourth year of implementation of scheduled practice expense cuts and partially due to new proposals detailed below. However, effects will differ substantially based on the mix of services provided by a practice.

The rule includes the following items related to payment for specific cardiovascular services:

  • A proposal to reduce payment when more than one cardiovascular diagnostic service is provided by the same physician practice at the same session.  This would result in a 25 percent reduction of the technical component of the lower-priced service.  CMS uses an example of an echocardiogram and a SPECT test performed on the same day – causing a reduction in 25 percent for the technical component of the echocardiogram. This policy was previously implemented for imaging services outside of cardiovascular care. 
  • A proposal to create new codes and payment for the work associated with caring for a patient following discharge from a hospital or nursing facility in order to improve care transitions. This work would be distinct from the work of discharge management performed in a hospital and require significant non-face-to-face work. 

The rule also details a series of policies that will help to determine payment adjustments in the future. Highlights include:

  • Physician Quality Reporting System (PQRS): Physicians successfully participating in the PQRS will receive a 0.5 percent bonus on all Medicare payments for 2013. This bonus will continue the next two years and transition to a penalty in 2015. However, the penalty in 2015 will be based on 2013 participation, similar to the e-prescribing penalty. CMS proposes a method of assessing the penalty that is intended to allow those who are unable to report on PQRS to avoid the penalty. CMS also proposes the inclusion of five new measures of note: a structural measure for participation in a clinical registry and four related to the appropriate use of cardiac stress imaging.   
  • Electronic Prescribing: Practitioners who did not report e-prescribing in 2011 or the first half of 2012 or who did not file a hardship exemption by July 2 will receive payments that are 1.5 percent lower than indicated by the physician fee schedule. Practitioners who successfully report their use of e-prescribing in 2012 or the first half of 2013 will avoid a penalty in 2014. The proposed rule would add two new hardship exemption categories for 2013 and 2014 for successful meaningful users and those who demonstrate intent to participate in the Electronic Health Record (EHR) Incentive Program and adopt a certified EHR. Given that the period for requesting a hardship exemption for 2013 has already ended, CMS would base determinations for these two proposed exemptions on information in the Registration and Attestation system for the EHR Incentive Program upon receipt of a hardship exemption request. The date that requests (and the information the requests are using as justification) must be submitted will be spelled out in the final rule. CMS is proposing an informal review process for the 2013 and 2014 e-prescribing payment adjustments similar to the process implemented for the PQRS program.
  • Public Reporting and Value-Based Modifier: CMS has begun to solidify details related to the planned expansion of public reporting of physician quality data and the use of performance data to adjust payment starting in 2015.  CMS proposes to start payment adjustments with those physicians in groups of 25 or more in 2015 and that the maximum penalty for lower quality be one percent for those eligible but does not propose a minimum penalty. 


For additional analysis of the proposed rule, click here.

In a statement, ACC President William Zoghbi, MD, FACC noted, "Congress has until the end of 2012 to come up with a solution to the flawed SGR payment formula and to prevent next year’s SGR-based cut, currently estimated at 27 percent, from taking effect. The need to fix SGR continues to be a top priority in the United States. The American College of Cardiology’s [ACC's] goal is a sustainable system that rewards quality and focuses on patient-centered care. While this rule takes steps in that direction, it is undermined by old ways of cutting payments without improving quality."

The proposed rule does not address all services that may be subject to review as part of the interim final rule. The ACC anticipates changes in coding and payment for PCI and ablation codes as part of that rule which will be released in November. 

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