2018 Physician Fee Schedule Recommendations
Medicare is accepting public comments on their proposed changes to the 2018 Physician Fee Schedule until September 11, 2017. This year's proposal includes a few potential game changers. I will be submitting recommendations to Medicare as an advocate for my physician clients.
Drafts of my recommendations will be presented on this page. Please complete and submit the comment form to the right if you would like to weigh in on any of these issues.
The proposed fee schedule can be accessed by clicking on the button below. My draft comments will be posted to this page which can be accessed at www.PhysicianFeeSchedule.com
I. Evaluation & Management (E/M) Guidelines and Care Management Services
The fact that Medicare is considering the elimination of the history and exam documentation requirements is disheartening. Since Medicare first published the guidelines, physicians have attended countless training programs, organizations have voluntarily audited millions of visit notes for compliance with the rules as recommended by the Office of Inspector General, they have purchased expensive electronic medical record programs, and physicians have changed the way they practice as efforts to comply with the guidelines. Eliminating the history and exam components of the documentation guidelines would negate all these efforts and constitute the largest disruption the healthcare system has ever seen.
Most of the confusion regarding the history and exam portions of the evaluation and management documentation guidelines was created, compounded, and perpetuated by Medicare and the Medicare Administrative Contractors (MACs). Rather than eliminating the requirements for physicians to document the history and exam components, Medicare should eliminate the ambiguities and require all MACs to apply a uniform standard.
Here are a few examples of how Medicare and MACs have created, compounded, and perpetuated confusion:
1. MACs are inconsistent regarding what should be credited as the “context” element of the History of Present Illness. Depending on how this term is defined, the supported level of service can change multiple levels.
2. MACs do not address if the status of three chronic or inactive conditions in the Assessment & Plan section of the note can be used to satisfy the History of Present Illness requirements.
3. The proposed Physician Fee Schedule indicates that there is a difference between the history components of the 1995 and 1997 sets of E&M Documentation Guidelines with the following statement, “The two versions have a slight difference in requirements for documenting the history.” The only variation between the history components of the 1995 & 1997 sets of documentation guidelines was the fact that the 1997 guidelines permitted the documented status of 3 chronic or inactive conditions to satisfy the history of present illness requirements for detailed and comprehensive levels of history while the 1995 set did not. This difference was eliminated by CMS in October, 2005.
4. MACs are not clear regarding what verbiage is acceptable to support a comprehensive Review of Systems. The documentation guidelines say, “a notation indicating all other systems are negative is permissible.” Physicians who stray from this specific verbiage, “all other systems are negative”, do so at considerable risk.
5. MACs do not agree on whether the statement “family history is non-contributory” should be credited as family history or interpreted to mean that the physician did not feel it was necessary to ask about family history. This standard varies by MAC.
6. The 1995 documentation guidelines do not clearly establish what differentiates the expanded problem focused level of exam from the detailed level or what a comprehensive exam is. The guidelines say, “Expanded Problem Focused -- a limited examination of the affected body area or organ system and other symptomatic or related organ system(s)” and “Detailed -- an extended examination of the affected body area(s) and other symptomatic or related organ system(s)” and “Comprehensive --
I recommend that Medicare publish a uniform documentation standard. The publication should address the ambiguities mentioned above and others. MACs and other government agencies/contractors should be required to follow the national standard as it is written. Clarifying the rules in this manner will eliminate most confusion acknowledged in the proposed rule without abandoning the financial and time investments that have been made to achieve compliance with the documentation guidelines.
Regarding Chronic Care Management, I recommend that Medicare eliminate all out of pocket expenses for these services. Effective management of chronic conditions will substantially reduce the overall cost of care. Most of the most expensive hospital admissions could be avoided if chronic conditions were effectively managed. Providing coverage for chronic care management was a great idea. Unfortunately, the monthly co-insurance patients must pay is price prohibitive for many. Because of this, healthcare organizations are not comfortable dedicating the time and financing needed to initiate and maintain effective chronic care management programs. Out of pocket expenses also preclude the life and cost-saving benefits of remotely monitoring pacemakers, defibrillators, heart failure devices, and implantable loop recorders which entail out of pocket expenses every 30 or 90 days.
Eliminating the out of pocket expenses for chronic care management and the cardiac rhythm management devices mentioned above would save a massive amount of money and prevent a massive amount of patient suffering.
E. Potentially Misvalued Services Under the PFS
The proposed rule mentions services related to the management and monitoring of cardiac rhythm management (CRM) devices as being potentially misvalued. I am requesting that you consider a pricing policy that facilitates remote monitoring as the standard of care for all CRM patients. Medicare’s current policy precludes many organizations from adequately staffing for effective remote monitoring and it makes remote monitoring price prohibitive for a large portion of the patients with CRM devices that could be monitored remotely.
I recommend that Medicare establish a national reimbursement rate for the technical component of remotely monitoring implantable cardiovascular monitors and implantable loop recorders (CPT code 93299). This service is currently contractor priced. MACs have set payment levels for this code as low as $13 (Noridian) and as high as $204 (National Government Services). This code is reported every 30 days. Because many Medicare patients incur a 20% coinsurance, patients in some states need to shell out $31.20/year while others need to shell out $489.60/year for the same service.
The proposed physician fee schedule presents codes 94726 (plethysmography), 76706 (abdominal aorta ultrasound), & 76586 (invalid code) as comparable to remote monitoring CRM devices for pricing purposes. The first two codes are diagnostic tests that take place one time. Remote monitoring are services rendered over periods of either 30 or 90 days and physicians could receive alerts at any time when medical conditions are exacerbated. Responding to these early alerts has proven to save lives, reduce hospital admissions, and lower the cost of managing patients.
An overwhelming amount of data on this topic was the basis for specialty society statements that attempted to establish remote monitoring as the standard of care:
“HRS Expert Consensus Statement on Cardiovascular Implantable Electronic Devices.”
Remote monitoring – a Class 1A recommendation “This consensus document reflects the wealth of recent clinical data generated by large randomized prospective trials from around the world that included patients with pacemakers, ICDs, and CRT-Ds from various manufacturers. These consistently show meaningful patient benefits from the early detection capabilities of automatic RM… These data form the basis of our recommendations that RM represents the new standard of care for patients with CIEDs”
AHA “Abstract 13944: Early Initiation of Remote Monitoring in CIED Patients is Associated with Reduced Mortality” “Our data show that survival is higher in patients who have a shorter time between device implant and remote monitoring initiation, across all CIED device types. These data suggest RM should be initiated as soon as possible following device implantation…early initiation of remote monitoring (within 91 days of device implant) reduces mortality by over 16%...”
The lack of a standard payment level for code 93299 and the fact that many patients must pay a 20% coinsurance has substantially restricted the proliferation of remote monitoring. I recommend establishing a national payment rate for code 93299 and eliminating out of pocket expenses for all CRM device remote monitoring services.
G. Proposed Payment Rates Under the Medicare Physician Fee Schedule for Nonexcepted Items and Services Furnished by Nonexcepted Off-Campus Provider-Based Departments of a Hospital
Medicare continues to assume that hospital-owned physician offices should be compensated more than privately owned physician offices, for identical services, because it is more expensive for a hospital to manage an office than a private practice. This assumption is totally incorrect!
When a hospital operates a physician office, it benefits from economies of scale that private physician offices can’t:
Medicare slashed compensation for the most common private practice services and increased compensation for the same services when rendered within a hospital-owned physician practice. This made it logical and wise for hospitals to acquire private physician practices. Unfortunately, the cost of care increased, out of pocket expenses increased, and many physicians are now forced to practice under alarming conflicts of interest. Specifically, the value based payment system incentivizes physicians to decrease the cost of care while maintaining high quality. Some of the best ways physicians can achieve these goals include preventing hospital admissions and by directing patients to the most cost-effective facilities for necessary procedures (ambulatory surgery centers, office-based cath labs, etc.) Reducing admissions and directing patients to cost-effective facilities cuts directly into the profit margins of the physician’s employer.
No More Consultation Codes
CMS' proposal to eliminate the history and exam key components of documentation is akin to Medicare deciding to ignore all consultation codes (99241 – 99245 & 99251 – 99255) in 2010. Prior to that, physicians were badgered to learn and apply the “3 Rs” of consultations. When electronic medical records began to flourish, questions arose regarding how the 3 Rs could be met. Because Medicare received too many questions regarding this issue, it decided to stop recognizing the consultation codes. That change created, compounded, and perpetuated confusion. Because non-Medicare payers did not ignore the consultation codes, healthcare organizations now need to code and report services differently based on payer. See CMS announcement by clicking the button below...
Necessity for Remote Monitoring
Patient visits, coronary, peripheral vascular, pacemaker/defibrillator, electrophysiology, & device clinic
Turnkey billing solutions for private practices, effective outsourcing for cardiology service lines of hospitals.
Jim Collins, CPC, CCC