Cheryl Clark | December 2, 2014
Changes in relative work value, practice expense, and malpractice expense can move the bottom line rate of pay up or down, and even a few pennies can make a difference in a frequently billed code.
To pay code wonks who track provider pay by specialty group, “Table 93” is the first place they look every November when Medicare releases its Physician Fee schedule code changes that will take effect Jan. 1.
Practically speaking, Table 93 is a list of winners and losers in the annual tug and pull for a fixed pot of federal money. It shows, in a hypothetical sense, how various changes for codes designating thousands of healthcare services will affect reimbursement for each of 57 healthcare providers, from the allergist/immunologist to the nurse practitioner, to the vascular surgeon.
Changes in any of three components—relative work value, practice expense, and malpractice expense—can move the bottom line rate of pay up or down, and even a few pennies can make a difference in a frequently billed code.
Looking back four years, the combined impact column of that table shows a huge range of changes to date.
Chiropractors are the big winners, with a 14% pay increase, 12% of which kicked in Jan. 1 this year. The biggest losers were diagnostic testing facility practitioners, which took a 23% cut. Reimbursements for independent laboratory and radiation therapy center providers were reduced by 20% and 17% respectively. In between are a few surprises.
Neurology Cuts ‘Arbitrary’
Bruce Sigsbee, MD, a spokesman for the American Academy of Neurology, says the group is unhappy with its overall 7% cut in pay, largely due to cuts in the value attributed for electromyography work, which took effect in code changes in 2013. “CMS came up with its own internal methodology… ignoring recommendations” from the American Medical Association’s committee and cutting the code’s value by 50%, Sigsbee says.
“We felt their cuts were rather arbitrary.”
The net result, he says, is “an enormous impact, a huge loss of revenue. Not surprisingly, the commercial payers were very quick to pick up the reductions and adopt (these code changes).”
Many of the changes were not unexpected, although their extent may have been surprising. Primary care providers, which includes family practitioners, internists and many geriatricians who bill those codes, were expected to be winners because the Patient Protection and Affordable Care Act mandated a 10% increase in their pay by 2016.
But if primary care providers get raises, that means others must get less. The money has to come from somewhere in the zero sum game that is mandated by Congress for a fixed pool of money for provider pay. The impact is compounded because private insurers often follow Medicare’s price-setting lead.
A Few Surprises
A look at the combined impact of adjustments to various billing codes over the last four years, reveal that psychiatrists, geriatricians, and chiropractors have had a leading edge for a variety of reasons, getting an 8%, 8%, and 14% increase respectively.
Pathologists, radiation oncologists, and neurologists have taken a hit over the same period, with cuts of 13%, 11%, and 7%, respectively.
Psychiatry is one of the big surprises. CMS agreed with the recommendations from the American Medical Association’s Relative Value Scale Update Committee (RUC) that psychiatry services should be paid better.
Becky Yowell, a deputy director of the American Psychiatric Association, explains the changes: “It says to us that (CMS) really feels there are access issues, and wants to encourage psychiatrists to be paid appropriately.” Specifically, she says there are three main reasons behind psychiatry’s 8% bump in pay:
1. CMS increased the work value of in the evaluation and management (E&M) portions of codes psychiatrists use to bill Medicare, which had long been undervalued. “You have more people seeking treatment, and a greater variety of medications to choose from, and more people with multiple comorbid conditions,” she says. Psychiatrists have to consider a lot more when they prescribe medications for patients with physical as well as mental issues than in past decades. “You need to have a better understanding for example of the impact a heart attack has on mental health.”
2. The pay increase recognizes that for $9.6 million Americans who are dually eligible — many of them younger than 65 who qualify for both Medicaid and Medicare and have severe mental illness or other disability— the psychiatrist provides a lot of primary care services.
3. There is a shortage of psychiatrists willing to accept Medicare reimbursement, which has meant access problems throughout the country. The pay increase, she says, “was a response to that.”
Geriatricians Get a Pay Bump
Among the winners are geriatricians, whose 8% increase—5% of which came in 2013—is in part because of the agency’s new transitional care management codes, designed to reimburse primary care doctors for their services coordinating care for patients recently discharged from a hospital, skilled nursing facility, or community mental health center starting in 2013, says Peter Hollmann, MD, a Rhode Island geriatrician and a spokesman for the American Geriatrics Society.
The codes take into consideration non-face-to-face phone time between care teams and patients and families.
Unfortunately, Hollmann says, many geriatricians have not been able to bill that code for a variety of reasons, one of which is that a lot of physicians still don’t know they can bill it.
“There may be some doctors who does this service, knows how to bill for it and get paid for it,” he said. But many do not. “You have to have a way of keeping track of what you’re doing with a given patient,” he says, adding that the amount was only about $30.
“I don’t want to sound ungrateful; it’s a great step forward,” Hollmann says. “But probably CMS overestimated that more services would be provided than actually will be.”
Next year, CMS will offer another new code, this one for complex care management of patients with two or more co-morbid conditions. The code will pay primary care providers $42.60 per month for non-face-to-face care if providers can meet certain criteria, such as having appropriate electronic health record systems and documentation capabilities.
Chiropractors Get Respect
Another surprise to many is the 14% increase in pay to the average chiropractor, 12% of which took effect Jan. 1, 2014.
That came about, says Anthony Hamm, president of the American Chiropractor’s Association, because several years ago CMS targeted chiropractic billing codes as “a high expenditure procedure” and asked for a review to see if the relative values for the work involved were appropriate.
Rather than downgrading the value, Hamm says, CMS increased it. However, the increase in payment is primarily due to a change in the methodology used to calculate three chiropractic manipulative therapy codes, recommended by the AMA’s RUC Health Care Professionals Advisory Committee Review Board (RUC HCPAC).
“Our argument was that there’s a set of osteopathic manipulation codes and the work value (a portion of the formula used to calculate the amount paid for that code) required is identical to that required for the chiropractic manipulative therapy codes. Therefore our value should be equal to those,” Hamm says. “The RUC HCPAC agreed,” and so did CMS.
“Politically, and from a healthcare marketplace standpoint, I believe the chiropractic profession is valued more by the payers and the public now than in the past, although I don’t think that entered into the conversation or the decision by CMS to raise our work value,” Hamm says.
However CMS to date refuses to pay for many chiropractic evaluation and management codes, and the ACA has petitioned the agency “to cover all procedures we are trained and licensed to perform.”
Source: Health Leaders Media
http://www.healthleadersmedia.com/print/PHY-310796/Physician-Fee-Schedule-Winners-and-Losers