Our take on the proposed PFS

November 2, 2015

Our take on the proposed PFS

Reviewing the proposed Physician Fee Schedule – part 1

Every July, Medicare (CMS) issues a proposed Physician Fee Schedule (PFS) for the upcoming year. It includes a variety of other issues related to Medicare physician payment that CMS is looking for public comment on. Then, in November, CMS issues it’s ”Final Rule,” which is a response to public comments as well as all of the final Relative Value Units (RVUs) assigned to every CPT code.

While the Medicare Physician Fee Schedule technically applies only to Medicare patients, almost all carriers use Medicare rates when setting their own rates – typically in a range of five to 20 percent.

The Advocacy Council, formerly JCAAI, reviewed all the items that impact practicing allergists. What do you need to know about? And what are we working on for you? We’re telling you over the course of this month.

Several years ago Congress mandated that certain high-expenditure CPT codes be reviewed for being potentially mis-valued (see: overvalued) – they are looking to decrease the RVUs assigned to the code. Every code on the mis-valued list is subject to revaluation mainly for physician cognitive services or physician work. Practice overhead is looked at separately.

Allergy has two codes on the list this year, 95004 (percutaneous testing) and 95165 (allergy vial preparation). The Advocacy Council doesn’t agree that 95004 needs to be revalued because the physician cognitive work RVU is only 0.01. Under RUC and CMS rules, no cognitive work valuation can go below 0.01. We know there is some physician work in this RVU since physicians are required, when using this code, to interpret the skin tests and to prepare a report, so we have asked CMS to remove 95004 from the list. We won’t know until the final rule is issued in early November whether we will have to survey 95004.

Reviewing the proposed Physician Fee Schedule – part 2

Medicare has proposed a change in the “incident-to” billing codes which involves the direct supervision requirement for 95165 (preparation of allergy vials). Currently, the rules require that a supervising physician be physically present in-office when vials are made. CMS is proposing that the supervising physician must also be the billing physician. We asked CMS to create an exception for the preparation of allergy vials since this typically takes place when the patient is not in the office. To us, it makes more sense for the ordering physician to bill for the service. We won’t know until November whether CMS accepts our proposal. 

We also asked for formal clarification that CMS does not intend to require that the supervising/billing physician be the same as the physician who establishes the patient’s plan of care and is responsible for the overall course of treatment. The PFS would eliminate a sentence in the Code of Federal Regulations (CFR) which states that the supervising physician does not need to be the same physician who originally saw the patient and also provided subsequent care. CMS has unofficially stated that this was not its intent, but we believe this sentence should remain.

We also pointed out to CMS that costs used to calculate reimbursement for drug testing (CPT Code 95018) are too low because CMS is using outdated costs for Pre-Pen. We gave CMS more recent data and believe this should increase RVUs for this code.

Reviewing the proposed Physician Fee Schedule – part 3

Currently allergists seem to be locked out of the market to manage the care of patients with chronic, severe, persistent asthma because the Chronic Care Management Codes require the patient have two or more chronic conditions. We questioned this seemingly arbitrary requirement. The presence of one chronic condition, which requires significant management skills and time, should be sufficient to allow us to bill for the chronic care management code (99490). We also noted that ICD-10 coding should allow CMS to more easily identify patients suffering from chronic, severe, persistent, bronchial asthma.

We also commented on patient self-management (CPT 98960-98962). CMS currently considers this service to be bundled with E/M services. We shared our belief that patients with severe persistent asthma need to self-manage to ensure control and prevent exacerbations that result in ED visits or re-admissions. This non-compensated service is frequently provided by nurses or other clinical staff with special training in asthma education. We urged CMS to recognize that this kind of education keeps patients out of the hospital and reduces costs, and asked that they begin paying for this service separately outside of the E/M services.