Unless Congress takes further action, the Centers for Medicare and Medicaid Services (CMS) estimates the 2011 Medicare conversion factor will be $26.6574, according to the proposed rule released June 25th. The estimate takes into account the 21.1% payment reduction that has been postponed until December 2010 and an additional 6.1% reduction to the payment update for 2011.
The 2011 Medicare Physician Fee Schedule also will implement several provisions of the Patient Protection and Affordable Care Act (PPACA), including provisions on primary care, prevention, access to care, payment accuracy, and the Physician Quality Reporting Initiative (PQRI). Among the proposed changes:
Effective January 1, 2011, PPACA waives the Part B deductible and the 20% coinsurance for Medicare covered preventive services recommended by the U.S. Preventive Services Task Force (USPSTF), as well as the initial preventive physician examination and the annual wellness visit.
PPACA provides coverage for annual wellness visits, in addition to the current initial preventive physical examination (IPPE). CMS proposes to develop separate Level II HCPCS codes for the first annual wellness visit, to be paid at the rate of a Level 4 office visit for a new patient (similar to the IPPE), and for the subsequent annual wellness visits, to be paid at the rate of a Level 4 office visit for an established patient.
The law requires the annual wellness visit to include at least the following six elements: 1) establish or update the individual's medical and family history; 2) list individual's current medical providers and suppliers and all prescribed medications; 3) record measurements of height, weight, body mass index, blood pressure and other routine measurements; 4) detect any cognitive impairment; 5) establish a screening schedule for the next 5 to 10 years including screenings appropriate for the general population, and any additional screenings that may be appropriate because of the individual patient's risk factors, and 6) furnish personal health advice and coordinate appropriate referrals and health education.
PPACA provides for incentive payments equal to 10% of a primary care practitioner's allowed charges for primary care services under Part B. These incentive payments would be made quarterly based on the primary care services furnished in CY 2011 by the primary care practitioner, in addition to any physician bonus payments for services furnished in Health Professional Shortage Areas (HPSAs). PPACA also provides for a 10% incentive payment for general surgeons. The incentive payments would be made quarterly to the general surgeon when the major surgical procedure is furnished in a zip code that is located in a Health Professional Shortage Area.
PPACA requires CMS to periodically review and identify potentially misvalued codes and make appropriate adjustments to the relative values of the services that may be misvalued. CMS will continue to work with the Relative Value Update Committee (RUC) to address misvalued codes.
As a result of PPACA, Physicians Quality Reporting Initiative (PQRI) incentive payments are authorized through calendar year 2014, with a penalty thereafter for eligible professionals who do not satisfactorily report. For 2011, PPACA states that physicians may earn an incentive payment of 1.0% of the physician's estimated total allowed charges for covered professional services under Medicare Part B provided during the reporting period.
Other revisions concern physician assistants, bone density tests, certified nurse-midwife services, clinical diagnostic lab tests in rural areas, physician self-referral for certain imaging services, power-driven wheelchairs, and the filing deadline for Medicare claims.