CMS Releases 2013 MPFS Proposed Rule

July 9, 2012

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On July 6, 2012, the Centers for Medicare & Medicaid Services (CMS) issued a proposed rule that updates payment policies and rates for physicians and physician extenders for services paid under the Medicare Physician Fee Schedule (MPFS) in calendar year (CY) 2013. CMS projects that total payments under the MPFS in 2013 will be approximately $86 billion. Based on its proposal, CMS estimated that Medicare payments to family practitioners would increase by seven percent, internists and pediatricians by five percent and geriatricians by four percent. Meanwhile, payments to neurologists would increase by one percent. Without a change in the law from Congress, the proposed one percent increase does not include the effects of the 27 percent reduction in Medicare payments from the Sustainable Growth Rate (SGR) in CY 2013.

This article will provide an overview of the items in the proposed rule of interest to neurology.

Primary Care and Care Coordination

In response to concerns from the physician community that the care coordination included in many of the E/M services, such as office visits, does not adequately describe the non–face–to–face care management work involved in primary care, CMS is proposing to create a new HCPCS G–code that specifically describes post–discharge transitional care management services. The code would describe all non–face–to–face services related to the transitional care management furnished by the community physician or qualified physician extender within 30 calendar days following the date of discharge from a hospital, nursing facility and specified outpatient services.

CMS is also proposing to pay physicians for services furnished in an “advanced primary care practice” that has implemented a medical home model supporting patient–specific care. CMS believes that targeting primary care management payments to advanced primary care practices would have many merits including ensuring a basic level of care coordination and care management.

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 notes that any proposals should be aligned with other incentive programs (including the Electronic Prescribing Incentive Program, Electronic Health Records Incentive Program, Medicare Shared Savings Program, etc.) wherever possible to decrease the burden of participation in these programs. 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 two new stroke measures that can be submitted via registry or claims:

  • stroke and stroke rehabilitation: tissue plasminogen activator (considered)
  • stroke and stroke rehabilitation: tissue plasminogen activator (administered initiated).

CMS is, however, also proposing to remove the measure stroke and stroke rehabilitation: Computed Tomography (CT) or Magnetic Resonance Imaging (MRI) Reports because it is no longer endorsed by the National Quality Forum.

Electronic Prescribing Incentive Program (eRx)

The program provides incentive payments through 2013 to successful e–prescribers. In CY 2013, the program applies a penalty of 1.5 percent to those who are not successful e–prescribers. CMS is proposing to change the definition of a group using eRx Group Practicing Reporting Option (GPRO) from a minimum of 25 eligible professionals to 2 eligible professionals. CMS is also proposing to lower criterion for group practices with 2–24 eligible professionals because their smaller size necessitates a lower reporting threshold. 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. 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 must be submitted will be outlined out in the final rule. CMS is also proposing an informal review process for the 2013 and 2014 e–prescribing payment adjustments similar to the process implemented for the PQRS program.

Value–Based Payment Modifier

The value–based payment modifier will start affecting payment rates starting in 2015. All group practices that consist of 25 or more eligible professionals will be subject to the value–based payment modifier effective January 1, 2015. For groups of 25 or more that do not participate in the PQRS, CMS is proposing to set their value modifier at a 1.0 percent payment reduction. The value–based modifier will function in both directions by rewarding high–performing physicians with increased payments and by punishing low–performing physicians with decreased payments. It is important to note that physician groups can avoid all negative adjustments simply by participating in the PQRS.

CMS proposes that the quality measures used in determining the value–based payment modifier be as closely aligned with other incentive programs (such as the PQRS) as possible. Physicians will also be able to choose at which level they are measured (by practice or individually). CMS will focus on outlier physicians at the beginning of implementation but will gradually increase the scope of the modifier to all physicians and more quality measures by January 1, 2017.

The proposed rule will be reviewed in its entirety by the AAN staff and any comments needed to protect the interests of neurologists will be filed by the September 4, 2012, deadline. Please continue to visit the AAN website for regulatory updates.