AAMC Summary and Analysis - Physician Fee Schedule for Calendar
Year 2000: Proposed Rule, July 22, 1999
Resource-based Malpractice RVUs
The Balanced Budget Act of 1997 required that HCFA implement
a resource-based malpractice relative value unit scale in
the year 2000. The current malpractice relative value units
are charge-based from Medicare claims data accumulated in
1989. This notice presents HCFA's proposal to establish a
methodology and to calculate new RVUs for the malpractice
component of the Medicare Fee Schedule payment formula
The new system utilizes actual malpractice premium data from
various insurers throughout the country. Some specialties
are not specifically recognized by insurers for the purpose
of accumulating premium and risk classification data; therefore,
HCFA mapped all of the HCFA specialties to those where actual
data had been accumulated.
HCFA calculated a risk factor for each specialty based on
the national average premium for each specialty. Where specialties
engaged in both surgical and non-surgical procedures, separate
risk factors were calculated. In addition, HCFA added a "risk
of service" calculation in developing the malpractice
RVU for each code. The "risk of service" for a code
was determined by using the physician work RVUs for that code.
HCFA encountered a problem where there were codes without
a physician work component, such as the technical components
of diagnostic tests. In these cases, the charge based malpractice
RVUs were retained. Comments are requested on this issue.
Finally, the RVUs were rescaled to insure that the new set
of resource based RVUs were budget neutral to the previous
set of charge based RVUs. Malpractice RVUs represent about
3.2 percent of the Medicare payment amount.
Practice Expense Relative Value Units (PE-RVUs)
This year, 1999, was the first year of the four-year transition
to a resource based relative value scale for practice expenses.
In this notice, HCFA is proposing several changes to the current
PE-RVUs. Some of these changes are minor, while others have
a more significant effect. In addition, HCFA provides an update
on the refinement process to the resource-based methodology
and data issues. This process was mandated by Congress and
was to have been completed by the end of 1999.
Refinement process. HCFA states that one of its main
strategies for resolving the outstanding practice expense
methodological issues was to seek a mechanism for obtaining
expert advice and technical support. To this end, in May 1999,
HCFA finally awarded a contract to obtain this assistance.
HCFA also established the Practice Expense Advisory Committee
(PEAC), which was convened this past February and April, to
provide recommendations on the refinement of procedure-specific
(code-level) PE-RVUs.
Physicians' clinical staff time in the facility setting.
HCFA is proposing to remove a physician's clinical staff time
hours spent in the hospital setting from the Clinical Practice
Expert Panel (CPEP) data. Some of the original CPEP physician
panels that developed the code specific direct cost data included
the time a physician's own staff spent in the hospital as
a direct clinical practice expense. HCFA has decided to remove
these costs because they would result in paying twice for
the same service (hospitals are paid for these types of personnel
through the DRG payment). In addition, HCFA believes it is
not typical for most specialties to use their own staff in
facilities. Finally, HCFA argues that inclusion of these costs
in the physician payment is contrary to both the law and regulations.
Pathologist direct patient care hours. There
is a minor change to adjust the pathology direct patient care
hours. This would result in the removal of 3 hours from total
patient care hours for pathologists.
Pediatric surgical times updated. HCFA will
update the current "low" work times used in the
practice expense RVUs for pediatric surgical procedures with
more recent data (the same data ultimately used in the physician
work values) for 48 codes. This will be done in the final
rule.
Vascular surgery "cross-walk". Comments
on the final rule of November 1998 objected to the practice
expense per hour for vascular surgeons. Since only 10 vascular
surgeons were surveyed by the AMA SMS, HCFA combined their
data with cardiac and thoracic surgeons to calculate the practice
expense cost per hour. Based on the comments, HCFA proposes
to change the methodology for calculating the practice expense
per hour for vascular surgeons by cross walking them to the
practice expense per hour of "all physicians."
HCFA has addressed several practice expense related issues
where problems have been identified:
Site of service differential.There has been
confusion over the definitions HCFA has been using for "facility"
and "non-facility" categories for PE-RVUs. The proposed
rule attempts to clarify these categories by defining a "facility"
as a skilled nursing facility (SNF), hospital, and ambulatory
care facility (ASC). As a general rule, if the patient is
a "facility" patient or a facility will bill for
the service, the practitioner must bill using the facility
site-of-service designation.
HCFA is proposing three other clarifications:
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For services performed in an ASC that are NOT on the ASC list of approved
ASC procedures, the non-facility RVUs would be used for
payment as these would be considered the same as if performed
in a physician's office setting.
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Outpatient rehabilitation services provided in a hospital
or a skilled nursing facility (SNF) are paid using the
non-facility practice expense values, not the facility
values.
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A skilled nursing facility (SNF) is considered a facility;
however, a nursing home is not. Physicians should designate
that their service in a nursing home setting is a facility
service (lower payment), unless they can verify that no
Part A claim will be made for the service by the facility.
HCFA is asking for comments about this issue.
Facility and non facility PE-RVUs. The "facility"
practice expense values for several codes in the final rule
were higher than the PE-RVUs for the service when performed
in a "non-facility." This seems to be in conflict
with the concept of the site of service differential. HCFA
is proposing to limit the facility RVUs so they would not
be greater than the non-facility RVUs.
The notice includes some additional proposals:
Pathology Services Provided by Independent Laboratories.
Currently, under the physician fee schedule, an independent
laboratory can bill and receive payment for the technical
component (TC) of physician pathology services for a hospital
inpatient. HCFA proposes to prohibit independent laboratories
from billing for the technical component (TC) of physician
pathology services provided to hospital inpatients. (This
is consistent with all other TC billings.) This proposal is
to conform the billing for these services to Medicare's Hospital
Prospective Payment System (PPS) bundling rules for laboratory
services.
Discontinuous Anesthesia Time. Payment for
anesthesia services is based on the sum of base units plus
time units multiplied by a locality-specific anesthesia conversion
factor. The base unit is valued to include pre-operative,
intra operative and post-operative anesthesia care.
In many situations, once the anesthesiologist or certified
registered nurse anesthetist (CRNA) is in attendance, he/she
remains continuously with the patient for all components of
the service. These components include the establishment of
venous access, initial monitoring, induction, maintenance
of anesthesia during the procedure, and conclusion of attendance
by the physician or CRNA (that is, once the patient is placed
safely under post-operative care).
HCFA is proposing to permit the provider to sum up the blocks
of time around a break in continuous anesthesia care, as long
as there is continuous monitoring of the patient within the
blocks of time. Also, HCFA is making a conforming regulatory
change to add non-medically directed CRNAs to the regulations
as well as medically-directed CRNAs.
CPT Modifier -25. Currently, Medicare does
not allow a physician to bill for a visit service in addition
to a procedure unless a separately identifiable visit service
beyond the normal pre- and post-procedure care was provided.
If a separate visit service was necessary, the service should
be billed with modifier -25 in order to receive separate payment.
To avoid confusion, HCFA is proposing that for procedures
where the global surgery rules do NOT apply, a provider may
only bill for a separately identifiable visit service by using
the CPT modifier -25. Since every procedure has an inherent
visit component, in order for a visit service to be billed,
there must be a significant, separately identifiable service
documented in the medical record.
Nurse Practitioner (NP) Qualifications. HCFA
is proposing to provide less restrictive requirements regarding
a masters degree. The proposed requirement, among the other
criteria to meet the NP qualifications for a Medicare billing
number that are listed in the rule, is that "on or after
January 1, 2003, a NP applying for a Medicare billing number
for the first time must possess a master's degree in nursing."
Percutaneous Thrombectomy of an Arteriovenous Fistula.
Currently there are no CPT codes for this procedure. Acting
on a recommendation from the Society of Cardiovascular and
Interventional Radiologists, HCFA is proposing to implement
a new HCPCS code for percutaneous thrombectomy and/or revision,
arteriovenous fistula, and autogenous or nonautogenous dialysis
graft until a permanent CPT code is established by the AMA.
This procedure will have a 90-day global period and be carrier
priced until a recommendation from the AMA's relative value
unit committee (RUC) is received.
Pulse Oximetry, Temperature Gradient Studies, and Venous
Pressure Determinations. HCFA is proposing to discontinue
separate payment for these codes and bundle them into the
payment for other services.
Coverage of Prostate Cancer Screening Tests. The Balanced
Budget Act of 1997 (BBA) requires coverage of certain cancer
screening tests by the Medicare program. Coverage of two tests
is proposed: digital rectal examinations (DRE), with a proposed
HCPCS code of G0102, although payment would be bundled into
the visit service payment; and screening prostate-specific
antigen blood tests (PSA) with a proposed HCFPCS code of G0103.
The rule specifies that each of the tests can be covered only
once in a year.
Diagnostic tests. HCFA is clarifying two issues originally
discussed in the October 31, 1997 final rule on physician
supervision of diagnostic tests. HCFA is proposing to add
an exception to the supervision rule that would specify that
no physician supervision is required for diagnostic tests
performed by NPs and certified nurse specialists (CNSs) when
they are authorized by State to perform these tests. In addition,
HCFA is proposing to modify section 410.32(b)(3) by means
of a parenthetical stating that diagnostic tests that a PA
is legally authorized to perform under State law require only
a general level of physician supervision.
Also, a second exception is being proposed, that is, physician
supervision rules would not apply to pathology and laboratory
codes in 80000 series of CPT payable under the physicians
fee schedule.
VentricularAssist Device Impantations (CPT Codes 33975
and 33976). HCFA is proposing to eliminate the global
surgical fee periods for these codes due to rapid changes
in this technology and in medical practice. Surgeons may bill
separately for all pre- and post- operative work performed
for these codes, requiring submission of the operative report,
anesthesia record, and the hospital discharge summary along
with the claim for the implantation procedure.
Use of Operating Microscope (CPT Code 69990).
HCFA would pay separately for code 69990 only if it is submitted
as an "add-on" code to a primary procedure code
for which the use of code 61712 or 64830 was acceptable. Separate
payment of 69990 would be made for any of the following primary
procedure codes: 61304 - 61711; 62010 - 62100; 63081 - 63308;
63704 - 63710; 64831; 64834 - 64836; 64840 - 64858; 64861
- 64870; 64885 - 64898; and 64905 - 64907.
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