Medicare Seeks to Pay for Postdischarge Coordination


Doctors providing primary care services could earn some additional money next year under a new Medicare proposal that would pay them for coordinating the care of their patients who have been discharged from a hospital or nursing home.

Medicare proposes to create a new G code that would allow physicians to bill for postdischarge transitional care services such as obtaining and reviewing the patient’s discharge summary; reviewing diagnostic tests and treatments; updating the medical record within 14 business days post discharge; establishing a new care plan; educating the patient or caregiver within 2 business days post discharge; and communicating with other health care providers.

Marilyn B. Tavenner

The G code would apply when a Medicare beneficiary is discharged from an inpatient stay, a skilled nursing facility, an outpatient hospital observation unit, partial hospitalization services, or a community mental health center.

Officials at the Centers for Medicare and Medicaid Services (CMS) estimate that the use of the new G code could increase payments to family physicians by 7%; other doctors who provide primary care services could see a bump of 3%-5% starting in January 2013.

"Helping primary care doctors will help improve patient care and lower health care costs long term," CMS Acting Administrator Marilyn B. Tavenner said in a statement.

The addition of the new G codes is a "good step," said Dr. Glen Stream, president of the American Academy of Family Physicians. The AAFP has been working on this issue for awhile and earlier this year issued recommendations on better ways to pay for primary care services. Dr. Stream said they would next like to see the CMS develop evaluation and management codes that are specific to primary care, rather than simply increase payments for the 99213 and 99214 codes that are used by many specialties.

The postdischarge transitional care services plan was part of the 2013 Medicare Physician Fee Schedule proposed rule, which was released July 6.

But the fee schedule proposal is not all good news. The proposed rule also details the 27% across-the-board cut to physician fees scheduled to take effect on Jan. 1. The reduction is required by law, based in part on spending targets set under the Sustainable Growth Rate (SGR) formula, which links fees to changes in the gross domestic product.

That formula has been criticized by physicians and lawmakers for years. While no long-term solution to the SGR problem has ever been formulated, lawmakers have taken short-term measures to keep the physician fee cuts from going into effect over the last several years.

The proposed rule would also mean cuts to payments for many cardiology diagnostic tests. Under the proposal, CMS is seeking to expand its multiple-procedure payment reduction policy to diagnostic tests in both cardiology and ophthalmology.

Starting in January 2013, there would be an across-the-board reduction of 25% to the technical component for second and subsequent procedures performed by the same physician or physicians in the same group practice for the same patient on the same day. The cut will not apply to the professional component of the fee. The proposed rule lists 131 diagnostic cardiovascular services that would be subject to the multiple-procedure payment reduction policy.

Dr. William Zoghbi, president of the American College of Cardiology, said the planned reductions in cardiology diagnostic test fees would be bad for both physicians and patients.

"This policy disadvantages physicians who aim for efficiency, and reduces payments based on a misguided understanding of how different services, such as echocardiology and SPECT imaging, are from one another," Dr. Zoghbi said in a statement. "Furthermore, it would lead to a major inconvenience to patients."

The 2013 fee schedule proposal also outlines the implementation of the physician value-based payment modifier, which adjusts physician payments based on the quality and cost of the care they provide. The program, which was mandated under the Affordable Care Act, will be phased in over 3 years starting in 2015.

The proposed rule also would implement the physician value-based payment modifier for all medical groups with 25 or more eligible providers starting in 2015.

Groups that do not participate in the Physician Quality Reporting System would see a 1% cut in Medicare payments. Groups that do participate would be paid in part based on their performance. Groups with higher quality and lower costs would be paid more, and those with lower quality and higher costs would be paid less, according to CMS. The payment adjustments made in 2015 will be based on 2013 performance in the PQRS.

CMS will publish the proposed rule in the Federal Register on July 30, and will accept public comments until Sept. 4. The agency plans to finalize the physician payment rule by Nov. 1.

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