Cardiology Sees Wins, Losses in Medicare Fee Schedule


The Medicare physician fee schedule for 2013 is a mixed bag for cardiologists, with impending cuts based on the Sustainable Growth Rate formula as well as a cut to pay for imaging and certain procedures, and the possibility of a slight uptick for care coordination.

"This year’s final rule cuts payments for important cardiovascular services at a time when many cardiology practices are already vulnerable," said Dr. William Zoghbi, president of the American College of Cardiology, in a statement.

Under current law, the SGR formula will kick in Jan. 1 and lop one-fourth off doctors’ pay under Medicare, unless Congress steps in to halt the cut.

In issuing the fee schedule final regulation on Nov. 1, the Obama administration noted that Congress has reversed the mandated cut every year since 2003.

The administration "is committed to fixing the SGR update methodology and ensuring these payment cuts do not take effect," according to a statement. "Predictable, fiscally responsible physician payments are essential for Medicare to sustain quality and lower health care costs over the long term."

The American College of Cardiology also called for pay predictability. "The ongoing uncertainties about Medicare payments that are a direct result of the SGR formula make it nearly impossible to plan and invest in the future," Dr. Zoghbi said.

Even with an SGR fix, cardiologists will see an average 2% reduction in pay because of an expansion of the multiple procedure payment reduction policy. Under that policy, the Centers for Medicare and Medicaid Services reduces payment for a second and subsequent advanced imaging service that is done in the same session or on the same day by the same provider. That policy now applies to the technical component of certain cardiovascular and ophthalmologic diagnostic tests and for imaging services. Essentially, it cuts pay for those services by 25%.

Among the services that will be affected: complete electrocardiogram (CPT code 93000), cardiovascular stress test (93015), and ambulatory blood pressure monitoring (93784).

The move was expected, but the ACC is "definitely disappointed," according to Brian Whitman, associate director of regulatory affairs at the College. The continuing reductions will help to push many cardiologists into hospital-based employment, he predicted.

The fee schedule final rule also outlined a new set of codes that pays physicians to coordinate care within 30 days of discharge from a hospital or nursing home. The rule creates two new CPT codes (99495 and 99496) that can be used for patient care that is not face to face, such as phone consults, chart reviews, and e-mail communications.

While primary care physicians are expected to report these codes most often, cardiologists will also be involved occasionally in these care transitions, Mr. Whitman said.

Cardiologists who run heart failure clinics or who are heart failure specialists, or who may be involved in post–myocardial infarction care are likely to use the transition codes, he added.

Starting next year, a physician using the codes can also conduct the discharge, but he or she must also have had an existing relationship with the patient, defined as having had at least one face-to-face visit within the previous 3 years.

Also included in the final rule: changes to the value-based modifier program. The modifier is designed to pay physicians based on the quality of care they deliver. In the proposed rule issued in July, physicians in groups of 25 or larger would have been subject to the new pay plan in 2015. The final rule increases the size of the group to 100 initially. According to the CMS, the change was made so the agency – and physicians – could gain experience with the methodology and approach before the program is expanded to smaller physician groups.

The value-based modifier will be expanded to all physicians in 2017.

The final rule also outlines how the CMS will expand the Physician Compare website, which was launched in 2010 and currently includes basic information about approved Medicare providers, and whether they are considered successful prescribers under the Medicare Electronic Prescribing Incentive Program. The Affordable Care Act requires the CMS to start making physician performance data available in 2013.

The agency says that next year it will post the names of physicians who successfully report on the Physician Quality Reporting System’s Cardiovascular Prevention measures, as part of the Health and Human Services department’s Million Hearts campaign.

In another final rule issued Nov. 1, the CMS announced that, as expected, it will pay certain providers the Medicare pay rate for certain primary care services provided under Medicaid in 2013 and 2014.


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