CMS relaxes in-office services regulations in 2009 final rule
The Centers for Medicare & Medicaid Services (CMS) has released final rules on the Medicare Physician Fee Schedule (MPFS) and Hospital Outpatient Perspective Payment System (HOPPS), which set the payment regulations for the office and hospital outpatient settings for 2009.

The final ruling from CMS states that the conversion factor for the MPFS will be $36.07 effective Jan. 1, 2009—a 5.3 percent decrease from the current conversion factor of $38.08.  However, the American College of Cardiology (ACC) said the change “includes some good news for cardiology in terms of administrative burden, but some unfortunate news about physician payment.”

Also, as part of the final MPFS rule, CMS is not requiring all imaging be subject to the Independent Diagnostic Testing Facility (IDTF) quality standards for 2009. In referencing its decision, the agency cited the enactment of section 135 of the Medicare Improvements for Patients and Providers Act of 2008 (MIPPA), which requires that all sites that provide CT, MR, and nuclear medicine services, including PET, for Medicare patients to be accredited by January 2012.

The ACC said that MIPPA includes accreditation requirements for providers of the technical component of advanced imaging to be paid for services provided to Medicare patients beginning in 2012. The association said it “strongly supported this component of MIPPA.”

In addition, CMS is not requiring physicians and nurse practitioners to meet certain quality and performance standards when providing diagnostic testing services, except mammography services, within their medical practice.  

The agency also announced payments for a series of new codes related to cardiac device monitoring, as well as new bundled codes that describe transthoracic echocardiography with spectral and color flow Doppler and stress echocardiography with stress ECG monitoring.

Also, new anti-markup regulations, which seek to take the profit out of reassignment of benefits for diagnostic tests billed by one entity but the service, either professional component or technical component, provided by another, will become effective Jan. 1, 2009, under the final ruling.

CMS said that if a physician is willing to provide a service for less than the rates paid in the MPFS, then Medicare should be billed the lower rate and realize the profit. However, the agency has relaxed its requirements on how it defines physicians who are part of a practice and the parameters for site of service where the procedures are performed, according to the American College of Radiology (ACR).  

Although MIPPA put in place a 1.1 percent update to the Medicare conversion factor, CMS projects that overall Medicare payments to cardiology will fall by 2 percent in 2009. The ACC said the cut will result primarily from two policy changes: First, the third year of the four-year transition to a new formula for calculating practice expense relative value units (RVUs) will reduce payments for a number of cardiovascular imaging services. Second, MIPPA requires that the current budget neutrality adjustment applied to work RVUs be incorporated into the conversion factor.

Michael A. Mussallem, chairman and CEO of Edwards Lifesciences and board chairman of Advanced Medical Technology Association (AdvaMed), said the association is pleased that CMS did not move forward with its proposal to begin gainsharing, which could have created an exception to federal rules against self-referrals that would allow incentive payments and cost-savings to be shared with physicians.

The American College Radiology (ACR) said that the anti-markup rule and lack of implementation of the IDTF rules also leave a relaxed rule on who performs a procedure or supervises medical imaging equipment, not specifying whether it should be a radiologist or even the same physician. Medicare admits that relaxing the rules allows for all entities to be in compliance with the anti-markup regulations by Jan. 1, 2009.   

CMS also issued a final rule for the conversion factor for hospital outpatient payments, instituting a 3.6 percent increase from $63.69 for 2008 to $66.06 in 2009. The reduced conversion factor if hospitals do not meet the hospital quality reporting requirements is $64.78, the agency said.

Medicare also finalized its proposal to move forward with the five new ambulatory payment classifications for ultrasound, CT/CTA without contrast, CT/CTA with contrast, MR/MRA without contrast and MR/MRA with contrast. When more than one ultrasound, CT or CTA, MR or MRA study is performed in the same session, the hospital will submit the claim for the multiple studies and Medicare will send back one bundled payment, according to the rule.
According to the ACC, the final rule increases the bonus payment for PQRI participation to 2 percent and adds additional reporting methods, including using the ACC's IC3 Program as a reporting alternative. Physicians in 2009 may also receive a separate 2 percent bonus for qualified e-prescribing, as created under MIPPA. The ACC said it is “developing educational tools to assist members in learning how to participate in each of these programs.”