Dreams of permanent pay fix fade as House passes one-year SGR fix; ICD-10 also faces potential delay

March 27th, 2014 - Scott Kraft   
Categories:   Diagnosis Coding   Medicare Physician Fee Schedule (MPFSDB)   Reimbursement  
0 Votes - Sign in to vote or comment.

Leaders on Capitol Hill spent so much time debating, discussing and even reaching a tentative deal on a permanent repeal to the Sustainable Growth Rate (SGR) formula that has caused so much payment uncertainty for physician practices that people started to think it would actually happen.

It looks like those thoughts were premature, as a breakdown in discussion has led to yet another temporary, one-year freeze to physician payment rates that would take effect on April 1, 2014 and extend through March 31, 2015.

The one-year extension passed the House of Representatives on a voice vote on March 26, and is awaiting action in the Senate. The current, temporary payment fix, which ironically was supposed to provide extra time for a permanent fix, is set to expire March 31, 2014. With no action, physician payments would drop by more than 20%.

In addition to the payment fix, the bill also imposes a one-year delay on ICD-10-CM diagnosis code implementation by preventing CMS from recognizing it prior to Oct. 1, 2015.

While there are no guarantees until the Senate passes the bill and it is signed by the President, the House passed it on a voice vote and there are indications that House and Senate leaders have agreed to the legislation.

Most physician specialty groups oppose the bill, despite the one-year ICD-10 delay, because of the lack of a permanent payment fix.

In addition to the SGR fix and ICD-10 delay, the bill would continue to give temporary extensions to the 1.0 minimum work GPCI floor and the therapy cap exceptions process that enables providers to get fairly liberal exemptions beyond the therapy limits.

Some other interesting provisions in the legislation:
  • Deduction limits on employer sponsored health plans would be eliminated.
  • Private sector lab payments would be reported to CMS starting in 2016 and used to calculate Medicare’s lab payments. The labs would report the data, which would be used to set a weighted median payment for Medicare.
  • Payments would be reduced for the technical component of imaging tests done not using imaging equipment up to standard, a change designed to promote quality that would be effective in 2016. Reductions would be 5 percent in 2016 and 15 percent in 2017 and beyond.
  • CMS would be authorized to collect the inputs used to set relative value units from any reliable source and use the information to help set the values. Information could come from provider surveys and electronic health records, among other places. CMS is authorized to pay for the information.

###

Questions, comments?

If you have questions or comments about this article please contact us.  Comments that provide additional related information may be added here by our Editors.


Latest articles:  (any category)

Emergency Department - APC Reimbursement Method
September 15th, 2022 - Christine Woolstenhulme, CPC, CMRS, QCC, QMCS
CMS pays emergency department visits through a payment method using Ambulatory Payment Classifications (APCs). Most payers also use the APC reimbursement system; however, there may be some differences in payer policies (always review your specific payer policy). APCs are the primary type of payment made under the OPPS, comprising groupings ...
Why Medical Coding and Billing Software Desperately Needs AI
September 7th, 2022 - Find-A-Code
It has been said that the healthcare industry is notoriously slow in terms of technology adoption. One need only look at how convoluted medical coding and billing are to know that it needs a technology injection. Specifically, medical coding and billing software desperately needs artificial intelligence (AI).
CMS says Less Paperwork for DME Suppliers after Jan 2023!
August 18th, 2022 - Christine Woolstenhulme, QCC, QMCS, CPC, CMRS
Attention providers, suppliers, billers, and vendors who bill Durable Medical Equipment (DME) to Medicare!  Currently, a supplier receives a signed Certificate of Medical Necessity (CMN) from the treating physician or creates and signs a DME Information Form (DIFs); these are required to be sent with the claim. However, this is about ...
Things to Consider Before Upgrading Medical Billing Software
August 11th, 2022 - Find-A-Code
Your practice has utilized the same medical billing software for years. The medical billing staff says it is time for a change. You don't necessarily disagree, but you also don't know where to begin your search for new software. There are so many vendors offering so many products that making sense of it all can be challenging.
Calendar Year 2023 Medicare Advantage and Part C & D Payment Policies
August 9th, 2022 - Aimee L. Wilcox, CPMA, CCS-P, CST, MA, MT
Each year CMS publishes an Advance Notice of the upcoming years Medicare Advantage (MA) Capitation Rates and Part C and Part D Payment Policies and asks for comments related to it. Each of the comments are carefully reviewed and responded to and often are impactful to changes seen between the Advance Notice and final publication referred to as the Rate Announcement. With health equity as a primary focus for 2023, CMS announced some policy changes that may impact your organization.
How CMS Determines Which Telehealth Services are Risk Adjustable
August 9th, 2022 - Aimee L. Wilcox, CPMA, CCS-P, CST, MA, MT
Medicare Advantage Organizations (MAOs) have gone back and forth on whether or not to use data collected from telehealth, virtual Care, and telephone (audio-only) encounters with Medicare beneficiaries for risk adjustment reporting, but the following published documents from CMS cleared that up once and for all by providing an answer to a question specifically related to this question.
OIG Investigates SCAN Health for Risk Adjustment Overpayments With Surprising Results
July 26th, 2022 - Aimee L. Wilcox, CPMA, CCS-P, CST, MA, MT
We’ve seen a number of OIG risk adjustment data validation (RADV) audits recently where the independent review contractor was simply looking for any codes the payer reported that were not supported by the documentation, in an effort to declare an overpayment was made and monies are due to be repaid. However, it was refreshing to read this RADV audit and discover that the independent review contractor actually identified HCCs the payer failed to report that, while still resulting in an overpayment, was able to reduce the overpayment by giving credit for these additional HCCs. What lessons are you learning from reading these RADV audit reports?



Home About Contact Terms Privacy

innoviHealth® - 62 E 300 North, Spanish Fork, UT 84660 - Phone 801-770-4203 (9-5 Mountain)

Copyright © 2000-2022 innoviHealth Systems®, Inc. - CPT® copyright American Medical Association