The WASHINGTON WATCHLINE is

published monthly and provides

timely information to NAMDRC

members on pending legislative

and regulatory issues that im-

pact directly on the practice of

pulmonary medicine

NAMDRC’s primary mission is to

improve access to quality care

for patients with respiratory dis-

ease by removing regulatory

and legislative barriers to appro-

priate treatment.

INSIDE THIS ISSUE

About NAMDRC…. ................... …..7

NAMDRC Application .............. .....8

NAMDRC Leadership……….……....5

Product and Technology News......6

NAMDRC

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Vienna, VA 22182-2222

Phone: 703-752-4359

Fax: 703-752-4360

Email: ExecOffice@namdrc.org

December 2012 www.namdrc.org VOLUME 22 No. 12

"NAMDRC will directly affect your practice more than any other organization to which you belong."

THE 2013 MEDICARE PHYSICIANS

FEE SCHEDULE

The Final Rule for the 2013 Medicare Physicians Fee Schedule was released on November 1: http://www.ofr.gov/OFRUpload/OFRData/2012-26900_PI.pdf

New Rules:

1. Care coordination codes 2. Rules for avoiding a 2015 payment adjustment 3. Administrative claims-based reporting mechanism for PQRS 4. Application of the Value Based Modifier

Refinement of Current Rules:

1. Change in definition of group practice for PQRS 2. Face to Face Rules for prescribing DME 3. Additions to the Physician Compare Website 4. Alterations in reimbursement for certain codes

Care Coordination

In the preliminary physician’s fee schedule for 2013 CMS proposed establishing a post-discharge transitional care HCPCS code (GXXX1) which would pay for care coordination services outside of face-to-face encounters for coordination of care following discharge from an inpatient hospital stay, skilled nursing facility, and certain outpatient services. In submitted comments, multi-ple organizations suggested that CMS confer with the AMA CPT Editorial Panel that was in the process of developing similar codes. CMS has decided to accept the AMA codes with certain modifications and has established a value for them. The new CPT codes, 99495 and 99496, may be used to report the transitional care management (TCM) services.

December 2012 VOLUME 22 NO 12 PAGE 2

The components of these new codes, as modified for Medicare purposes, have been outlined in the final rule: ● 99495 Transitional Care Management Services with the following required elements: ++ Communication (direct contact, telephone, electronic) with the patient and/or caregiver within 2 business days of dis-charge. ++ Medical decision making of at least moderate complexity during the service period. ++ Face-to-face visit, within 14 calendar days of discharge. ● 99496 Transitional Care Management Services with the following required elements: ++ Communication (direct contact, telephone, electronic) with the patient and/or caregiver within 2 business days of dis-charge. ++ Medical decision making of high complexity during the service period. ++ Face-to-face visit, within 7 calendar days of discharge. Transitional care management commences upon the date of discharge and continues for the next 29 days. A physician may report both the discharge management code and a TCM code although the TCM code cannot be submitted until the 30th day after discharge. Please note the discharge day service cannot also qualify as the face to face visit required in the first 7 or 14 days. Only one individual will be compensated for transitional care and only once per patient within 30 days of discharge. The first face to face visit is part of the transitional care management service and is not reported separately. Additional E/M services after the first face-to-face visit may be reported separately. However, an individual who reports codes 99495, 99496 may not report care plan oversight services (99339, 99340, 99374-99380), prolonged services with-out direct patient contact (99358, 99359), anticoagulant management (99363, 99364), medical team conferences (99366-99368), education and training (98960-98962, 99071, 99078), telephone services (98966-98968, 99441-99443), end stage renal disease services (90951- 90970), online medical evaluation services (98969, 99444), preparation of special reports (99080), analysis of data (99090, 99091), complex chronic care coordination services (99481X- 99483X), medication ther-apy management services (99605-99607), during the time period covered by the transitional care management services codes. CMS is assigning an RVU of 4.68 to CPT TCM code 99495 with intra-service time of 40 minutes, and an RVU of 6.59 with intra-service time of 50 minutes for 99496.

Criteria for Satisfactory Reporting for the 2015 Payment Adjustment

The Affordable Care Act added a financial penalty, to be applied in 2015, for physicians who do not satisfactorily report data on PQRS quality measures. For the 2015 payment adjustment, CMS established CY 2013, that is, January 1, 2013 through December 31, 2013, as the reporting period for the 2015 penalty. The penalty amount will be applied to the estimated Medicare Part B PFS allowed charges for all covered professional services for each provider who does not meet the new criteria. The payment adjustment for 2015 will be a 1.5% reduction in Medicare compensation and for 2016 it will be a 2% reduction. There are three options for meeting the criteria for avoiding the 2015 PQRS payment penalty: -Meet the criteria for the 2013 PQRS incentive; -Report 1 applicable measure or, for eligible professionals only, measures group; or -Elect to be analyzed under the administrative claims-based reporting mechanism. Unlike the criteria for satisfactory reporting for the 2013 and 2014 PQRS incentives, which requires an eligible pro-fessional to report on measures based on a percentage of applicable patients or patient count, this criterion only requires that an eligible professional or group practice report on 1 measure or, for individual providers only, 1 measures group for at least 1 applicable patient using a claims, qualified registry, or EHR-based reporting mechanism during the payment adjust-ment reporting period. For providers electing to use the administrative claims-based reporting mechanism to avoid a pay-ment adjustment they must report ALL clinical quality actions required in the CY 2013 PFS for 100 percent of the cases in which the measures apply.

December 2012 VOLUME 22 NO 12 PAGE 3

Administrative Claims-based Reporting Mechanism

The administrative claims-based reporting option is being implemented as a temporary option under PQRS and CMS is only finalizing its use for the 2015 PQRS payment at this time. Unlike the traditional claims based reporting option, a provider would not be required to submit Quality Data Codes on claims to CMS for analysis. Rather, CMS would analyze every eligible professional’s or group practice’s patient’s Medicare claims to determine whether the eligible professional or group practice performed any of the clinical quality actions required in the CY 2013 PFS proposed rule. Providers wishing to use the administrative claims reporting mechanism must submit a registration statement that includes: the eligible pro-fessional’s name and practice name, the eligible professional’s TIN and NPI for analytical purposes, and the eligible pro-fessional’s contact information. To submit this registration statement, CMS offers the following options: ● If technically feasible, submission of this statement via the web; and ● If technically feasible, submission of an eligible professional’s or group practice’s intent to register to use the administra-tive claims-based reporting mechanism by placing a G code on at least 1 Medicare Part B claim. For the 2015 payment adjustment, providers will be able to elect the administrative claims-based reporting mechanism until October 15, 2013.

Application of the Value-Based Payment Modifier

In addition to penalties for incomplete reporting under PQRS and lack of participation in the EMR and eRx pro-grams, providers will face possible reduced compensation under the Value-Based Payment Modifier beginning in 2015. In the 2013 proposed rule, CMS stated its intention to apply the 2015 Value-Based Payment Modifier (2013 reporting period) to physician groups of 25 or more eligible professionals. Several comments were submitted objecting to this proposal since few smaller groups had any experience reporting under PQRS. In the final rule CMS agreed that it would be reasonable to focus on groups with 100 or more providers before expanding the application of the modifier to smaller groups. However, CMS has restated its commitment to applying the modifier to all providers by 2017. CMS also signaled plans to increase the amount of payment at risk under this program as they gain additional experience with the methodologies used to as-sess the quality of care furnished and the cost of care. Identification of the groups of physicians subject to the modifier for their 2015 compensation will be based on a query of Provider Enrollment, Chain, and Ownership System (PECOS) on Oc-tober 15, 2013. In addition to the PQRS reporting requirements, the Value-Based Payment Modifier will include both quality of care and cost measures collected by CMS: CMS Quality of Care Measures: (a) A composite of rates of potentially preventable hospital admissions for heart failure, chronic obstructive pulmonary dis-ease, and diabetes. (b) A composite of rates of potentially preventable hospital admissions for dehydration, urinary tract infections, and bacte-rial pneumonia. (c) Rates of an all-cause hospital readmissions measure. CMS cost Measures: Costs assigned to physician groups subject to the value-based payment modifier will be assessed based on the following cost measures: (a) Total per capita costs for all attributed beneficiaries; and (b) Total per capita costs for all attributed beneficiaries with diabetes, coronary artery disease, chronic obstructive pulmo-nary disease, or heart failure. Total per capita costs include all fee-for-service payments made under Medicare Part A and Part B.

December 2012 VOLUME 22 NO 12 PAGE 4

Group Practice Redefined

There are two paths for a provider to participate in the PQRS: (1) as an individual or (2) as part of a group practice participating in the PQRS group practice reporting option (GPRO). For the 2010 Physician Quality Reporting System, CMS defined group practice as practices with 200 or more eligible professionals. In 2011 CMS added a second group reporting option, the GPRO II, designed with smaller groups in mind. Accordingly, CMS expanded the definition to include practices with 2-199 eligible professionals. The Center observed that most of the smaller group practices that self-nominated to par-ticipate in GPRO II for 2011 subsequently opted out of participation. For the 2012 reporting period, CMS changed the defi-nition of "group practice" to groups with 25 or more eligible professionals and consolidated GPRO I and II into a single GPRO. In the 2013 rule, CMS has defined a group practice as "a single Tax Identification Number with 2 or more eligible professionals, as identified by their individual National Provider Identifier, who have reassigned their billing rights to the TIN. Despite the experience in 2011, the rational expressed by CMS is that expanding the definition and allowing small group practices of 2-24 eligible professionals to participate in the GPRO will encourage greater participation in PQRS. In one of those contradictions that occasionally appear in these rules, several paragraphs later, CMS goes on to limit report-ing via the GPRO web interface to group practices composed of at least 25 eligible professionals. In addition, CMS has discovered that it will not be technically feasible to accept group practice reporting data via the claims-based reporting mechanism at this time. And, for group practices of 2-99 eligible professionals using direct EHR and EHR data submission vendor products, CMS is postponing availability of this option until 2014. For groups of 2-24 providers that elect to report as a group the only option available is to report by the registry-based reporting mechanism. CMS anticipates posting list of qualified registries in the spring of 2013 for reporting periods occurring in 2013. The final list of qualified registries will be posted at:

http://http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/PQRS/index.html The Deadline for group practices to self-nominate and select its reporting mechanism has been extended from January 31 of the year in which the group practice wishes to participate in the GPRO until October 15. If a group practice participates in PQRS as a group practice, the eligible professionals in the selected group practice cannot participate in the PQRS individually. Should a group practice change its TIN, eligible professionals within the group practice have the option to participate in PQRS individually.

Face-to-face Encounter Requirements for DME

In efforts to address issues of fraud in the DME space, CMS has clarified the requirements for dispensing DME including oxygen, nebulizers and CPAP devices. For orders for DME to be deemed valid all of the following must occur: (A) The physician must document and communicate to the DME supplier that the physician or a physician assistant, a

nurse practitioner, or a clinical nurse specialist has had a face-to-face encounter with the beneficiary on the date of the written order up to 6 months before the date of the written order.

(B) During the face-to-face encounter the physician, a physician assistant, a nurse practitioner, or a clinical nurse specialist must conduct a needs assessment, evaluate, and/ or treat the beneficiary for the medical condition that supports the need for each covered item of DME ordered. (C) The face-to-face encounter must be documented in the pertinent portion of the medical record (for example, history, physical examination, diagnostic tests, summary of findings, diagnoses, treatment plans or other information as it may be appropriate). Physician must sign or cosign the pertinent portion of the medical record indicating the occurrence of a face-to-face encounter for the beneficiary for the date of the face-to-face encounter when performed by a physician assistant, a nurse practitioner, or a clinical nurse specialist.

2012-2013 EXECUTIVE COMMITTEE

AND BOARD OF DIRECTORS

OFFICERS Lynn T. Tanoue, MD President Dennis E. Doherty, MD President-Elect Timothy A. Morris, MD Secretary/Treasurer Steve G. Peters, MD Past President BOARD OF DIRECTORS Charles W. Atwood, MD Peter C. Gay, MD Nicholas S. Hill, MD James P. Lamberti, MD Thomas M. Siler, MD Maida V. Soghikian, MD PRESIDENT’S COUNCIL George G. Burton, MD John Lore, MD Louis W. Burgher, MD, Ph.D. Alan L. Plummer, MD E. Neil Schachter, MD Joel M. Seidman, MD Frederick A. Oldenburg, Jr., MD Paul A. Selecky, MD Neil R. MacIntyre, MD Steven M. Zimmet, MD Joseph W. Sokolowski, MD Peter C. Gay, MD Steve G. Peters, MD EXECUTIVE DIRECTOR Phillip Porte ASSOCIATE EXECUTIVE DIRECTOR Karen Lui, RN, MS DIRECTOR MEMBER SERVICES Vickie Parshall

December 2012 VOLUME 22 NO 12 PAGE 5

The requirements for DME suppliers have also been clarified. A supplier must maintain the written order and the supporting documentation provided by the physician, physician assistant, nurse practitioner, or clinical nurse specialist and make them available to CMS upon request for 7 years from the date of service.

Physician Compare Website

CMS continues to express their firm belief in the power of public reporting to influence provider behavior. The Hospital Compare and Physician Compare Websites are the tools that CMS will use to accomplish their goals. The intent of the website is to provide consumers with quality of care information to make informed decisions about their healthcare. CMS intends to utilize Physician Compare to publicly report quality of care data and physician performance results on each participating physician. While the websites are being built out using Medicare data, the final provider profiles are available to all payers and patients. In the 2013 final rule, CMS discusses further additions to the Physician Compare Website. When fully mature the website will publically report for each physician: -The measures collected under the PQRS. -An assessment of patient health outcomes and functional status of patients. -An assessment of the continuity and coordination of care and care transitions, including episodes of care and risk-adjusted resource use. -An assessment of efficiency. -An assessment of patient experience and patient, caregiver, and family engagement. -An assessment of the safety, effectiveness, and timeliness of care. - Board Certification information Basic administrative data is pulled from the Provider Enrollment, Chain, and Ownership System. For 2013, CMS will begin to add data reported under the existing PQRS. Spe-cifically, CMS will be targeting posting the names of eligible professionals who satisfac-torily report PQRS Cardiovascular Prevention measures group in support of the Million Hearts Initiative in 2014 for the 2013 reporting period. CMS is planning to provide pa-tient experience data as soon as feasible. The final rule adopts a policy under which CMS will administer a patient experience of care survey for calendar year 2013 and 2014 for all group practices of 100 or more eligible professionals that sign up for the PQRS GPRO web interface with plans to start to make public the results in 2014. They have not indicated the time line for making the information on individual providers public; however, they have cited a strong desire from consumers for this data. It is well worth reviewing your profile on the Physician Compare Website and taking steps to correct misinformation.

http://www.medicare.gov/find-a-doctor/provider-search.aspx

Alterations in Reimbursement for Certain Codes

Codes nominated for review included CPT code 95800 unattended sleep study, CPT code 94762 continuous overnight pulse oximetry as well as the HCPCS, clinical labor for pulmonary rehabilitation services, G0424. CMS elected to make no changes to CPT code 95800 but did change the practice expense for overnight oximetry and the clinical labor for pulmonary rehabilitation.

PRODUCT AND TECHNOLOGY NEWS!

NAMDRC is providing this space to our benefactors and patrons who provide us with infor-

mation about new products and innovations related to pulmonary medicine. NAMDRC re-

serves the right to edit this copy as appropriate.

December 2012 VOLUME 22 NO 12 PAGE 6

For CPT code 94762 CMS is allowing 480 minutes (8 hours) of equipment time for the pulse oximetry recording slot. Based on comments received they are adjusting the supplies and equipment price inputs associated with the ser-vice. These values are reflected in the CY 2013 PFS direct PE input database available under downloads for the CY 2013 PFS final rule on the CMS Web site. Since the legislation authorizing pulmonary rehabilitation as a covered benefit became law, CMS has received many comments regarding the appropriate value of the code. In the 2013 final rule CMS proposed to modify the direct practice expense labor inputs for this service to allocate 15 additional minutes to the Respiratory Therapist (L042B) (for a total of 30 minutes) and to delete the time allocated to the CORF social worker/psychologist. Commenters requested that the respiratory therapist time be increased to 60 minutes however CMS responded that because pulmonary rehabili-tation services can be furnished in groups they believe that 30 minutes of respiratory therapist time would be more ap-propriate for valuing the typical pulmonary rehabilitation service. It was also pointed out that the 15 minutes of social worker time had a higher value than 15 minutes of respiratory therapist time and this change would result in reduced compensation for the code. CMS agreed with that observation. The 2013 CMS quality measures and instructions can be found:

http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/PQRS/MeasuresCodes.html

Additional information on the Physician Quality Reporting System is located:

http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/PQRS/index.html

HAPPY HOLIDAYS!!!!!!!!!! …...FROM YOUR FRIENDS AT NAMDRC….

ABOUT NAMDRC:

Established over three decades ago, the National Association for Medical Direction of Respiratory Care

(NAMDRC) is a national organization of physicians whose mission is to educate its members and address regula-

tory, legislative and payment issues that relate to the delivery of healthcare to patients with respiratory disor-

ders.

NAMDRC members, all physicians, work in close to 2,000 hospitals nationwide, primarily in respiratory

care departments and critical/intensive care units. They also have responsibilities for sleep labs, management of

blood gas laboratories, pulmonary rehabilitation services, and other respiratory related services.

NAMDRC MEMBERSHIP BENEFITS AT A GLANCE...

Monthly publication of the Washington Watchline, providing timely information for practicing

physicians;

Publication of Current Controversies focusing on one specific Pulmonary/Critical Care Issue in

each publication;

Regulatory updates;

Discounted Annual Meeting registration fees;

The Executive Office Staff as a resource on a wide range of clinical and management issues; and

The knowledge that NAMDRC is an advocate for you and your profession.

http://www.namdrc.org/coding.html

One of NAMDRC’s primary reasons for existence is to provide both clinicians and patients with the most up-to-date

information regarding pulmonary medicine. Bookmark this page!

The complexity of our nation’s health care system in general, and Medicare in particular, create a true challenge for

physicians and their office staffs. One of NAMDRC’s key strengths is to offer assistance on a myriad of coding, cover-

age and payment issues.

In fact, NAMDRC members indicate that their #1 reason for belonging to and continuing membership in the Associa-

tion is its voice before regulatory agencies and legislators. That effective voice is translated into providing members

with timely information, identifying important Federal Register announcements, pertinent statements and notices by

the Centers for Medicare and Medicaid Services, the Durable Medical Equipment Regional Carriers, and local medical

review policies.

December 2012 VOLUME 22 NO 12 PAGE 7

December 2012 VOLUME 22 NO 12 PAGE 8