Q: What is happening with the 2010 Medicare Physician Fee Schedule?

A: The Defense Appropriations Bill (H.R. 3326) signed by President Obama provides for a 60-day delay in the 21.2-percent cut in Medicare physician reimbursement scheduled to take effect on January 1, 2010. A slight modification to the 2009 conversion factor was utilized to calculate physician reimbursements during January and February. Other changes published in the final ruling posted November 25, 2009 were implemented January 1, 2010.


Is the sustainable growth rate formula still a concern?

A: Yes. Only Congress has the ability to fix or eliminate the SGR. The Centers for Medicare & Medicaid Services proposes a technical change to the formula by removing the expense of physician-administered drugs in the office. This change does not eliminate the fee reductions but is a constructive adjustment.


Q: What changes will occur for Ambulatory Surgery Centers?

A: 2010 is the third year of transition for ASC Medicare payment reform. The 2010 facility reimbursement rates are a 25/75 blend of calendar year 2007 ASC rates and revised ASC payment rates. The Medicare Modernization Act froze the ASC payment rates through 2009. In 2010, the ASC conversion factor increases 1.2 percent by the Consumer Price Index for Urban Consumers. Despite the increase, the net effect of change from 2009 remains insignificant.

There are other issues to consider with ASCs. The Department of Health and Human Services increased funding for unannounced ASC surveys. They expect 1,300 surveys in the next 12 months. The focus is adherence to the revised Conditions for Coverage effective May 18, 2009. Included in the revised version is the need for a comprehensive history and physical (H&P) within 30 days prior to surgery for all surgical procedures.

The H&P should be appropriate for the planned surgery. We suggest that the ASC's policy manual include guidelines for H&Ps.

As for the Hospital Outpatient Departments, rates increased only approximately 3 percent for 2010.


Q: Do I still file outpatient or inpatient consultation codes?

A: No. Although they are still present in the CPT 2010 manual, outpatient consultations (99241 thru 99245) and inpatient consultations (99251 thru 99255) will no longer be payable by Medicare. CMS cites lack of understanding and confusion over their use as the rationale for eliminating them. Physicians should use either evaluation and management (992xx) or ophthalmology (920xx) codes in place of outpatient consults. Hospital care codes (99221 thru 99223) or ophthalmology codes replace inpatient consult codes for Medicare beneficiaries. We expect commercial payers to reconsider how they pay for consultations but do not expect them to immediately follow CMS's lead.


Q: What new CPT and ICD-9 codes appeared in the 2010 manuals?

A: The 2010 coding manuals contain a small number of new codes applicable to ophthalmic practices. Released semiannually by the American Medical Association, a new Category III code implemented on July 1, 2009 appears in the hardcopy CPT 2010: 

   • 0207T—Evacuation of meibomian glands, automated, using heat and intermittent pressure, unilateral.

Coverage and payment for Category III codes remains at carrier discretion. 
New ICD-9 codes appear in the 2010 manual but were effective October 2009.  They are:

   • 376.02—Acute chemical conjunctivitis; and

   • V87.45—Personal history of systemic steroid therapy.


Q: Will we have to prepare for the implementation of ICD-10 in 2010?

A: No. Implementation of ICD-10 is currently scheduled to occur on October 1, 2013. This change increases the level of specificity and increases the number of diagnosis codes to approximately 155,000 from the current 17,000. Expect more information on preparing for this change.


Q: Are there any changes to coding for Avastin?

A: Yes. In October 2009, CMS released a new code for a small dose of bevacizumab (Avastin, Q2024). Physicians immediately objected to the new reimbursement rate of $1.41 per 0.25 mg as it did not cover their costs. CMS announced in mid-November that it would no longer recognize the Q2024 code and would delete it on January 1, 2010. Physicians would then return to their prior instructions for claim filing.

Facilities should have continued to use the Q2024 code until January 1, 2010 at which time "C9257—bevacizumab, inj, 0.25 mg" replaced it. This new code is only for facility use.

Q: What compliance changes may apply to my practice?

A: The annual publication of the OIG work plan identifies a series of items applicable to ophthalmology. Returning issues include:

   • E/M services during global surgery periods;

   • adherence to assignment rules;

   • place of service errors;

   • medicare billings with the modifier "-GY."

New issues for scrutiny include:

   • imaging services;

   • physician billing for Medicare hospice beneficiaries;

   • Medicare as a secondary payer;

   • critical access hospitals;

   • medicare incentive payments for e-prescribing;

   • the ASC payment system;

   • payments for off-label anticancer pharmaceuticals and biologicals.


Q: Should I be concerned about audits?

A: Possibly. CMS continues to step up efforts to ensure continued reductions in overpayments.

We expect the following programs and contractors to be very active in 2010:

   • the Comprehensive Error Rate Testing program;

   • Zone Program Integrity Contractors;

   • Recovery Audit Contractors.


Q: Is compliance with the Red Flag Rule required?

A: Compliance with the Red Flag Rule is still required, however, the Federal Trade Commission delayed the enforcement of the Red Flag Rule again to June 1, 2010. The Red Flag Rule requires "creditors" to develop and implement a written identity theft prevention and detection program. This delay was at the request of the members of Congress. Activity exists in Congress to allow exemptions to the rule. This postponement provides an opportunity for Congress to finalize their bill relating to the Red Flag Rule.


Q: Is the Physician Quality Reporting Initiative continuing?

A: The PQRI will continue in 2010. Important points include:

   • The bonus remains at 2 percent of total Medicare-allowed dollars;

   • The eight ophthalmic measures applicable in 2009 remain in 2010;

   • Two new ophthalmic measures were added but are only available if you report through a registry;

   • Two reporting periods exist: January 1 thru December 31, 2010 and July 1 thru December 31, 2010;

   • 2010 successful participants will be posted on the Web.

In order to receive the bonus, providers must successfully report at least 80 percent for each of three quality measures. The choice to participate in PQRI remains voluntary.


Q: Will the e-prescribing bonus continue in 2010?

A: Yes. Section 132 of the MIPPA legislation provides the opportunity for a bonus payment to eligible professionals who successfully prescribe (as defined by the statute) their patients' medications electronically, beginning in 2009 and continuing in 2010, at 2 percent of Medicare allowed dollars.

Major changes exist to report and qualify for the bonus. They include:

   • Reporting the code only when e-prescription is placed with G8553: At least one prescription created during the encounter was generated and transmitted electronically using a qualified e-prescription system;

   • Each eligible provider reports at least 25 times during the reporting period;

   • You may utilize qualified registries and EHR products to report;

   • You can include services furnished in SNF, domiciliary care or home care.

Participation in the e-prescribing bonus program remains voluntary.


Q: What changes will occur with enrollment?

A:  Enrolling a new provider and updating existing providers through the Provider Enrollment, Chain and Ownership System requires immediate attention. Claims with an ordering/referring physician name and NPI number will be denied after April 4, 2010 if the ordering/referring physician is not in the system.

The Medicare Part B premiums remain unchanged for 2010 for most beneficiaries. Approximately 27 percent of Medicare beneficiaries will see an increase in their premiums. Those affected include: new enrollees during the year; beneficiaries subject to the income-related additional premium; and beneficiaries who do not have their Part B premiums withheld from social security benefit payments, including Medicare/Medicaid beneficiaries. The Part B deductible increases to $155.