In our December 2007 article, we discussed the Medicare final payment rule for physicians (“Medicare final rule: Little good news for urologists”). However, in late December, Congress changed the rules, albeit slightly. These changes, among others in 2008, warrant urologists’ attention.
Congress passed a law increasing payment for physicians for the first 6 months of 2008 by 0.5%, therefore averting the 10.1% decrease that was planned. This gives Congress another 6 months to put a fix to the problem. Otherwise, our pay will decrease even further. AUA, the American Association of Clinical Urologists, American Medical Association, and American College of Surgeons, along with all physicians, will have to do more political “begging” to avert a pay cut.
The other positive part of the new law is funding of 1.5% for the Physician Quality Reporting Initiative (PQRI) reporting beyond 2008 to 2009 and 2013. Why those dates? What happened to 2010, 2011, and 2012?
Congress has to fund any payments that it authorizes within a 5-year period. This means it had to find monies to pay for the 2008 and the 2009 payments. It did not want to identify the monies for 2010, 2011, and 2012. 2013 is 6 years out, and Congress is not required to fund that far in advance. We would assume that legislators wanted to acknowledge the fact that they wanted to continue the program past 2009, but did not want to hassle with having to find the monies to pay for it.
Two other changes were made to the payment system. First, the Geographic Cost of Practice Index floor of 1.00 was extended for the same 6-month period the conversion factor raise is in effect. Second, the 5% bonus for physician scarcity areas was also extended for the same time period. No changes were made to the relative values.
We would like to emphasize that the PQRI program has been funded through 2009 and has been targeted for continuation well beyond. The message sent by Congress with this inclusion is clear: Quality is still an issue. We highly recommend that you participate and receive that bonus. It may be a hassle and may cost you more than the bonus you’re going to be paid, but we do think it’s important to play the game. If you don’t, we’re concerned that the political fallout will be more costly in the long term.
New modifier definitions
Recent changes to the definitions of CPT modifiers deserve some additional comment. The definition of modifier –22 was changed. Previously the modifier title was “unusual procedural services,” used only if there were “unusual” anatomic circumstances beyond your control causing significant extra work during aprocedure. The new definition is “increased procedural services.” CPT states that if there is substantially greater work—increased intensity, time, severity of patient’s condition, or technical difficulties—than typically required, you can use the –22 modifier. Supporting documentation must be submitted with the claim.
A new modifier was added. Modifier –92, alternative laboratory platform testing, is applied when a kit or transportable instrument is used at the patient’s site to check laboratory tests. Apparently, it is specific for HIV testing codes 86701-86703, but the definition is such that it could be expanded to other procedures in the future.
Numerous other modifiers were changed to emphasize that any “qualified provider” could use them by removing the word “physician” from its definition.
OIG plan for 2008
On an annual basis, the Office of the Inspector General (OIG) conducts a comprehensive work-planning process to identify the areas most worthy of attention in the coming year. It allocates about 80% of its resources to work related to the Centers for Medicare & Medicaid Services. We have identified 10 issues from the OIG report that we consider areas of concern related to urology in 2008: place of service errors, evaluation and management services during global surgery periods, Medicare payments for selected physician services, Medicare “incident to” services, facility services, assignment rules by Medicare providers, business relationships and the use of MRI, geographic areas with high utilization of ultrasound services, geographic areas with a high density of independent diagnostic testing facilities, and physician reassignment of benefits.
The annual targets of E&M service level, consultations, and the appropriate use of modifiers have appeared in past years, but have been moved to ongoing status and removed from the specific yearly target list.
The OIG is concerned with fraud, not mistakes. We all know that we are paid a much higher fee to provide services in our office than in the hospital. If you make a mistake on a claim and list office on a service performed in a hospital, you will not hear from the OIG. If you bill it that way routinely to increase income, you may receive a non-friendly visit from the OIG. You do not want a visit from the OIG. It can change the color of your uniform.
Urologist Ray Painter, MD, is president of Physician Reimbursement Systems, Inc., in Denver and is also publisher of Urology Coding and Reimbursement Sourcebook
Mark Painter is CEO of PRS Urology SC in Denver.
Disclaimer:
The information in this column is designed to be authoritative, and every effort has been made to ensure its accuracy at the time it was written. However, readers are encouraged to check with their individual carrier or private payers for updates and to confirm that this information conforms to
