Nov 09 2010

CMS Releases its CY 2011 PFS Final Rule

CMS has released its CY 2011 Medicare Physician Fee Schedule (PFS) Final Rule.  As described by CMS, notable provisions of the Final Rule relate to:

  • Waiver of the Part B deductible and coinsurance for most preventive services (including preventive services recommended by the U.S. Preventive Services Task Force).
  • Coverage of annual wellness visits in which beneficiaries receive prevention plan services.
  • Incentive payments for certain primary care practitioners who provide a certain amount of primary care.  To make it easier for rural practitioners to qualify for the incentives, CMS will not consider charges for inpatient care and emergency department visits in calculating whether the practitioner met the primary care threshold of sixty percent.  CMS will generally identify eligible practitioners for CY 2011 using claims data and the physician’s specialty designation from 2009, but will use 2010 claims data for newly enrolled practitioners.  
  • An incentive payment for major surgical procedures performed by in health professional shortage areas.  General surgeons will be eligible for the incentive payments.
  • Permission for physician assistants to perform the level of care certification required for coverage under Medicare’s skilled nursing facility benefit.
  • An increase in the payment for certified nurse-midwife services to 100% of the PFS amount.
  • The reinstatement of reasonable cost payment for certain clinical diagnostic laboratory tests provided by hospitals with fewer than 50 beds and which are located in certain rural areas.
  • Amendments to the in-office ancillary services exception to the Stark laws.  With respect to magnetic resonance imaging, computed tomography and positron emission tomography, physicians will have to disclose to a patient in writing at the time of referral that they may obtain such services from another supplier.  The physician will have to provide the patient a list of five alternative suppliers within a 25-mile radius of the physician’s office.
  • The expansion of round two of the DMEPOS competitive bidding program to 91 metropolitan statistical areas.
  • The identification of additional categories of codes that may be misvalued under the PFS.
  • A 25% reduction for the practice expense component of the second and subsequent outpatient therapy service provided by a given provider to a beneficiary on the same date of service.  The policy will apply to all Part B outpatient therapy services.
  • An adjustment to the equipment utilization factor for expensive diagnostic imaging equipment and an increase in the multiple procedure payment reduction for the technical component of certain single-session imaging services.
  • A reduction in the maximum period for submitting Medicare claims to not more than 12 months after the date of service and a requirement to file claims for services performed prior to January 1, 2010 no later than December 31, 2010.  Exceptions to these filing requirements are made for retroactive entitlement situations, dual-eligible beneficiary situations and retroactive disenrollment from Medicare Advantage plans or PACE provider organizations.

You can review the entire Final Rule here or CMS’s summary here.  The Final Rule is effective January 1, 2011.