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CMS Previews 2012 MPFS Final Rule, Moves Closer to Pay for Performance

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  • November 2, 2011
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The Centers for Medicare & Medicaid Services (CMS) released, Nov. 1, a sneak peek at the final rule with comment period that will update payment policies and rates for physicians and nonphysician practitioners (NPPs) for services paid under the Medicare Physician Fee Schedule (MPFS) in 2012.
For the 11th consecutive year, physicians face deep, across-the-board cuts in Medicare reimbursement—a 27.4 percent reduction, instead of the proposed 29.5 percent—unless Congress acts to change the law before yearend, according to a CMS press release. The Obama administration says it opposes the impending rate reductions, which are based on a Sustainable Growth Rate (SGR) formula adopted in the Balanced Budget Act of 1997, and favors “a permanent and sustainable fix” for the issue. In every year except 2002, Congress has acted to prevent cuts mandated by the SGR.

Per the requirements of the Affordable Care Act, the final rule will finalize quality and cost measures that will be used to establish a new value-based modifier “that would adjust physician payments based on whether they are providing higher quality and more efficient care.” CMS must begin making payment adjustments to certain physicians and physician groups on Jan. 1, 2015. The adjustments would apply to all physicians by Jan. 1, 2017.
Additional highlights of the MPFS final rule include:

  • Application of the multiple procedure payment reduction policy to the professional interpretation of advance imaging services. Expect reduced payment for all but the initial service when the same physician or group practice furnishes multiple imaging services to the same patient on the same day.
  • Updates to several physician incentive programs, including the Physician Quality Reporting System (PQRS), the e-Prescribing Incentive Program, and the Electronic Health Records (EHRs) Incentive Program.
  • An expansion of services that may be furnished via telehealth, to include smoking cessation services.
  • Adoption of criteria for a health risk assessment (HRA) to be used with annual wellness visits (AWVs). According to CMS, “The HRA is intended to support a systematic approach to patient wellness and to provide the basis for a personalized prevention plan.” Payment for the AWV will increase “modestly” to reflect the additional office staff time required to administer the HRA.
  • A greater emphasis on the “potentially misvalued code” initiative: CMS will focus “on the codes billed by physicians in each specialty that result in the highest Medicare expenditures under the MPFS to determine whether these codes are overvalued.”

The final rule with comment period will appear in the Nov. 28, 2011 Federal Register.

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