Part B Insider (Multispecialty) Coding Alert

Published on Fri Nov 18, 2005 PDF

Not much money, lots of extra work, in pay for performance

There's "lots of buzz," but not much action about pay for performance (P4P) schemes, in which your physician will receive more money for meeting quality standards, according to a new paper from the Center for Studying Health System Change.

Ten out of 12 nationally representative communities in the U.S. have no P4P programs right now, and physicians in those communities are anywhere from "skeptical" to "hostile" about P4P.

California health plans, led by the Integrated Healthcare Association and the California Association of Physician Groups, is paying $40 million in bonuses to physicians for improving their performance. Meanwhile, Boston health plans are paying providers to reduce costs, including prescribing more generic drugs or using fewer imaging tests.

Physicians only get interested in P4P when "they see real dollars at stake," the Center's study says. But even once you show them the money, physicians are concerned about quality measures adding to their documentation loads. Doctors see P4P moving existing dollars around instead of adding new dollars to the pot.

Most doctors aren't really aware of P4P yet, but many doctors fear P4P will mean "a little more money and a lot more work," the study notes. So far, P4P works much better for larger medical groups and not so well for the majority of practices in the country, which have fewer than five doctors each.

For P4P to work, it should be geared toward smaller practices, agrees a new paper from the American College of Physicians. You shouldn't be judged by clinical measures unless they're based on solid evidence and focused on improving quality, not just slashing costs. The 38-page report from the ACP lays out some principles for P4P plans.

• Your physician can't perform lung-volume reduction surgery at a facility unless it's approved as a lung-transplant facility or certified by the Joint Commission on Accreditation of Healthcare Organizations, according Transmittal 44, issued Dec. 2. Also, a facility could be approved as part of the National Emphysema Treatment Trial, CMS says.

• Transmittal 775, dated Dec. 2, revises the claims processing manual to reflect new codes for visits to a domiciliary, rest home or nursing home, 99234 -99337.

• Bone marrow and peripheral blood stem cell transplantation must include mobilization, harvesting and transplant of bone marrow or peripheral blood stem cells, CMS clarifies in Transmittal 43, dated Dec. 2. Also, the procedure must include high-dose chemotherapy or radiotherapy prior to transplant, or Medicare won't cover it.