Pediatric Coding Alert

Plus: Chronic care management pay may be coming your way next year.

Although the proposed 2015 Medicare Physician Fee Schedule didn’t include an overhaul to the payment formula as many physicians had hoped, it did offer some positive news in other areas—as well as surprises that could help pediatricians’ bottom lines.

No Negative Conversion Factor—Yet

On July 11, CMS published its Proposed Medicare Physician Fee Schedule for 2015. The 609-page document is applicable to your pediatric practice because most private payers base their fees on Medicare payment amounts.

When it comes to the conversion factor, the proposed fee schedule had some optimistic news. Because the Protecting Access to Medicare Act won’t allow any cuts in the conversion factor through March 31, 2015, CMS is projecting a conversion factor of $35.7977 through that date. Even better, CMS calculated the figures in the proposed rule based on the assumption that the same conversion factor will be applicable throughout the year, the agency says on page 544 of the document. 

Of course, if Congress doesn’t step in, the conversion factor will be cut by approximately 20.9 percent. “We do not have a projection for the SGR for the last three quarters of 2015 yet,” said CMS’s Kathy Bryant during a July 13 call regarding the proposed fee schedule. Although previous estimates said the conversion factor would be about $28.3528, for the rest of the year, that could change, Bryant stressed.

Other specialties, such as ophthalmologists, may see cuts whether or not Congress votes to avert that deep discount, but pediatricians are slated to neither take a cut or get a payment boost. Pediatric payments are expected to remain the same in 2015 as it is this year.

Chronic Care Pay Could Offer Extra Reimbursement

There are some nuances in the proposal that could allow pediatricians to see new income opportunities, since CMS appears to be following through on its promise to offer separate payment for chronic care management (CCM) services starting in 2015. CMS is proposing a $41.92 payment rate for a CCM code that can be billed once a month for qualified patients. 

“This is for patients who have two or more chronic conditions,” Bryant said, who added that the supervision requirements could be more flexible for CCM than originally thought. “We are proposing that with respect to CCM, incident to services could be provided with general supervision rather than direct supervision if clinical staff were providing the service. In all other ways, the general incident to requirements would apply. This policy will also apply to CCM services that are non-face-to-face.”

This positive additional flexibility provides the opportunity to be paid for those time intensive non-face-to face clinical support services provided by nurses and other clinical staff, that are so important to providing a medical home for children with significant special health needs.

Farewell to Global Periods?

CMS also appears to be interested in severely cutting global periods from surgical procedures, although the proposal doesn’t suggest taking this step until 2017 at the earliest. “We are proposing to transform all 10- and 90-day global codes to 0-day global codes beginning in CY 2017,” CMS says in a fact sheet about the fee schedule proposal. “The OIG has identified a number of surgical procedures that include more visits in the global period than are being furnished.” 

Because CMS seems to believe that its programs are wasting cash by paying doctors for global periods that include visits the doctors don’t actually perform, the agency is proposing to include “all services provided on the day of surgery, and to pay separately for visits and services actually furnished after the day of the procedure beginning in CY 2017,” CMS says in its fact sheet.

This would mean that any postoperative services you perform would be billable on an a la carte basis, said CMS’s Ryan Howe during the July 11 call. For most physicians, this would be a welcome change—unless CMS decides to grossly undervalue the surgical codes once the agency removes the global periods from the value units. 

For example: Code 12031 (Repair, intermediate, wounds of scalp, axillae, trunk and/or extremities [excluding hands and feet]; 2.5 cm or less) currently has a 10-day global period, which means that if you stitch up a patient’s head wound on Aug. 1, you must include all postsurgical services for the next ten days into the fee you get for the code. However, if the global period proposal is finalized, you would get to bill for follow-up visits within that ten day period separately after 2017.

The global period proposal is part of CMS’s larger plan to identify and revise “potentially misvalued codes” over a multi-year effort. The proposed rule adds another 80 codes to the list of services for which CMS intends to adjust payment levels.

To read the 609-page proposed rule, visit https://s3.amazonaws.com/public-inspection.federalregister.gov/2014-15948.pdf, where you can also learn how to comment in advance of the Final Rule (the deadline for comments is Sept. 2).