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January 2011 Client Newsletter

HAPPY HOLIDAYS, Medicare fee schedule, and Red Flags rule

We hope you enjoyed the holidays!

Congress & President Obama did provide 2 nice “gifts” for the new year:
1) Medicare Fee Schedule changes that were to end on 11/30 have been extended thru 12/31/11, and
2) Physicians and other healthcare providers (including ambulance) were exempted from the Red Flags Rule.

As you know, Medicare payment rates under the Medicare Physician Fee Schedule (MPFS) are set according to statutory criteria. Even though the SGR rate will remain stable thru 12/31/11, there are other factors (e.g., RVU updates) that can change the amount paid for individual CPT codes. Once the new rates are published, we will know better how payments will be affected in 2011.

Medicare 2011 Preventive services

Medicare implemented a new Annual Wellness Visit (AWV) service which does NOT require a deductible or co-insurance for the patient. The current Initial Preventive Physical Exam (IPPE) which is available within the first 6 months of Medicare eligibility has a 2010 Allowed Amount of $146.88. The Allowed Amounts for all 2011 codes, including the new AWV, are being recalculated by Medicare based on the 0% change in the SGR and should be re-published any day now (still not available 1/3/11).

Another preventive service that will not have a deductible or co-insurance is Counseling to Prevent Tobacco Use (includes counseling to stop smoking) (codes G0436 & G0437). CMS allows 2 separate attempts and up to 4 visits each attempt per year.

Medicare EMs changes

As you already know from an email from me in November, beginning January 1, 2011 CMS will require ambulance services to track and report mileage to the nearest tenth of a load mile for all trips up to 100 load miles. CMS stated that ambulance services which do not currently have the ability to track tenths of miles must acquire that ability. CMS says this policy change could "save" Medicare - up to $80 million per year.
Additionally, the Rule will decrease annual reimbursement updates by a so-called "productivity adjustment." Beginning in 2011, the Ambulance Fee Schedule will be subject to this adjustment and is expected to reduce Medicare reimbursement to the ambulance industry by around $30 million in the first year that it takes effect.

The Final Rule also talks about CMS's intention to develop a "course of action" to implement the retroactive 2% urban, 3% rural, and 22.6% super rural bonus payments. Ambulance services have being waiting for months for CMS to reprocess these claims.

The Ambulance Inflation Factor (AIF) for 2011 is -0.1%. The AIF in 2010 was 0.0%.

Physical / occupational therapy Medicare fee cut

Just a reminder and as a follow-up to the email last month with a copy of the Medicare MLN Matters article, effective 1/1/11 Medicare will be decreasing their payment when:
· The same patient is seen the same day by more than 1 therapist in the same practice (e.g., PT & OT), or
· A patient receives more than 1 service or unit of service, or both, on the same day.

The modality with the highest RVU’s will be paid in full for the first unit, with all additional units and services paid at the lower rate to reflect the 20% reduction in the Practice Expense portion of the service(s).

Medicare 2011 ePRESCRIPTION (eRx) & PQRI

We have reviewed the 2011 CMS eRx requirements – the same code will be used in 2011.

If you plan to do PQRI in 2011, be sure to check with Rich for 2011 PQRI requirements. They do change each year and the current year’s codes MUST be used in order to get paid.

Just a reminder that CMB will assist you with selection at no cost. The time to negotiate fees, including future options that you may or may not want, is before signing the purchase agreement.


As you know, CMS backed off their 1/1/11 date to implement their requirement for all ordering and/or referring providers to be in the PECOS system due to the significant current backlog in processing provider enrollment applications. CMS announced in December 16th that the new “Placeholder” date for compliance is July 5, 2011.
2011 Client Newsletter Archive