DEPARTMENT OF HEALTH AND HUMAN SERVICES Centers for Medicare & Medicaid Services ...

1250 Pages·2010·3.98 MB·English

DEPARTMENT OF HEALTH AND HUMAN SERVICES
Centers for Medicare & Medicaid Services
42 CFR Parts 405, 409, 410, 411, 413, 414, 415, and 424
[CMS-1503-P]
RINs 0938-AP79
Medicare Program; Payment Policies Under the Physician Fee Schedule and Other
Revisions to Part B for CY 2011
AGENCY: Centers for Medicare & Medicaid Services (CMS), HHS.
ACTION: Proposed rule.
SUMMARY: This proposed rule addresses proposed changes to the physician fee
schedule and other Medicare Part B payment policies to ensure that our payment systems
are updated to reflect changes in medical practice and the relative value of services. It
also addresses, implements or discusses certain provisions of both the Affordable Care
Act and the Medicare Improvements for Patients and Providers Act of 2008. In addition,
this proposed rule discusses payments under the Ambulance Fee Schedule, Clinical
Laboratory Fee Schedule, payments to ESRD facilities, and payments for Part B drugs.
Finally, the proposed rule includes a discussion regarding the Chiropractic Services
Demonstration program, the Competitive Bidding Program for Durable Medical
Equipment and Provider and Supplier Enrollment Issues associated with Air
Ambulances. (See the Table of Contents for a listing of the specific issues addressed in
this proposed rule.)
DATES: To be assured consideration, comments must be received at one of the
addresses provided below, no later than 5 p.m. on [[OOFFRR——iinnsseerrtt ddaattee 6600 ddaayyss aafftteerr tthhee
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ADDRESSES: In commenting, please refer to file code CMS-1503-P. Because of staff
and resource limitations, we cannot accept comments by facsimile (FAX) transmission.
You may submit comments in one of four ways (please choose only one of the
ways listed):
1. Electronically. You may submit electronic comments on this regulation to
http://www.regulations.gov. Follow the instructions for "submitting a comment."
2. By regular mail. You may mail written comments to the following address
ONLY:
Centers for Medicare & Medicaid Services,
Department of Health and Human Services,
Attention: CMS-1503-P,
P.O. Box 8013,
Baltimore, MD 21244-8013.
Please allow sufficient time for mailed comments to be received before the close
of the comment period.
3. By express or overnight mail. You may send written comments to the
following address ONLY:
Centers for Medicare & Medicaid Services,
Department of Health and Human Services,
Attention: CMS-1503-P,
Mail Stop C4-26-05,
7500 Security Boulevard,
Baltimore, MD 21244-1850.
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4. By hand or courier. If you prefer, you may deliver (by hand or courier) your
written comments before the close of the comment period to either of the following
addresses:
a. For delivery in Washington, DC--
Centers for Medicare & Medicaid Services,
Department of Health and Human Services,
Room 445-G, Hubert H. Humphrey Building,
200 Independence Avenue, SW.,
Washington, DC 20201
(Because access to the interior of the Hubert H. Humphrey Building is not readily
available to persons without Federal government identification, commenters are
encouraged to leave their comments in the CMS drop slots located in the main lobby of
the building. A stamp-in clock is available for persons wishing to retain a proof of filing
by stamping in and retaining an extra copy of the comments being filed.)
b. For delivery in Baltimore, MD--
Centers for Medicare & Medicaid Services,
Department of Health and Human Services,
7500 Security Boulevard,
Baltimore, MD 21244-1850.
If you intend to deliver your comments to the Baltimore address, please call
telephone number [phone] in advance to schedule your arrival with one of our
staff members.
Comments mailed to the addresses indicated as appropriate for hand or courier
delivery may be delayed and received after the comment period.
FOR FURTHER INFORMATION CONTACT:
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Rebecca Cole, [phone], for issues related to physician payment and for all
other issues not identified below.
Cheryl Gilbreath, [phone], for issues related to payment for covered
outpatient drugs and biologicals.
Roechel Kujawa, [phone], for issues related to ambulance services.
Glenn McGuirk, [phone], for clinical laboratory issues.
Randall Ricktor, [phone], for Federally Qualified Health Center Issues.
Pauline Lapin, [phone], for issues related to the chiropractic services
demonstration BN issue.
Troy Barsky, [phone], or Kristin Bohl, [phone], for issues related to
physician self-referral.
Troy Barsky, [phone], or Fred Grabau [phone], for issues related to
timely filing rules.
Henry Richter, [phone], or Lisa Hubbard, [phone], for issues
related to renal dialysis provisions and payments for end-stage renal disease facilities.
Diane Stern, [phone], for issues related to the physician quality reporting
initiative and incentives for e-prescribing.
Sheila Roman, 410-786-6004, or Pamela Cheetham, 410-786-2259, for issues
related to the Physician Resource Use Feedback Program and value-based purchasing.
Joel Kaiser, [phone], for issues related to the DME provisions.
Jim Bossenmeyer, [phone], for issues related to provider and supplier
enrollment issues.
SUPPLEMENTARY INFORMATION:
Inspection of Public Comments: All comments received before the close of the comment
period are available for viewing by the public, including any personally identifiable or
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confidential business information that is included in a comment. We post all comments
received before the close of the comment period on the following Web site as soon as
possible after they have been received: http://www.regulations.gov. Follow the search
instructions on that Web site to view public comments.
Comments received timely will also be available for public inspection as they are
received, generally beginning approximately 3 weeks after publication of a document, at
the headquarters of the Centers for Medicare & Medicaid Services, 7500 Security
Boulevard, Baltimore, Maryland 21244, Monday through Friday of each week from 8:30
a.m. to 4 p.m. To schedule an appointment to view public comments, phone [phone]-
3951.
Table of Contents
To assist readers in referencing sections contained in this preamble, we are
providing a table of contents. Some of the issues discussed in this preamble affect the
payment policies, but do not require changes to the regulations in the Code of Federal
Regulations (CFR). Information on the regulation’s impact appears throughout the
preamble, and therefore, is not discussed exclusively in section V. of this proposed rule.
I. Background
A. Development of the Relative Value System
1. Work RVUs
2. Practice Expense Relative Value Units (PE RVUs)
3. Resource-Based Malpractice (MP) RVUs
4. Refinements to the RVUs
5. Adjustments to RVUs Are Budget Neutral
B. Components of the Fee Schedule Payment Amounts
C. Most Recent Changes to Fee Schedule
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II. Provisions of the Proposed Rule for the Physician Fee Schedule
A. Resource-Based Practice Expense (PE) Relative Value Units (RVUs)
1. Overview
2. Practice Expense Methodology
a. Direct Practice Expense
b. Indirect Practice Expense per Hour Data
c. Allocation of PE to Services
(i) Direct costs
(ii) Indirect costs
d. Facility and Nonfacility Costs
e. Services with Technical Components (TCs) and Professional Components
(PCs)
f. Alternative Data Sources and Public Comments on Final Rule for 2010
g. PE RVU Methodology
(i) Setup File
(ii) Calculate the Direct Cost PE RVUs
(iii) Create the Indirect Cost PE RVUs
(iv) Calculate the Final PE RVUs
(v) Setup File Information
(vi) Equipment cost per minute
3. Proposed PE Revisions for CY 2011
a. Equipment Utilization Rate
b. HCPCS Code-Specific PE Proposals
(1) Biohazard Bags
(2) PE Inputs for Professional Component (PC) Only and Technical
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Component (TC) Only Codes Summing to Global Only Codes
(3) Equipment Time Inputs for Certain Diagnostic Tests
(4) Cobalt-57 Flood Source
(5) Venom Immunotherapy
(6) Equipment Redundancy
(7) Equipment Duplication
(8) Establishing Overall Direct PE Supply Price Inputs Based on Unit Prices
and Quantities
c. AMA RUC Recommendations in CY 2010 for Changes to Direct PE Inputs
(1) Electrogastrography and Esophageal Function Test
(2) 64-Slice CT Scanner and Software
(3) Cystometrogram
(4) Breath Hydrogen Test
(5) Radiographic Fluoroscopic Room
d. Referral of Existing CPT Codes for AMA RUC Review
e. Updating Equipment and Supply Price Inputs for Existing Codes
B. Malpractice Relative Value Units (RVUs)
1. Background
2. Malpractice RVUs for New and Revised Services Effective Before the Next 5
Year Review
3. Revised Malpractice RVUs for Selected Disc Arthroplasty Services
C. Potentially Misvalued Codes Under the Physician Fee Schedule
1. Valuing Services Under the PFS
2. Identifying, Reviewing, and Validating the RVUs of Potentially Misvalued
Services under the PFS
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a. Background
b. Progress in Identifying and Reviewing Potentially Misvalued Codes
c. Validating RVUs of Potentially Misvalued Codes
3. CY 2011 Identification and Review of Potentially Misvalued Services
a. Codes on the Multis-Specialty Points of Comparison List
b. Codes with Low Work RVUs Commonly Billed in Multiple Units Per
Single Encounter
c. Codes with High Volume and Low Work RVUs
d. Codes with Site-of-Service-Anomalies
e. Codes with “23-hour” Stays
4. Expanding the Multiple Procedure Payment Reduction (MPPR) Policy to
Additional Nonsurgical Services
a. Background
b. Proposed CY 2011 Expansion of the Imaging Technical Component
MPPR Policy to Additional Combinations of Imaging Services
c. Proposed CY 2011 Expansion of the MPPR Policy to Therapy Services
5. High Cost Supplies
a. Background
b. Future Updates to the Prices of High-Cost Supplies
D. Geographic Practice Cost Indices (GPCIs)
1. Background
2. GPCI Update
a. Physician Work GPCIs
b. Practice Expense GPCIs
1) The Affordable Care Act Requirements for PE GPCIs
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2) Summary of CY 2011 Proposed PE GPCIs
c. Malpractice GPCIs
d. General GPCI Update Process
3. Payment Localities
E. Physician Fee Schedule Update for CY 2011
1. Rebasing the Medicare Economic Index (MEI)
a. Background
b. Use of More Current Data
c. Rebasing and Revising Expense Categories in the MEI
(1) Developing the Weights for Use in the MEI
(2) Physician’s Own Time
(3) Physician’s Practice Expenses
(A) Non-physician Employee Compensation
(B) Office Expenses
(C) Professional Liability Insurance (PLI) Expense
(D) Medical Equipment Expenses
(E) Medical Supplies Expenses
(F) All Other Professional Expenses
d. Selection of Price Proxies for Use in the MEI
(1) Expense Categories in the MEI
(A) Physician’s Own Time (Physician Compensation)
(B) Nonphysician Employee Compensation
(C) Utilities
(D) Chemicals
(E) Paper
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(F) Rubber and Plastics
(G) Telephone
(H) Postage
(I) All Other Labor-Intensive Services
(J) Fixed Capital
(K) Moveable Capital
(L) Professional Liability Insurance
(M) Medical Equipment
(N) Other Professional Expenses
(2) Productivity Adjustment to the MEI
e. Results of Rebasing
f. Adjustments to the RVU Shares to Match the Proposed Rebased MEI
Weights
III. Code-Specific Issues for the PFS
A. Therapy Services
1. Outpatient Therapy Caps for CY 2011
2. Alternatives to Therapy Caps
a. Background
b. Current Activities
c. Potential Short-Term Approaches to Therapy Caps
B. Diabetes Self-Management Training (DSMT) Services (HCPCS Codes G0108
and G0109)
1. Background
2. Proposed Payment for DSMT Services
C. End-State Renal Disease Related Services for Home Dialysis (CPT code 90963,