Cms Plays Spoiltsport On Your Pay

Owing to the flawed Sustainable Growth Rate (SGR) formula to calculate Medicare fees

, Medicare payments to doctors are also due to fall, and medical practices will face a perfect storm of payment nightmares.

Practices are not sure what will transpire on January 1, 2011. Some newly-elected Senators and House members will be in place in the new year, and it's not clear whether the present Congress will make changes affecting 2011 pay prior to January or whether they'll leave these issues for the new Congress to solve.

Some specialties will face additional cuts apart from dealing with conversion factor fluctuations.While the most affected practices will be those that specialize in radiology, the cuts will most certainly have a significant impact on specialty practices that are already financially stretched.

The Fee Schedule also incorporates several provisions of the Affordable Care Act of 2010 that was passed last March. Firstly, you will see that coverage has been established for annual wellness visits for Medicare patients. The rule that was issued on November is a major step toward improving the health status of Medicare beneficiaries by providing coverage for an annual wellness visit that will allow a physician and patient to forge closer ties to improve the patient's long term health.

"If you carry out a procedure that meets CMS's description of an annual wellness visit, you shouldn't report a code from CPT's preventive medicine section to your Medicare carrier," indicates the Final Rule.

CMS doesn't make payments for preventive medicine services billed under 99381-99397. Instead, you should report one of the following newly-established HCPCS codes:

G0438 -- Annual wellness visit; includes a personalized prevention plan of service (PPPS), first visit

G0439 -- subsequent visit.

Even though most of these wellness examinations are normally carried out by the patient's internist or family physician, occasionally a urologist will carry out this service. If so, think about the above codes and information to help you bill properly and be paid for this service.

CMS has assigned 2.43 physician work RVUs to G0438 and 1.50 RVUs to G0439, and these codes will be effective on January 1, 2011. Beneficiaries who have been enrolled in Part B for a year will be eligible for an initial preventive physical exam, (also known as an IPPE, which is billed with G0402).

Post the first 12 months of Part B coverage on or after January 1, 2011, beneficiaries would be eligible for an initial preventive physical exam. After the first 12 months of Part B coverage on or after January 1, 2011, beneficiaries would be eligible for an annual wellness visit as described by the new G codes, thinking that the patient has had an IPPE within the preceding 12 month period, states the Fee Schedule.

by: James Article

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