More PQRS requirements in Medicare final rule


In this article, we discuss the impact of and reactions to the 2014 Medicare physician fee schedule final rule.

The 2014 Medicare physician fee schedule final rule was released just before this past Thanksgiving, almost 3 weeks after the usual release. It contains a mix of good news and bad, both for urologists and physicians in general.

The delayed release, caused by the government shutdown, did not change the reach of the final rule, which addressed a number of issues. The rule itself is a continuation of policy moves that affect not only 2014 payments but also payments under the Medicare program for the next several years.

In last month’s column, we speculated on what the rule would contain and provided a number of suggestions for your practice in relation to the Affordable Care Act. At press time, Congress had approved a temporary 3-month patch for physician payment in 2014. Several proposals were still in the works for a permanent, long-term fix of the sustainable growth rate, so we remain hopeful that the conversion factor for Medicare fees will be adjusted upward in the near future.

In this article, we will discuss the impact of and reactions to the 2014 final rule.

Changes to PQRS

Medicare finalized a number of issues surrounding the Physician Quality Reporting System (PQRS) and the effects of the program. In summary, the number of measures that you will need to successfully report has gone from three measures with one national quality strategy (NQS) measure to nine measures, including three NQS measures. Medicare stated that the program has now been in place for 6 years and that physicians should be capable of successfully reporting more measures.

Successfully reporting any one measure still requires that the measure be completed for 50% of patients eligible for the measure. For 2014, successful reporting will earn you a bonus of 0.5% of all Medicare-allowed amounts for services provided to traditional Medicare patients in 2014 and will exempt each successful provider from a 1.5% cut in Medicare payments for 2016. Medicare has indicated that it will make adjustments to the number of measures required for a single national provider identifier if the physician or non-physician provider does not see enough patients who meet the denominator for at least nine measures.

If you are reporting under the Group Practice Reporting Option, you will also collect patient feedback as a part of PQRS for 2014. The Clinician and Group Consumer Assessment of Health Care Providers and Systems (CG-CAHPS) has already been in place for 1 year for groups of more than 100 providers. The CG-CAHPS is a survey process through a certified vendor that may address many aspects of the practice but includes the following issues:

  • getting timely care, appointments, and information

  • how well providers communicate

  • patients’ rating of provider

  • access to specialists

  • health promotion and education

  • shared decision making

  • health status/functional status

  • courteous and helpful office staff

  • care coordination

  • between-visit communication

  • helping your patients to take medication as directed

  • stewardship of patient resources.

Results of these surveys will be presented by the Centers for Medicare & Medicaid Services to the public on the Physician Compare website ( after a 30-day review period, for each group, beginning this year. CMS intends to expand the reporting process to groups of 10 or more reporting the measure for 2014, making the data public in 2015. The final rule indicates this process is directed by the ACA, so the data collection and expanded reporting to all practices are expected by 2017.


Use care with claims-based reporting

Be aware that Medicare would like to see claims-based reporting replaced by other reporting methods; as such, the final rule has removed claims-based reporting for some measures. When selecting your measures, check carefully that Medicare accepts the method of reporting.

You have five options to report PQRS measures:

  • claims-based reporting

  • direct EHR-based reporting

  • EHR reporting through a qualified registry

  • data registry-based reporting

  • clinical data registry reporting.

Clinical data registry reporting is a new option this year and will likely be the preferred choice in the future, as this option provides access to data at a clinical level and further expands the data being included beyond Medicare patients.

Choose your best option for reporting for 2014 and begin reporting or at least collecting required information as soon as possible. Success for EHR and data registry reporting is higher than for claims-based reporting, and it is recommended that you move away from claims-based reporting of PQRS measures, which appear to be an integral part of Medicare payments for the foreseeable future.

Data collected regarding meaningful use, PQRS, e-prescribing, and, as mentioned above, CG-CAHPS, are intended to be released to the public through the CMS website. Every physician in the Provider Enrollment, Chain, and Ownership System is included in the Physician Compare website to help patients select the best doctor. The website is up and running. You can enter your provider name into the search and find the listed address and a notation indicating that you have been successful in reporting for meaningful use, PQRS, and e-prescribing programs.

As noted, CMS plans to add the CG-CAHPS data in 2014. The final rule also indicates that CMS is trying to deliver detail on the individual measures reported successfully for each provider in the same website.

We expect that the addition of data to the site will be followed by awareness campaigns to drive Medicare patients to shop for doctors based on these data points.

Value-based payment modifications

PQRS reporting does not only affect PQRS incentives and cuts but will also affect your value-based modifier payments in the future. Value-based modifications for payment will be phased in over a 3-year period.

Groups of 100 or more will see value-based payment modifications in 2015. Groups of 10 or more will see value-based modifications based on reporting of PQRS and comparative claims data in 2016. Although CMS has stated in one place that groups from 10 to 99 will not be subject to negative adjustments in 2016, in another place it was suggested that an automatic negative value-based adjustment for any group above 10 will be initiated if PQRS is not successfully reported (table 1).

In the spirit of “better safe than sorry,” we would encourage all urology practices to report PQRS in 2014. As reimbursements are not expected to increase in an appreciable manner, each of these cuts, although small, will add up in an environment that can ill afford a decrease.

Biopsy coding changes

We addressed CPT coding changes in our last article. There were no additional CPT code changes; however, CMS snuck a small change to Healthcare Common Procedure Coding System (HCPCS) codes that will impact urology.

HCPCS codes G0416, G0417, G0418, and G0419 have been changed to indicate the samples can be collected by any method. CMS has indicated that it will now require these codes for specimens over nine collected not only through transperineal biopsy but also via transrectal biopsy.

The codes now read: G0416 (Surgical pathology, gross and microscopic examination for prostate needle biopsies, any method; 10-20 specimens), G0417 (Surgical pathology, gross and microscopic examination for prostate needle biopsies, any method; 21-40 specimens), G0418 (Surgical pathology, gross and microscopic examination for prostate needle biopsies, any method; 41-60 specimens), and G0419 (Surgical pathology, gross and microscopic examination for prostate needle biopsies, any method; greater than 60 specimens).

According to the Federal Register, these changes were scheduled to be adopted by Medicare on Jan. 1, 2014. You will have to monitor private payers for their intentions with these codes. (See table 2 for a look at RVUs for a 12-specimen biopsy without geographic adjustment.)

We dodged a bullet (at least temporarily) this year, as CMS has decided to delay implementation of a proposal to level payments in the office with those provided in an outpatient setting or an ambulatory surgical center. These proposals and the impacts for urology outlined in the proposed rule released in June 2013 would have had a substantial impact on several in-office services provided by urologists.

Without going into detail, it appears CMS has agreed to study the proposal further based on feedback from several groups, including the AUA, that opposed the change. We expect this proposal to be re-introduced in 2014 to impact 2015 payments.


Changes in RVUs for urology codes

That being said, the RVUs for several codes that are routinely used by urologists were negatively affected by process adjustments. In the end, urology was projected to be down by 1% by CMS. The AUA projections place the overall change at around –4%.

Here are the in-office code/payment changes to watch for:

  • Urodynamics codes have once again been affected by changes in the RVU process. The majority of codes in this section have decreased by 7% to 8% for the total, with the majority of the decrease affecting the technical component (TC) of each code.

  • Cryotherapy of the prostate, cystoscopy with stent, ureteral stent insertion, cryosurgery of a penile lesion, and insertion of a temporary prostatic stent have also deceased for the office setting by 8% to 10%.

  • Codes for limited pelvic, complete pelvic, limited abdominal, and scrotum ultrasound and the prostate volume for brachytherapy code have all been significantly decreased due to changes in the equipment and usage assigned to each code.

  • The biggest decrease in the office setting is slated for code 76942 (ultrasound guidance for needle placement). The TC was decreased by 78%, resulting in a 66% decrease to the global value for this service.

  • Code 88305 (Level IV-Surgical pathology, gross and microscopic examination [of the defined specimens listed]) also suffered a decrease in RVU for the technical component of 8%.

  • The only codes to be increased by an amount worth noting for urology in the office setting were 51710 (change of cystostomy tube, complicated), up 31%, and 76872 (diagnostic transrectal ultrasound), up 21% for the global value.

No codes for the hospital setting were increased in an amount worth noting. Five codes were decreased in value for the facility setting: 50125 (explore and drain kidney): –8%; 50360 (transplantation of kidney): –10%; 50782 (reimplant ureter in bladder): –16%; 53025 (incision of urethra): –12%; and 54380 (repair penis): –15%.

Remember that these changes in value will affect contracts that are updated to the 2014 resource-based relative value scale for private payers, your Medicare, Medicare Advantage plans, and most of your Medicaid and Department of Defense plans.

Medicare Advantage payment decreasing

Medicare Advantage plans are receiving a decrease in payment from Medicare. You will need to carefully monitor your Medicare Advantage contracts for decreases as well.

We are left to conclude only that it could have been worse. The downward trend in fee for service continues, as does the increase in oversight and reporting that are required for participation in Medicare. You will need to look at your practice to determine what processes you will need to implement. Office efficiency should clearly be a focus for each practice as margins continue to shrink on the reimbursement side. Additionally, data collection and monitoring and competition based on quality are quickly becoming a focus for all parts of the marketplace. Clinical data, combined with revenue and cost data, will be essential as alternative payment models are explored by all payers.

Amidst the doom and gloom that seem to be raining down, remember that you provide an essential service and that your relationship and interaction with the patient does count.UT

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