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Compliance Newsletter: Q1 2013

Compliance Newsletter: Q1 2013

Zero Percent – 2013 Medicare Physician Fee Schedules (MPFS)

(Effective for dates of service 01/01/2013 and after)

On January 1, 2013, Congress passed the American Taxpayer Relief Act of 2012. This bill extends the current zero percent (0%) update for the MPFS through the end of 2013. The Pricing files below are a complete replacement of the previously posted files and reflect the new provisions in the law. Please note that the MPFSDB Conversion Factor and several Relative Value Units were also updated for 2013. This means that although the update is 0%, the 2013 rates will not necessarily match 2012 allowances. The changes in RVU’s for the ED E&M codes are minimal. More info»

Medicaid Parity Final Ruling

 The Medicaid parity final rule that temporarily hikes Medicaid payment rates to Medicare levels for the primary care services they provide. Nationally, Medicaid’s average payment rate for physician services is just two-thirds of what Medicare pays.

Thee final rule, which the Centers for Medicare & Medicaid Services released Nov. 1, sets Medicaid payments for “primary care” services provided by primary care physicians at 100% of Medicare rates for calendar years 2013 and 2014. States will receive an additional $11 billion from the federal government during this period to administer the enhanced pay rates. The Affordable Care Act authorized the temporary pay parity provision.

In order for physicians to qualify under the ruling, must have the following primary designation status (Emergency Medicine and OB/GYN were not considered as Primary Care):

  • Practicing physicians who self-attest that they are board certified with a specialty designation of family medicine, general internal medicine and pediatric medicine, or ;
  • Subspecialists related to those specialty categories as recognized by the American Board of Medical Specialties, American Osteopathic Association, or the American Board of Physician Specialties who also self-attest that they are board certified, or ;
  • Physicians related to the specialty categories of family medicine, internal medicine and pediatrics who self-attest that at least 60 percent of all Medicaid services they bill or provide in

PQRS (Physician Quality Reporting System)

Alert: Beginning in 2015, the program also applies a negative payment adjustment to eligible professionals who do not satisfactorily report data on quality measures for covered professional services.

The Physician Quality Reporting System (Physician Quality Reporting System or PQRS) is a reporting program that uses a combination of incentive payments and payment adjustments to promote reporting of quality information by eligible professionals. The program provides an incentive payment to practices with eligible professionals (identified on claims by their individual National Provider Identifier [NPI] and Tax Identification Number [TIN]) who satisfactorily report data on quality measures for covered Physician Fee Schedule (PFS) services furnished to Medicare Part B Fee-for-Service (FFS) beneficiaries (including Railroad Retirement Board and Medicare Secondary Payer).

Beginning in 2015, the program also applies a payment adjustment to eligible professionals who do not satisfactorily report data on quality measures for covered professional services. The PQRS payment adjustment applies to all of the eligible professional’s onal’s Part B covered professional services under the Medicare Physician Fee Schedule (PFS). Accordingly, eligible professionals receiving a payment adjustment in 2015 will be paid 1.5% less than the MPFS amount for that service. For 2016 and subsequent years, the payment adjustment is -2.0%.

To avoid the 2015 PQRS payment adjustment, individual eligible professionals and CMS- selected group practices participating in the PQRS Group Practice Reporting Option (GPRO) will have to satisfactorily report data on quality measures for covered professionals services provided in 2013. This will require the group to sign up on a CMS web site. The sign up has to occur between July 15 and Oct. 15, 2013. Your Client Services Directors will have more on this at the appropriate time.

(MOC) Maintenance of Certification PQRS Program Incentive Requirements for 2013


CMS is continuing the Maintenance of Certification Program Incentive that began in January 2011. Eligible professionals (Board Certified by ABEM) (not AOBEM) who were incentive eligible for the Physician Quality Reporting System, or “Physician Quality Reporting”, (formerly known as the Physician Quality Reporting Initiative, or PQRI) could receive an additional 0.5% incentive payment when Maintenance of Certification Program Incentive requirements are also being met.


In order to qualify for the additional 0.5% incentive payment for the 2013 Physician Quality Reporting System based the physician will need to complete the following by 12-31-2012:

  • Satisfactorily submit data, without regard to method, on quality measures under Physician Quality Reporting, for a 12-month reporting period either as an individual physician or as a member of a group practice. This is automatically being done by MedData.
  • Successfully complete an LLSA in calendar 2012.
  • Complete and report to ABEM a Practice Improvement (PI) activity.
  • Complete and report a communication/professionalism (CP) activity.

This does count toward the MOC that is required by ABEM. It is more than ABEM requires.

The Maintenance of Certification Program will need to submit to CMS, by the eligible professional which can be easily done on the ABEM website. Once you complete the process on-line they take the reporting responsibility. It does cost $25.

CMS is allowing a window for those who completed their PI and/or CP in 2012 but did not report. The extension for reporting is until March 8, 2013.

If you did not accomplish the above requirements in 2012, then you will have the same opportunity in 2013 to qualify for 2014.

ABEM was one of only 9 specialty boards that made this available to its members.

2013 PQRS Measures Updates

Emergency Medicine: The following measures were retired in 2013 *effective January 1st:

  • (Measure #57): Emergency Medicine: Community-Acquired Pneumonia (CAP): Assessment of Oxygen Saturation
  • (Measure #58): Emergency Medicine: Community-Acquired Pneumonia (CAP): Assessment of Mental Status
  • (Measure #92): Acute Otitis Externa (AOE): Pain Assessment

The following measures will continue to be reported by MedData:

  • (Measure #28): Aspirin at Arrival for Acute Myocardial Infarction (AMI)
  • (Measure #54): Emergency Medicine: 12-Lead Electrocardiogram (ECG) Performed for Non Traumatic Chest Pain
  • (Measure #55): Emergency Medicine: 12-Lead Electrocardiogram (ECG) Performed for Syncope (Measure #56): Emergency Medicine: Community-Acquired Pneumonia (CAP): Vital Sign
  • (Measure #59): Emergency Medicine: Community-Acquired Pneumonia (CAP): Empiric Antibiotic
  • (Measure #91): Acute Otitis Externa (AOE): Topical Therapy
  • (Measure #93): Acute Otitis Externa (AOE): Systemic Antimicrobial Therapy

Hospitalist: There were no changes to Hospitalist PQRS measures in 2013

Wound Care: Measure #186 (Chronic use of Compression System in Patients with Venous Ulcers) was retired in 2013 *effective January 1st.

2013 OIG (Office of Inspector General) Work plan for Part B Physician Services

Electrodiagnostic Testing—Questionable Billing (New)

The OIG will review Medicare claims data to identify questionable billing for electrodiagnostic testing. The OIG We will also determine the extent, to which Medicare utilization rates differ by provider specialty, diagnosis, and geographic area for these services.

Part B Imaging Services—Payments for Practice Expenses

The OIG We will review Medicare payments for Part B imaging services to determine whether they reflect the expenses incurred and whether the utilization rates reflect industry practices.

Diagnostic Radiology—Medical Necessity of High-Cost Tests

The OIG will review Medicare payments for high-cost diagnostic radiology tests (CT & MRI) to determine whether they were medically necessary and the extent to which the same diagnostic tests are ordered for a beneficiary by primary care physicians and physician specialists for the same treatment. Medicare will not pay for items or services that are not “reasonable and necessary.”

Evaluation and Management Services—Use of Modifiers During the Global Surgery Period

The OIG will review the appropriateness of the use of certain claims modifier codes during the global surgery period and determine whether Medicare payments for claims with modifiers used during such a period were in accordance with Medicare requirements.

Claims Processing Errors—Medicare Payments for Part B Claims With G Modifiers (New)

The OIG will determine the extent to which Medicare improperly paid claims from 2002 to 2011 in which providers entered GA, GX, GY, or GZ service code modifiers, indicating that Medicare denial was expected. Providers may use GA or GZ modifiers on claims they expect Medicare to deny as not reasonable and necessary pursuant to CMS’s Claims Processing Manual.

More info»

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