PHYSICIAN FEE SCHEDULE SERVICES
The conversion factors under the Medicare Physician Fee Schedule for 1998 will change as follows:
These changes do not include changes in relative values. The actual increase or decrease for an individual physician or group of physicians will depend on the mix of services provided.
Geographic Practice Cost Index (GPCI) Changes
Physician Supervision of Diagnostic Tests
With the exception of certain procedures personally performed by independent qualified psychologists, clinical psychologists, qualified audiologists, and physical therapists who are certified as qualified electrophysiologic clinical specialists, all diagnostic tests payable under the physician fee schedule must be furnished under at least a general level of physician supervision. General supervision means the procedure is furnished under the physician' s overall direction and control, but the physician s presence is not required during the performance of the procedure. Under general supervision, the training of the non- physician personnel who actually perform the diagnostic procedure and the maintenance oft e necessary equipment and supplies are the continuing responsibility of the physician.
In addition, some tests also require either direct or personal supervision. Direct supervision in the office setting does not mean that the physician must be present in the room when the procedure is performed. However, the physician must be present in the office suite and immediately available to furnish assistance and direction throughout the performance of the procedure. Personal supervision means a physician must be in attendance in the room during the performance of the procedure. When direct or personal supervision is required, physician supervision at the specified level is required throughout the performance of the test.
This policy applies to technical components (TCs) (including TCs billed globally with the professional component (PC) of the procedure) and other diagnostic procedures which do not have relative value units reflecting physician work.
Independent Diagnostic Testing Facilities (IDTFs)
The operational aspects of this new type of facility are still under development. Entities wishing to be recognized as IDTFs must send a letter to the Part B carrier for their service area attesting that they meet all IDTF criteria set forth in federal regulations (42 CFR §410.33). As soon as a carrier determines that an entity qualifies as an IDTF, the carrier will notify the entity of its new status and billing number.
Increase in Work Relative Value Units for Global Surgical Services to Account for the 1997 Increases for Work Relative Value Units in Evaluation and Management Services
At that time, no adjustments were made to the work RVUs assigned to global sur ical services, which, in addition to the surgical procedure, include the related pre-service an post-service evaluation and management visits a surgeon provides within a defined period of time. Effective January 1, 1998, work RVUs for global surgical services will increase to make them consistent with the 1997 increases in the work RVUs for evaluation and management services.
Change in Billing for Caloric Vestibular Testing
NON-PHYSICIAN FEE SCHEDULES -1998 UPDATE FACTORS
Each year, the non-physician fee schedules are adjusted by a default formula set in the statute by Congress, unless other Congressional action is taken to modify the update factor. Under the default methodology, the 1998 updates are as follows.
Clinical Laboratory Services
Reasonable Charge Payment Changes
Durable Medical Equipment and Prosthetics and Orthotics
Change in or Screening Mammography
Change in Payment Methodology and Amounts for Physician Assistants, Nurse Practitioners, and clinical Nurse Specialists
BALANCED BUDGET ACT OF 1997 (BBA of 1997) PROVISIONS
Change in Coverage for Screening Mammography
Change in Coverage for Screening Pap Smear and Pelvic Examinations
Coverage of Colorectal Cancer Screening
Screening fecal-occult blood tests are covered at a frequency of once every 12 months for individuals who have attained age 50. A new code, GO 107, has been created to be used for screening fecal-occult blood tests. This code will be paid at the same amount as code 82270, diagnostic fecal-occult blood test, under the clinical laboratory fee schedule for your area.
A screening flexible sigmoidoscopy is covered at a frequency of once every 48 months for individuals who have attained age 50. A new code, GO 104, has been created for screening flexible sigmoidoscopy. This code will be paid at the same amount as code 45330, diagnostic flexible sigmoidoscopy, under the physician fee schedule in your area. If during the course of the screening flexible sigmoidoscopy a lesion or growth is detected which results in a biopsy or removal of the growth, the procedure code for a flexible sigmoidoscopy with biopsy or removal of lesion should be reported rather than code GO 104.
A screening colonoscopy is covered at a frequency of once eve 24 months for individuals at high risk for colorectal cancer. The law defines hi risk as a person w o, because of family history, prior experience of cancer or precursor neoplastic polyps, a history of chronic digestive disease condition (including inflammatory bowel disease, Crohn's disease, or ulcerative colitis), the presence of any appropriate gene markers for colorectal cancer, or other predisposing factors, faces a high risk for colorectal cancer. A new code, GO105, has been created for screening colonoscopy. This code will be paid at the same amount as code 45378, diagnostic colonoscopy, under the physician fee schedule in your area. If during the screening colonoscopy a lesion or growth is detected which results in a biopsy or removal of the growth, the procedure code for a colonoscopy with biopsy or removal of lesion should be reported rather than code GO 105.
A screening barium enema may be substituted for either a screening flexible sigmoidoscopy or a screening colonoscopy if an individual's physician has determined that the screening barium enema will be as effective as the screening flexible sigmoidoscopy or screening colonoscopy for that individual. Payment will not be made for both a screening barium enema and a screening flexible sigmoidoscopy for an individual who is not at risk for colorectal cancer during the same 48 month period, nor will payment be made for oth a screening barium enema and a screening colonoscopy for an individual who is at high risk for colorectal cancer during the same 24 month period. Two new codes, GO 106 (Colorectal cancer screening; alternative to GO 104, screening sigmoidoscoy, barium enema) and GO 120 (Colorectal cancer screening; alternative to GO 105, screening co onoscopy, barium enema), are to be used for barium enemas that are substituted for either the sigmoidoscopy or the colonoscopy , as indicated by the appropriate code nomenclature. Substitution of the barium enema for either t e screening sigmoidoscopy or screening colonoscopy must be ordered in writing by the beneficiary' s attending physician. Both GO 106 and GO 120 will be paid at the same amount as code 74280, diagnostic barium enema, under the physician fee schedule for your area.
Additionally, two other codes, GO 121 (Colorectal cancer screening; colonoscopy on individual not meeting criteria for high risk) and GO122 (Colorectal cancer screening; barium enema), are to be used when the high risk criteria are not met, or a barium enema is performed but not as a substitute for either a sigmoidoscopy or colonoscopy. Both of these codes are non-covered services.
Changes in the Diabetes Benefit
Private Contracts Between Beneficiaries and Physicians/Practitioners
At this time, HCFA is requiring that a physician or practitioner who has signed an agreement to participate in Medicare must terminate that agreement at the end of a calendar year before he or she may opt out of Medicare during the next calendar year. For example, a participating physician who signs or automatically rolls over a current year participation agreement during the 1998 enrollment period cannot exercise the private contracting option in 1998. HCFA is exploring whether it would e administratively possible to permit physicians and practitioners to exercise the private contracting option at times other than the annual participating physician enrollment period. In order to allow physicians and practitioners more time to consider this option, and in view of the many other changes that were enacted in the BBA of 1997, HCFA is extending the 1998 enrollment period for an additional month, until February 2, 1998. A decision concerning whether to allow physicians to exercise the private contract option at times other than the annual enrollment period, will be made before February 2, 1998.
Physicians and practitioners who reassign benefits to organizations that participate in Medicare (such as their employer, a facility whose services are provided or a health care delivery system) may not opt out because they are bound by the participation agreement signed by the organization that bills and is paid for their services. In order for the physician or practitioner to opt out of Medicare, either the organization must terminate its participation agreement or the physician or practitioner must terminate the reassignment of Medicare benefits to the organization.
With respect to non-covered services, a private contract is unnecessary and section 4507 does not apply. In other words, beneficiaries continue to be able to pay for any services that Medicare does not cover out of their own pockets, under the payment arrangement they make with their physician, without having to enter into a private contract subject to the provisions of section 4507. Examples of noncovered services include cosmetic surgery, hearing aids, routine physical exams, and certain screening preventive benefits more frequently than a specified number during a given period of time (e.g., a screening mammogram more than once a year).
A physician or practitioner may furnish a service that Medicare covers under some circumstances but which the physician anticipates would not be deemed "reasonable and necessary" by Medicare in the particular case (e.g., multiple nursing home visits, some concurrent care services, two mammograms within a twelve month period, etc.). If the beneficiary receives an "Advance Beneficiary Notice" that the service may not be covered by Medicare and that the beneficiary will have to pay for the service if it is denied by Medicare, a private contract is not necessary to bill the beneficiary if the claim is denied.
Under §4507 of the BBA, when a physician or practitioner chooses to enter into a private contract with a Medicare beneficiary to provide services that would otherwise be covered by Medicare, no services provided by that individual are covered by Medicare and no Medicare payment can be made to that physician or practitioner directly or on a capitated basis. The physician or practitioner must "opt out" of Medicare for a two - year period. Under the statute, the physician or practitioner cannot choose to opt out of Medicare for some Medicare beneficiaries but not others; or for some services but not others.
Medicare will make payment for covered, medically necessary services that are ordered by a physician or practitioner who has opted out of Medicare, if the physician or practitioner has acquired a unique provider identification number (UPIN) from Medicare and provided that the services are not furnished by a physician or practitioner who has opted out.
In an emergency or urgent care situation a physician or practitioner who opts out may treat a Medicare beneficiary with whom he or she does not have a private contract. In that case, the physician or practitioner may not charge the beneficiary more than what a non-participating physician would be permitted to charge and must submit a claim to Medicare on the beneficiary' s behalf. Payment will be made for Medicare covered items or services furnished in emergency or urgent situations when the beneficiary has not signed a private contract.
Physicians who provide services to Medicare beneficiaries enrolled in the new Medical Savings Account (MSA) demonstration created by the BBA of 1997 are not required to enter into a private contract with those beneficiaries and opt out of Medicare for two years under §4507.
A physician who is a member of a group practice may enter into a private contract under §4507 and opt out of Medicare, without affecting the ability of the other members of the group practice to provide and bill for Medicare services.
Contents of the Private Contract With the Beneficiary
Under §4507 of the BBA, a valid private contract must:
Contents of the Affidavit The physician or practitioner must file an affidavit with Medicare no later than 10 days after the first private contract is entered into. Under §4507 of the BBA, a valid affidavit must:
Additional information on private agreements will be included in a future bulletin.
One Year Delay in Implementing New Practice Expense Component
Starting in 1999, there will be a 3-year transition period to phase in the resource based relative value units, which will be fully implemented in 2002.
Expanded Requirements for Furnishing Diagnostic Information
Also effective January 1, 1998, physicians and practitioners are required to provide diagnostic or other medical information to other entities that furnish services ordered by the physician or practitioner. Physicians and practitioners will be required to provide diagnosis or other medical information to the entity furnishing the service at the time the service is ordered when the Secretary (or fiscal agent of the Secretary) requires such information in order for payment to be made. For example, physicians and practitioners will now be required to provide diagnosis or other medical information at the time the service is ordered to the entity furnishing the service when a Local Medical Review Policy (LMRP) exists requiring such diagnosis or other medical information from the entity performing the service.
Temporary Restoration of Coverage for Portable EKG Equipment Transportation
The procedure codes involved are 93000 (a 12-lead EKG with interpretation and report) or 93005 a 12-lead EKG, tracing only, without interpretation and report). When multiple patients receive services at the same site, the transportation payment amount must be prorated among all patients seen. These payments may be made only under the following circumstances:
Change in Payment Methodology and Amount for Nurse Practitioners, Physician Assistants, and Clinical Nurse Specialists
Payments for Drugs and Biologicals
Effective January 1, 1998, drugs and biologicals not paid on a cost or prospective payment basis are paid at the lower of the billed charge or 95 percent of the average wholesale price (AWP). This change in payment allowance recognizes the fact that the average wholesale price is not a true discounted price and, therefore, does not reflect the cost to the physician or supplier furnishing the drug to the Medicare beneficiary. Part B deductible and coinsurance requirements apply.
OTHER IMPORTANT INFORMATION
Enforcement of Child Support Provisions of the Debt Collection Act of 1996
Medicare Fraud, Waste and Abuse