Understanding Complex Physician Fee Schedule Changes in 2010

 The Physician Fee schedule has had numerous and confusing updates this year, so I thought a quick note to customers about how we can help would be in order.  Key issues include:

• The January 2010 RVU file had multiple updates and corrections.
• The April 2010 RVU file was not published by CMS.
• The Affordable Care Act created RETROACTIVE payment changes to the some RVUs and the conversion factor back to 01/01/2010.
• The payment rates for July 2010 are still in flux.

The January 2010 RVU file had multiple updates and corrections. We monitor CMS for updates and make those updates in our system generally within 2 weeks or sooner.  Each year, the PFS final rule includes a table that indicates the RVUs and conversion factor for the upcoming year.  This data is then officially published in the PPRVU file on the CMS web site.  Our experience is that the PPRVU file published in the fall is typically updated with major corrections well into January, typically because the regulatory Final Rule is published before legislative actions enacted by Congress fully funds the program. 

The final RVU (version 4) was published by CMS in late January.  In May, 2010, CMS re-issued an HR version of the RVU file.  We detected a reduction in the conversion factor, and changes in RVUs as well, which could result in either an increase or decrease in payment for many codes.  Here is a note from CMS:

NOTE: These files reflect changes as a result of practice expense (PE) and malpractice (MP) relative value unit (RVU) corrections and provisions of the Patient Protection and Affordable Care Act (the Affordable Care Act), as modified by the Health Care and Education Reconciliation Act of 2010, which President Obama signed into law on March 23, 2010, and March 30, 2010, respectively.

TIPS FOR USERS:

• By March, we had detected 4 changes, and the final version that was loaded to the RVU calculator and the Physician Fee Reimbursement Toolkit Calculator was the RVU10R4 file.
• Go to the Physician Fee Schedule Codebook Download center for access to each of the PPRVU file versions and a difference report. 
• On Coding & Revenue Resource Center or Audit & Revenue Resource Center, go to Coding Comply to download the latest most up-to-date information, download the entire history, or create your own custom export based on your preferred codes, dates and changes.

The April 2010 RVU file was not published by CMS. 

TIPS FOR USERS:

• January data was carried through to the April-June quarter.  This data appears when you enter a Quarter 2 service date in the RVU Calculator or Physician Fee Reimbursement Toolkit Calculator.

The Affordable Care Act created a RETROACTIVE payment reduction to the conversion factor back to 01/01/2010.  In May, CMS issued a new PPRVU file in which the conversion factor was reduced from 36.0846 to 36.0791.  The name of this file is RVUHR2.  There were also a few non-paybable G Codes that appeared in RVUHR2 that was not in the RVUAR4 file. TIPS FOR USERS:

• Work with your payer to determine how past paid 2010 claims will be adjusted for this retroactive reduction.

The payment rates for July 2010 are still in flux.  Watch the Daily E-Mail alert and publications from your payer for updates.  Here is an important message from CMS regarding this:

 The Continuing Extension Act of 2010, enacted on April 15, 2010, extended the zero percent (0%) update to the 2010 Medicare Physician Fee Schedule (MPFS) through May 31, 2010. The Centers for Medicare & Medicaid Services (CMS) believes Congress is working to avert the negative update scheduled to take effect June 1, 2010.

To avoid disruption in the delivery of health care services to beneficiaries and payment of claims for physicians, non-physician practitioners, and other providers of services paid under the MPFS, CMS has instructed its contractors to hold claims containing services paid under the MPFS (including anesthesia services) for the first 10 business days of June.

This hold will only affect MPFS claims with dates of service June 1, 2010, and later. This hold should have minimum impact on provider cash flow because, under the current law, clean electronic claims are not paid any sooner than 14 calendar days (29 for paper claims) after the date of receipt. Be on the alert for more information about the 2010 Medicare Physician Fee Schedule Update.