American Society of Hematology

New Medicare Regulations Benefit Hematologists; ASH Advocacy Improved Physician Payment

Published on: November 02, 2012

On November 1, 2012, the Centers for Medicare and Medicaid Services published three final regulations of importance to Hematologists:

  1. Medicare's Physician Fee Schedule for CY 2013
  2. Medicare's Hospital Outpatient Prospective Payment System for CY 2013
  3. Medicaid Payment for Services Furnished by Certain Primary Care Physicians and Charges for Vaccine Administration

The Medicare Physician Fee Schedule rule provides updates to payment rates for physician services and includes changes to payment policies and the quality reporting initiatives associated with the fee schedule. According to CMS, payment rates for Hematology/Oncology services will increase by 2 percent based on the changes made in this rule. Of course, this does not factor in the looming 27 percent cut in payment if Congress does not avert scheduled cuts by January 1, 2013.

ASH is pleased to report that CMS has proposed payment for two new codes for transitional care management (TCM) services provided to patients being discharged from acute, rehabilitation, or long-term acute hospital stays into the community. Primary care providers and specialists can bill these for new services within 30 days following discharge. The new codes include one face-to-face visit post-discharge as well as non face-to face services such as phone or electronic communications, patient and family education, reviewing discharge information, contacts with other health professionals, scheduling and arranging for other services that occur within 30 days of discharge. Both codes require the physician to communicate with the patient (direct contact, telephone or electronic) within 2 business days of discharge. The two codes – 99495 TCM with decision-making of moderate complexity and 99496 TCM with high complexity decision-making – will be paid $163 and $230, respectively. ASH had advocated for not restricting the new codes to only primary care physicians but also specialists providing these services and is pleased with this outcome. ASH expects CMS will provide detailed guidance on the implementation of the transitional care management codes.

The Medicaid rule implements a provision of the Affordable Care Act stipulating that Medicaid reimbursement for certain primary care services equal Medicare rates in 2013 and 2014. While originally thought to only apply to physicians who are board-certified in family medicine, internal medicine or pediatrics, the final Medicaid rule included subspecialists in these fields and will result in increased payments for adult and pediatric hematologists. The applicable E&M codes are CPT codes 99201 through 99499, and vaccine administration codes are 90460, 90461, 90471 – 90474 and their successors. To be eligible for the increased payment, physicians will have to attest to their board certification or show that 60 percent of all Medicaid services that they bill, or provide in a managed care environment, are for the specified E&M services. The federal government will reimburse states 100 percent of the difference between the states' 2009 payment rate and the Medicare rate for 2013 and 2014.

ASH actively advocated for making cognitive specialists such as hematologists eligible for these enhanced payment proposals, by commenting on the proposed rules and including it on our agenda with Congress and is pleased to see the results of these efforts in the Medicare and Medicaid rules. ASH is carefully analyzing these regulations and will provide the membership with additional information in the coming weeks. In the meantime, further advocacy efforts are needed to assure that congress provides for stable medicare physician payments. Please visit ASH's Advocacy Center to send a letter to your Representative and Senators today. 

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