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Medical Coding News Archives

CMS Releases Update to Physician Fee Schedule for 2009

November 11, 2008:

The update to the physician fee schedule for 2009, released in a final rule on October 30, includes a 1.1 percent increase mandated by Congress in the Medicare Improvements for Patients and Providers Act of 2008 (MIPPA). This means that, beginning January 1, 2009, the conversion factor for determining Medicare payments will be $36.0666.

In addition, some good news is that the Centers for Medicare and Medicaid Services has included the budget neutrality adjustment in the conversion factor. This means there is not a separate computation that must be made by providers trying to determine fee schedule payments.

Also addressed in the rule:

Identification of misvalued services: The Relative Value Update Committee (RUC) began a review of potentially misvalued codes and has made initial recommendations to CMS. In this final rule, CMS is accepting the valuation recommendations for these codes for calendar year 2009. It should be noted that CMS plans to review these codes in the future and may propose additional changes to the relative values assigned to these codes. This would be announced in future rules.

Telehealth services: Three new facility types are added to the list of authorized telehealth originating sites: a hospital-based or CAH-based renal dialysis center (including satellites), a skilled nursing facility (SNF), and a community mental health center (CMHC) as a result of MIPPA. The final rule also added new HCPCS codes specific to the telehealth delivery of follow-up inpatient consultations, allowing providers to bill for follow-up telehealth services. Additionally, the follow-up inpatient consultations are again on the list of Medicare covered telehealth services with CMS creating three new HCPCS level II codes to represent the service.

G0406 Follow-up inpatient telehealth consultation, limited, physicians typically spend 15 minutes communicating with the patient via telehealth
G0407 Follow-up inpatient telehealth consultation, intermediate, physicians typically spend 25 minutes communicating with the patient via telehealth
G0408 Follow-up inpatient telehealth consultation, complex, physicians typically spend 35 minutes or more communicating with the patient via telehealth

Follow-up consultations had been included before 2006 but ceased to be on the list of Medicare telehealth services when the American Medical Association deleted the specific codes for follow-up inpatient consultations. These codes must be billed with the modifier GT, via interactive audio and video telecommunications system, in order to be paid. Also note that the follow-up consultation codes are appropriate only when billing for telehealth services.

Changes to the enrollment and billing rules: The effective date of billing for physicians and nonphysician practitioners is the latter of: 1) the date of filing of a Medicare enrollment application that was subsequently approved by a Medicare contractor; or 2) the date an enrolled physician or nonphysician practitioner first started furnishing services at a new practice location. In addition, physicians and nonphysician practitioners who meet all program requirements may bill retrospectively:

  • For services furnished up to 30 days prior to the effective date, rather than the 23 months allowed under current regulations
  • For services furnished up to 90 days prior to the effective date if the president has declared an emergency under the Robert T. Stafford Disaster Relief and Emergency Assistance Act

Limits on billing: The final rule establishes that a provider will not be allowed to bill for services furnished after certain reportable events such as: 1) a federal exclusion or debarment, 2) a felony conviction; 3) a state license suspension or revocation; or 4) a determination that a practice location is not operational by CMS or its contractor.

For all other revocation actions, individual practitioners will be required to submit all outstanding claims within 60 days of the effective date of revocation.

Disclosure: The rule also requires providers and provider organizations to notify their Medicare contractor of a change of ownership, final adverse action, or change of location within 30 days.

Finally, the final rule does not change existing payment localities. The agency states that it will continue to study the issue and may propose revisions to the fee schedule areas used to calculate geographic practice cost indexes (GPCIs) and adjust payments in the future. 

Deborah C. Hall
Clinical/Technical Editor


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