CY 2012 Medicare Physician Fee Schedule (Final Rule)
The Centers for Medicare & Medicaid Services (CMS) released the CY 2012 Medicare Physician Fee Schedule final rule with comment period on November 2, 2011. It will be published in the Federal Register on November 28, 2011. Previously, AOTA drafted an analysis of the Medicare Physician Fee Schedule proposed rule and submitted comments to CMS regarding these proposals on August 30, 2011.
In the final rule, which will take effect on January 1, 2012, CMS updated outpatient payment policies that affect therapy services. Below are the key changes impacting occupational therapy:
Therapy Cap: The 2012 therapy cap is set at $1,880 for occupational therapy, and $1,880 for physical therapy/speech-language pathology combined. This is an $10 increase over the 2011 therapy cap of $1,870.
SGR: The statutory formula used to determine the physician payment update will use a sustainable growth rate (SGR) conversion factor of 24.6712, representing a fee schedule update for 2012 of -27.4% .
Expiring Policies: Both the exceptions process for the therapy cap and the temporary "doc fix" overriding negative fee schedule updates expires on December 31, 2011. Both of these policies require special Congressional legislation to address. AOTA, CMS, and Congress are working to address these issues, and CMS notes in the final rule that it will work with Congress on a permanent fix so patients and providers "no longer have to worry about the stability and adequacy of their payments from Medicare" (display copy p. 1173).
MPPR: No changes were made in the final rule to the multiple procedure payment reduction (MPPR) policy for therapy, and CMS confirmed its position that the policy is properly applied to the practice expense (PE) component of the payment formula at a rate of 25% for institutional settings and 20% for office settings. AOTA reads the letter of the law as setting a 20% reduction rate for all settings. CMS also extended the MPPR to the professional component (PC) of advanced imaging services - namely, CT, MRI, and ultrasound (there is already an MPPR for the technical component (TC) or advanced imaging services). CMS originally proposed an MPPR of 50% to the PC, but reduced it to 25% in the final rule.
Part B Group Therapy: CMS proposed to re-value 10 group service codes - including 97150 (group therapeutic procedures) - by adjusting the time for each code based on the typical number of patients per sessions. CMS suggested a typical number of 6 patients for all 10 of the group codes under review and, accordingly, proposed to divide the time for each group service code by 6. AOTA submitted comments extremely critical of this proposal, particularly because the basis for using 6 patients was based off vignettes for code 90853 (non-family group psychotherapy) - a type of therapy fundamentally different from code 97150 in both theory and practice. Based on comments from AOTA and other organizations, CMS stated in the final rule that it would not arbitrarily divide each code by 6 but would instead await pending RUC review of the group codes before taking further action (display copy pp. 79-80).
Additional Comments Sought: This is a final rule with comment period, and CMS is soliciting additional comments on the following areas: (1) The interim final work, practice expense, and malpractice RVUs (including the physician time, PE inputs, and the equipment utilization rate assumption) for new, revised, potentially misvalued, and certain other CY 2012 HCPCS codes listed in Addendum C, and (2) The physician self-referral designated health services codes listed in Tables 83 and 84 of the final rule.
Please send your questions and thoughts to the Reimbursement and Regulatory Department at firstname.lastname@example.org.
CMS Fact Sheet on the 2012 Medicare Physician Fee Schedule
CMS Fact Sheet on 2012 Medicare Physician Fee Schedule Policy Changes
CMS Press Release on the Final Rule