On November 19, 2008, the Centers for Medicare & Medicaid Services (CMS) published a Final Rule for Medicare payments in the physician fee schedule for calendar year (CY) 2009. This Final Rule affects physician, office and Independent Diagnostic Testing Facility (IDTF) payments for services billed on the 1500 claim form paid under the resource based relative value scale (RBRVS), also known as the Medicare Physician Fee Schedule (MPFS).

The 2009 Medicare physician payment Final Rule implements requirements mandated by the Medicare Improvement for Patients and Providers Act of 2008 (MIPPA). As a result, MIPPA exchanges a 15.1% cut with an overall 1.1% increase to physician payments.

Despite the MIPPA-mandated 1.1% increase, do not be confused by the decrease in the Conversion Factor being reduced from $38.09 in 2008 to $36.07 in 2009.  Other MIPPA and Final Rule provisions offset this decrease resulting in some providers experiencing an overall increase whereas others might see a decrease based upon the mix of procedures as a result of these converging payment policies.  These Final Rule and MIPPA provisions, including a revision in the way CMS applies the budget neutrality adjustment related to the five-year review of physician work RVUs as well as the third year phase-in of the practice expense methodology, has resulted in inconsistencies in final payment rates with some increases and decreases within and between CPT procedures.  Providers are encouraged to review each CPT code final 2009 rate individually to determine the reimbursement impact on services they provide.

Some other MIPPA-related provisions would:

• Make changes to the Physician Quality Reporting Initiative (PQRI), including a 2.0% bonus payment for 2009 and 2010.
• Implement a five-year program of incentive payments for eligible professionals who are "successful electronic prescribers."
• Extend the work GPCI floor and the therapy cap exception process through December 31, 2009. Additionally, MIPPA sets a permanent 1.5% work GPCI in Alaska, beginning January 1, 2009.
• Calls for providers of advanced diagnostic imaging services (e.g., MR, CT, PET, and nuclear medicine) to be accredited in order to receive payment for the technical component of those services by January 2012.

The Final Rule also:

• Defers a proposal to require physicians providing imaging and other tests in their office to be certified as Independent Diagnostic Testing Facilities.
• Seeks additional input on targeted exceptions to physician self-referral laws in order to permit incentive payments or shared savings programs.
• Finalizes and modifies Medicare's anti-markup rules.

Important Nuclear Medicine and Nuclear Cardiology final 2009 CMS policies include:

• NO changes for radiopharmaceutical payment methodology in the physician office or IDTF settings for 2009. Additionally, drugs, contrast agents and biologicals will continue to be paid at 106 percent of the average sales price (ASP+6). 
• The 2009 Final Rule continues its third year, with a 75% phase in of the "bottom up" methodology for determining practice expense (PE) (such as office overhead) RVUs, with the phase in over a total of four years with full implementation by 2010. In general, for procedures with high equipment costs, the rates will increase over time; those procedures less equipment intense will see reductions.
• Consistent with requirements of the DRA, this Final Rule continues to cap payment rates for imaging services under the physician fee schedule at the amount paid for the same services when performed in hospital outpatient departments. Twenty (20) Nuclear Medicine codes are affected by this policy in 2009. Details can be found in the SNM MPFS chart comparing 2008 to 2009 rates, see goldenrod rows.
• The final 2009 MPFS rule also continues a policy of reducing, by 25 percent, the payment for the Radiology Families technical component of multiple imaging procedures on contiguous body parts.  CMS will apply the multiple imaging reductions first, followed by the OPPS imaging cap, if applicable. Ten (10)  new cardiology, radiology or radiation oncology imaging codes were added to this list, and are now subject to the multiple procedure reduction:  CPT 70336, 70554,75557, 75559, 75561, 75563, 76776,76870, 77058, and 77059.
• CMS accepted significant revisions to the cardiac monitoring codes. These 2009 changes are a result of a multiple stakeholder workgroup addressing this changing technology, and terminology. Look for new, revised codes and values in this Final Rule.
• Quality Standards for Physicians and NPPs Providing Diagnostic Testing Services: CMS did NOT finalize the proposal to require that physicians and NPPs who furnish diagnostic testing services meet the quality and performance standards required for Independent Diagnostic Testing Facilities (IDTF). Of importance, CMS did not state they would NOT implement this in the future; they simply are deferring the decision for a later time, if necessary.
• CMS finalizes the anti-markup rule effective January 1, 2009. The anti-markup provisions will apply if a physician or other supplier bills for the technical component (TC) or professional component (PC) of a diagnostic test that was ordered by the physician or other supplier (or by a party related through common ownership or control) and the diagnostic test is performed by a physician who does not "share a practice" with the billing physician or other supplier. CMS adopts a hybrid approach to determining whether a physician "shares a practice" with the billing physician or other supplier. In doing so, CMS adopts "Alternative 1" and "Alternative 2" from the MPFS Proposed notice for 2009 with modifications. CMS also indicates that arrangements should be first analyzed under Alternative 1 and, if the performing physician does not satisfy the requirements of Alternative 1, an analysis under Alternative 2 may be applied on a test-by-test basis to determine whether the anti-markup payment limitation applies.  See page 69799 of the 2009 MPFS Final Rule published in the Federal Register, Vol. 73, No. 224 on November 19, 2008 for additional details.
• Two Opportunities for physician bonuses in 2009:

1.  Physicians and other eligible professionals who use qualified electronic prescribing (e-prescribing) systems to transmit prescriptions to pharmacies may earn an incentive payment of 2 percent of their total Medicare allowed charges during 2009. This incentive is in addition to a 2 percent incentive payment for 2009 for physicians who successfully report measures under the Physician Quality Reporting Initiative (PQRI), and both incentive payments are in addition to the 1.1 percent fee schedule update required by the Medicare Improvements for Patients and Providers Act of 2008 (MIPPA). Please note this bonus will be phased out over several years and eventually the bonus will be a penalty for those that meet the qualifications but do not e-prescribe. If you do not meet the qualifications providers will not be penalized.  There are certain requirements that must be met to participate in the e-prescribing incentive program.  Using the link noted above, please see Sections II (O2 and T) in the 2009 MPFS Final Rule for details and limitations.

2.  Physician Quality Reporting Initiative (PQRI): MIPPA makes PQRI permanent and authorized CMS to make incentive payments for satisfactorily reporting data on quality measures for covered professional services furnished by eligible professionals during the 2009 PQRI reporting period equal to 2 percent of the estimated total allowed charges (this includes allowed charges for radiopharmaceuticals) for all covered professional services furnished during the reporting period.

o    CMS finalizes 153 measures for 2009 reporting; specifications are available at http://www.cms.hhs.gov/pqri. In 2009 there are three methods to participate: (1) there are individual measures, where the provider must report on 1-3 measures (3 if they apply) with 80% compliance during the reporting period. (2) group measures, if a provider chooses this method they must report on the entire group during the reporting period and (3) registry based measures (CMS has published a list of approved registries).

o    For Nuclear Medicine professionals see table 2 below as CMS has included one new nuclear medicine measure in 2009. If your physician only qualifies to report one measure, this would qualify the physician for the bonus if they meet the 80% requirement. However, if your physician also qualifies for other measures they would be required to submit on a minimum two to three measures so read the rules carefully to ensure your physicians will get their 2% bonus at the end of 2009.

The Final Rule as posted on the CMS website can be found at: http://www.cms.hhs.gov/physicianfeesched/downloads/CMS-1403-FC.pdf.

The Final Rule went on display at the Federal Register on October 30, 2008. and was published November 19, 2008 (Federal Register, Vol. 73, No. 224). The information from this final notice is effective for services on or after January 1, 2009. 

New, Revised & Deleted 2009 CPT and HCPCS Level II Codes:

Important Changes for Nuclear Medicine Professionals 

The AMA released the 2009 CPT codes that will be effective January 1, 2009. As a reminder, CMS no longer allows a grace period for implementation of any code sets. This year you will find one new code and two deleted codes in the nuclear medicine procedure code section. These are all in the 78000 series. For 2009, nuclear medicine professionals will see changes to the computer processing codes and a new code in other procedures (see Category I table below).

Additionally, for the first time, nuclear medicine professionals will have nuclear medicine specific AMA Category II quality measures. One of these measures as noted earlier, CMS has accepted as a quality measure in the PQRI initiative, thereby allowing more nuclear medicine physicians to participate and potentially qualify for a 2% bonus in 2009. Additional educational materials and CMS guidance regarding appropriate utilization of the new measure will be forthcoming. The new codes and descriptions are provided below in the AMA Category II Table, for your information. These quality measures were effective October 1, 2008; however, they will not be listed in the 2009 CPT printed book but will appear in the 2010. A complete listing of the AMA Category II codes can be located at http://www.ama-assn.org/ama/pub/category/10616.html