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Fiscal cliff lifeline affects more provisions than SGR


The sustainable growth rate (SGR) wasn’t the only physician-linked provision passed by lawmakers in the early hours of New Year's Day. Several Medicare fee-for-service programs have been extended as part of the American Taxpayer Relief Act of 2012 as well.


The sustainable growth rate (SGR) wasn’t the only physician-linked provision passed by lawmakers in the early hours of New Year's Day. Several Medicare fee-for-service programs have been extended as part of the American Taxpayer Relief Act of 2012 as well.

Section 601-the Medicare Physician Payment Update-provides for a 0% update for services performed in 2013. The Centers for Medicare and Medicaid Services (CMS) is now reviewing the requirements of the new law, revising the 2013 Medicare Physician Fee Schedule (MPFS), and making corrections to the final rule it issued in November. The new law also sets the 2013 conversion factor at $34.0230, according to CMS.

The last-minute changes mean that Medicare claims administrator contractors may hold MPFS claims with January 2013 dates for up to 10 business days. Claims should be released into processing no later than January 16, and claims with dates of service before January 1 are unaffected. Medicare claims administration contractors will be posting the MPFS payment rates on their websites no later than January 23.

Also affected by new law is the 2013 Annual Participation Enrollment Program, which previously gave physicians until December 31, 2012, to change their participation status. The new law extends that deadline through February 15, 2013. The effective date for any participation status changes elected by providers during the extension remains January 1, 2013.

Section 602 of the new law is the Extension of Medicare Physician Work Geographic Adjustment Floor. The 1.0 floor on the physician work geographic practice cost index is extended through December 31, 2013, and the extension will be reflected in the revised 2013 MPFS.

Section 603-the Extension Related to Payments for Medicare Outpatient Therapy Services-extends the exceptions process for outpatient therapy caps through December 31. Outpatient therapy providers must submit the KX modifier on their therapy claims when an exception to the cap is requested for all medically necessary services furnished through December 31, according to CMS. In addition, the new law extends the application of the cap and threshold to therapy services performed in a hospital outpatient department (OPD), and counts outpatient therapy services furnished in a critical access hospital toward the cap and threshold.

Therapy caps are determined for a beneficiary on a calendar year basis, so all beneficiaries began a new cap for outpatient therapy services received on January 1. The combined cap for physical therapy and speech language pathology services in 2013 is $1,900, with a separate cap of $1,900 for occupational therapy services. Deductible and coinsurance amounts for therapy services count toward the, and also apply for services above the cap where the KX modifier is used, reports CMS.

Section 604-the Extension of Ambulance Add-On Payments-extends three Job Creation Act provisions: a 3% increase in ambulance fee schedule amounts for covered ground ambulance transports from rural areas and the 2% increase for transports from urban areas; a provision keeping rural designations the same as they were in 2006 for the calculation of air ambulance payment schedules; and a provision to increase the base payment rate for ground ambulance services for areas within the lowest 25th percentile by population density. CMS says it is still reviewing the 2013 Medicare Ambulance Fee Schedule to reflect the new law’s requirements.

Section 605 -the Extension of Medicare Inpatient Hospital Payment Adjustment for Low-Volume Hospitals-allows qualifying low-volume hospitals to receive add-on payments based on the number of Medicare discharges. This provision extends the payment adjustment through September 30, 2013, retroactive to October 1, 2012.

Section 606-the Extension of the Medicare-Dependent Hospital (MDH) Program-provides enhanced payment to support small rural hospitals for which Medicare patients make up a significant percentage of inpatient days or discharges. This provision extends the MDH program until October 1, 2013, and is retroactive to October 1, 2012.

Regarding the SGR patch, President Barack Obama has pledged to find a permanent solution to the annual Medicare payment cut threat, and he said he will continue to work with Congress to identify a long-term solution, according to the White House.


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© National Institute for Occupational Safety and Health
© National Institute for Occupational Safety and Health