CMS Announces Technical Issue that Delays Medicare Physician Fee Schedule until 1/15/15

Hold your claims! When CMS has an issue, we all have an issue. The Medicare Physician Fee Schedule that was published in the Federal Register this past November has been cancelled by CMS for correction of unspecified errors. MACs will hold claims until at least January 15, 2015 due to revisions to the conversion factor and relative value units (RVUs), so you will not have the correct fee schedule until Jan. 20 at the latest.

As a health plan or delegated entity, many issues face your claims department. While FFS Medicare claims are paid no sooner than 14 days, network contracts may call for shorter turn-around times and would require payment. There are four new AMA and HCPC codes that you don’t have pricing for yet. Medicare also adjusted RVUs for hundreds of codes. For example, the original 2015 physician fee schedule set the conversion factor at $35.8013, but the updated RVU file cites a conversion factor of $35.7457 that is set to expire March 31, 2015.

The impact will be minimal in most cases, but there will also be some major changes. For example, according to DecisionHealth, “the pricing revisions will add $385.27 to the payment for cardio reconstruction service, 33622 (Redo compl cardiac anomaly), bringing the total fee to $3,536.50. Orthopedists will receive almost $100 more – $749.78 – for rib fracture code 21812. On the other side of the ledger are services such as second level cervical diskectomy 22858, which now will pay $519.16, $152.83 less than originally calculated and hyperbaric oxygen therapy (99183). A $92.51 cut to that service will lower payment from $205.14 to $112.63.”

Status of Virtual Examiner® Update

PCG has abandoned weeks of work based on the November Medicare Physician Fee Schedule database (MPFSDB) and will be issuing the 1st Quarter Virtual Examiner® update without the 2015 fee schedule but with the CCI edits and other changes. When the final fee schedule is released by CMS, we will issue another Virtual Examiner® version. For more information, please refer to the MAC statements below.

National Government Service Statement

On November 13, 2014, the CY 2015 Medicare Physician Fee Schedule (MPFS) final rule was published in the Federal Register. In order to implement corrections to technical errors discovered after publication of the MPFS rule and process claims correctly, Medicare Administrative Contractors will hold claims containing 2015 services paid under the MPFS for the first 14 calendar days of January 2015 (i.e., Thursday January 1 through Wednesday January 14). The hold should have minimal impact on provider cash flow as, under current law, clean electronic claims are not paid sooner than 14 calendar days (29 days for paper claims) after the date of receipt.

Palmetto GBA Statement

CMS is in the process of issuing a revised 2015 Medicare Physician Fee Schedule. The revised fees will be published on or before January 20th.

Our Palmetto GBA Medicare Physician Fee Schedule (MPFS) tool allows you to display or download fees, indicators, and indicator descriptors. Start by selecting your fee’s year in the box below. As you answer questions, new ones will appear to guide your search. Use the “Clear” button to change the year or contractor. For more assistance with this tool, visit our Help page or fill out the Feedback form. For other fees not included in this tool (Ambulance, ASC, DMEPOS, Drugs and Clinical Laboratory) please visit our Fee Schedule Web page. You can find additional information on the CMS Physician Fee Schedule page.

Andria Jacobs

COO of PCG Software, Inc.