Government News
 DOI: 10.1176/appi.pn.2014.3a21
APA Welcomes CMS Acceptance of Increased Work Values
Psychiatric News
Volume 49 Number 5 page 1


There is a growing evidence base supporting the value of integrated care that includes clinical oversight that cannot be captured in the current coding structure.

Abstract Teaser

APA, responding to regulatory issues in the final rule issued by the federal government for the 2014 Medicare fee schedule, is applauding the acceptance of new, increased valuations of psychiatry codes and the creation of a new code category (G codes) to permit physician compensation for the non-face-to-face care-management services they provide to Medicare beneficiaries with complex chronic conditions.

In a January 27 letter to Marilyn Tavenner, administrator of the Centers for Medicare and Medicaid Services (CMS), APA CEO and Medical Director Saul Levin, M.D., M.P.A., also hailed the government’s broadening of the definition of “rural areas” to expand the locations qualifying for the delivery of telehealth services to include locations within urban areas.

“The changes that provide for the appropriate valuation of psychiatry services are essential for the realization of many of the objectives of health reform,” Levin wrote. “It is well known that a majority of high-cost Medicare patients have primary or secondary mental health and/or substance use disorders. Effective treatment of these individuals represents a step forward in both the quality and cost-effectiveness of health care. The appropriate valuation of psychiatry services recognizes the value proposition that psychiatry brings to the total health care system and should help to make psychiatric care more accessible to Medicare patients.”

The January comments in response to the government’s final rule on the fee schedule focused on regulatory issues and outlined the major points relevant to psychiatry, especially the acceptance of new values for psychiatric codes. Levin’s letter also addressed issues related to quality reporting and the “Value-Based Modifier” program. The comments did not address the overall physician fee schedule and the fate of the sustainable growth rate formula, both of which are still a moving target, pending debate on Capitol Hill (see box).

The acceptance of the new work values for psychiatric codes represents a major victory for psychiatry and is the culmination of a multiyear effort by APA and other mental health groups working with the AMA’s Relative Value Scale Update Committee (RUC) to create a new framework for psychiatric coding with values that better reflect the complexity of work involved in treating psychiatric patients. For a comprehensive description of the new work values, along with charts showing value increases for specific services, see “Government Accepts Higher Work Values for Psychiatry Codes” in the January 3 Psychiatric News.

Congress Yet to Agree on Medicare Fee Reform 

The fate of physician Medicare payment and the sustainable growth rate (SGR) formula is still to be resolved pending debate on Capitol Hill.

Days before the end of the 2013 congressional session, the Senate approved a federal budget compromise that included a three-month postponement of the 24.4 percent cut in physician Medicare reimbursement that was scheduled to take effect January 1. The House passed a similar three-month patch as part of its budget bill, and President Obama signed it at the end of the year.

Physicians are currently being paid according to the 2013 fee schedule, but the “patch” passed by Congress expires April 1. The Senate Finance, House Ways and Means, and House Energy and Commerce committees have released bipartisan and bicameral legislation (HR 4015/S 2000) to repeal the SGR and implement physician payment reforms under Medicare.

Highlights of the SGR repeal and Medicare Provider Payment Modernization Act of 2014 (S 2000/HR 4015) are as follows:

-Immediate and permanent repeal of the SGR.

-Positive annual updates—reimbursement increases—of 0.5 percent would be provided from 2014 to 2018, no annual updates would be provided from 2018 to 2022, and positive annual updates of 0.5 percent would be provided from 2023 onward.

-The Merit-Based Incentive Payment System is established that collapses three current incentive payment programs—Physician Quality Reporting System, Value-Based Modifier, and Electronic Health Records Meaningful Use—and incorporates key elements of each into one program for physicians beginning in 2018.

-Additional provisions are included regarding chronic care coordination, the targeting of misvalued services, and the sharing/publicizing of physician services.

Also important is the creation of the new G codes for complex care management that can aid in reimbursement of psychiatrists participating in integrated care team management of chronic conditions. “APA agrees with CMS’s efforts to design codes that will allow physicians to be compensated for the non-face-to-face complex chronic care management services they provide Medicare beneficiaries,” Levin wrote in the January 27 letter. “Many of our members frequently perform these services for Medicare’s most complex, chronically ill patients. . . . We see the establishment of this code [series] as a step toward appropriately reimbursing for care management services. There is a growing evidence base supporting the value of integrated care that also includes non-face-to-face clinical oversight by clinicians, work that cannot be captured in the current coding structure. It is our hope that codes will be developed for these types of services.”

Levin also expressed approval of broadening the definition “rural areas” to include certain urban areas—referred to as Metropolitan Statistical Areas (MSAs), where access to care is limited—for telemedicine. “Broadening the definition of ‘rural’ to include these urban locations will assist a significant underserved population in our cities, within which there is a high incidence of severe and persistent mental illness, in accessing psychiatric care,” Levin wrote.

More problematic are a number of issues related to CMS’s Physician Quality Reporting System, administrative burdens associated with different quality reporting measures used by multiple programs, the government’s Physician Compare website that reports participation in quality programs, and the proposed Value-Based Modifier (VBM).

Levin called for consolidation of quality measures used by different programs, an increase in reimbursement for psychiatric codes (especially for substance abuse), and the inclusion of disclaimers on the Physician Compare website making it explicit that participation—or lack of participation—in quality reporting programs is not indicative of the quality of care provided by a physician.

The VBM is a move by the government toward “pay-for-performance” by providing for differential payment to a physician or group of physicians under the Medicare Physician Fee Schedule based upon the quality of care furnished compared with cost during a performance period.

“We recognize payment systems for medicine are evolving so that ‘pay for performance’ is becoming the norm,” Levin wrote. “In preparation for the beginning of the value-based modifier (VBM), which will affect most of our members seeing Medicare beneficiaries in 2017, we ask CMS to create educational tools that will assist us in better understanding the likely effects of the VBM on the practice of psychiatry.” ■

For a summary of APA’s response to the final rule on the 2014 Medicare fee schedule, go to http://www.psychiatry.org/advocacy--newsroom/advocacy/advocacy-news and click on the link, “APA Responds to CY 2014 Medicare Physician Fee Schedule.”

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