By Christopher P. Young, Editor, G2 Compliance Advisor
The Medicare physician fee schedule (MPFS) will be adjusted to reflect a 21.2 percent negative update effective April 1 unless Congress acts to override or delay the cut as has been the case in previous years. According to the Centers for Medicare and Medicaid Services (CMS) program transmittal R3205CP issued on Feb. 27, Medicare administrative contractors (MACs) were instructed to retrieve the files and use them to update their systems. The transmittal has an effective date of Jan. 1 with an implementation date of April 6. Congress has a little more than 3 weeks to stop the reductions. So, here we are again with CMS, MACs, laboratories and other providers having to act at the last minute to avoid a claims filing nightmare depending on what Congress does. The 21.2 percent negative update to the fee schedule translates to a $7.53 reduction in the conversion factor.
The Protecting Access to Medicare Act of 2014 provided for a zero percent update to the MPFS between Jan 1 and March 31 to give Congress time to come up with a solution to the Sustainable Growth Rate (SGR) dilemma. Congress has yet to come up with an acceptable alternative to SGR and is once again faced with passing something to delay the cut until next year.
The accompanying MLN Matters, MM9104, provides some other information that directly affects laboratories in addition to the fee schedule problems.
- The new drug testing CPT codes, 80300 through 80377 will have a procedure status code of “I” meaning that these codes are not valid for Medicare purposes and that Medicare uses another code for reporting these services. While this was already known to many laboratories, it will now be codified in the payment system and can be denied automatically.
- Also, certain codes in the Multianalyte Assays with Algorithmic Analyses will receive a procedure status of “X,” meaning that they are excluded by statute because they do not meet the definition of a “physician service” for fee schedule purposes.
MACs will not search their files to retroactively retract or pay claims impacted by the above changes, but will adjust claims that providers bring to their attention. This does not give providers a license to ignore improperly paid claims where an overpayment exists. If a laboratory is aware it has been overpaid because of these issues, it must repay the Medicare program, and it must do it within 60 days of the discovery of the overpayment.