Federal Register, Volume 78 Issue 139 (Friday, July 19, 2013)

[Federal Register Volume 78, Number 139 (Friday, July 19, 2013)]
[Proposed Rules]
[Pages 43281-43532]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 2013-16547]

[[Page 43281]]

Vol. 78

Friday,

No. 139

July 19, 2013

Part II

Department of Health and Human Services

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Centers for Medicare & Medicaid Services

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42 CFR Parts 405, 410, 411, et al.

Medicare Program; Revisions to Payment Policies under the Physician
Fee Schedule, Clinical Laboratory Fee Schedule & Other Revisions to
Part B for CY 2014; Proposed Rule

Federal Register / Vol. 78, No. 139 / Friday, July 19, 2013 /
Proposed Rules

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DEPARTMENT OF HEALTH AND HUMAN SERVICES

Centers for Medicare & Medicaid Services

42 CFR Parts 405, 410, 411, 414, 423, and 425

[CMS-1600-P]
RIN 0938-AR56

Medicare Program; Revisions to Payment Policies under the
Physician Fee Schedule, Clinical Laboratory Fee Schedule & Other
Revisions to Part B for CY 2014

AGENCY: Centers for Medicare & Medicaid Services (CMS), HHS.

ACTION: Proposed rule.

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SUMMARY: This major proposed rule addresses changes to the physician
fee schedule and other Medicare Part B payment policies to ensure that
our payment systems are updated to reflect changes in medical practice
and the relative value of services, as well as changes in the statute.

DATES: Comment date: To be assured consideration, comments must be
received at one of the addresses provided below, no later than 5 p.m.
on September 6, 2013.

ADDRESSES: In commenting, please refer to file code CMS-1600-P. Because
of staff and resource limitations, we cannot accept comments by
facsimile (FAX) transmission.
You may submit comments in one of four ways (please choose only one
of the ways listed):
1. Electronically. You may submit electronic comments on this
regulation to http://www.regulations.gov. Follow the instructions for
``submitting a comment.''
2. By regular mail. You may mail written comments to the following
address only: Centers for Medicare & Medicaid Services, Department of
Health and Human Services, Attention: CMS-1600-P, P.O. Box 8016,
Baltimore, MD 21244-8016.
Please allow sufficient time for mailed comments to be received
before the close of the comment period.
3. By express or overnight mail. You may send written comments to
the following address only: Centers for Medicare & Medicaid Services,
Department of Health and Human Services, Attention: CMS-1600-P, Mail
Stop C4-26-05, 7500 Security Boulevard, Baltimore, MD 21244-1850.
4. By hand or courier. If you prefer, you may deliver (by hand or
courier) your written comments before the close of the comment period
to either of the following addresses:
a. For delivery in Washington, DC--Centers for Medicare & Medicaid
Services, Department of Health and Human Services, Room 445-G, Hubert
H. Humphrey Building, 200 Independence Avenue SW., Washington, DC
20201.
(Because access to the interior of the Hubert H. Humphrey Building
is not readily available to persons without Federal government
identification, commenters are encouraged to leave their comments in
the CMS drop slots located in the main lobby of the building. A stamp-
in clock is available for persons wishing to retain a proof of filing
by stamping in and retaining an extra copy of the comments being
filed.)
b. For delivery in Baltimore, MD--Centers for Medicare & Medicaid
Services, Department of Health and Human Services, 7500 Security
Boulevard, Baltimore, MD 21244-1850.
If you intend to deliver your comments to the Baltimore address,
please call telephone number (410) 786-7195 in advance to schedule your
arrival with one of our staff members.
Comments mailed to the addresses indicated as appropriate for hand
or courier delivery may be delayed and received after the comment
period.

FOR FURTHER INFORMATION CONTACT: Chava Sheffield, (410) 786-2298, for
issues related to practice expense methodology and impacts.

Ryan Howe, (410) 786-3355, for issues related to direct practice
expense inputs and telehealth services.
Joanna Baldwin, (410) 786-7205, for issues related to misvalued
services.
Ken Marsalek, (410) 786-4502, for issues related to the multiple
procedure payment reduction.
Heidi Oumarou, (410) 786-7942, for issues related to the revision of
Medicare Economic Index (MEI).
Roberta Epps, (410) 786-4503, for issues related to chiropractors
billing for evaluation and management services.
Craig Dobyski, (410) 786-4584, for issues related to geographic
practice cost indices.
Simone Dennis, (410) 786-8409, for issues related to therapy caps.
Darlene Fleischmann, (410) 786-2357, for issues related to ``incident
to'' services.
Corinne Axelrod, (410) 786-5620, for issues related to ``incident to''
services in Rural Health Center s or Federally Qualified Health
Centers.
Anne Tayloe-Hauswald, (410) 786-4546, for issues related to ambulance
fee schedule and clinical lab fee schedule.
Sandra Adams, (410) 786-2982, for issues related to Medicare shared
savings program.
Rashaan Byers, (410) 786-2305, for issues related to physician compare.
Christine Estella, (410) 786-0485, for issues related to the physician
quality reporting system and EHR incentive program.
Ronke Fabayo, (410) 786-4460 or Jay Blake, (410) 786-9371, for issues
related to individual liability for payments made to providers and
suppliers and handling of incorrect payments.
Rosemarie Hakim, (410) 786-3934, for issues related to coverage of
items and services furnished in FDA-approved investigational device
exemption clinical trials.
Jamie Hermansen, (410) 786-2064 or Jyme Schafer, (410) 786-4643, for
issues related to ultrasound screening for abdominal aortic aneurysms.
Pauline Lapin, (410)786-6883, for issues related to the chiropractic
services demonstration budget neutrality issue.
Andrew Morgan, (410) 786-2543, for issues related to e-prescribing
under Medicare Part D.
Michael Wrobleswki, (410) 786-4465, for issues related to value-based
modifier and improvements to physician feedback.
Elliot Isaac, (410) 786-4735, for malpractice RVUs and for any
physician payment issue not identified above.

SUPPLEMENTARY INFORMATION: Inspection of Public Comments: All comments
received before the close of the comment period are available for
viewing by the public, including any personally identifiable or
confidential business information that is included in a comment. We
post all comments received before the close of the comment period on
the following Web site as soon as possible after they have been
received: http://www.regulations.gov. Follow the search instructions on
that Web site to view public comments.
Comments received timely will also be available for public
inspection as they are received, generally beginning approximately 3
weeks after publication of a document, at the headquarters of the
Centers for Medicare & Medicaid Services, 7500 Security Boulevard,
Baltimore, Maryland 21244, Monday through Friday of each week from 8:30
a.m. to 4 p.m. To schedule an appointment to view public comments,
phone 1-800-743-3951.

Table of Contents

I. Executive Summary and Background

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A. Executive Summary
B. Background
II. Provisions of the Proposed Rule for PFS
A. Resource-Based Practice Expense (PE) Relative Value Units
(RVUs)
B. Misvalued Codes
1. Valuing Services Under the PFS
2. Identifying, Reviewing, and Validating the RVUs of
Potentially Misvalued Services
3. CY 2014 Identification and Review of Potentially Misvalued
Services
4. The Multiple Procedure Payment Reduction Policy
C. Malpractice RVUs
D. Medicare Economic Index (MEI)
E. Geographic Practice Cost Indices (GPCIs)
F. Medicare Telehealth Services for the Physician Fee Schedule
G. Therapy Caps
H. Requirements for Billing ``Incident To'' Services
I. Complex Chronic Care Management Services
J. Chiropractors Billing for Evaluation & Management Services
III. Other Provisions of the Proposed Regulations
A. Medicare Coverage of Items and Services in FDA
Investigational Device Exemption Clinical Studies--Revision of
Medicare Coverage
B. Ultrasound Screening for Abdominal Aortic Aneurysms
C. Colorectal Cancer Screening: Modification to Coverage of
Screening Fecal Occult Blood Tests
D. Ambulance Fee Schedule
E. Proposals Regarding the Clinical Laboratory Fee Schedule
F. Liability for Overpayments to or on Behalf of Individuals
Including Payments to Providers or Other Persons
G. Physician Compare Web Site
H. Physician Payment, Efficiency, and Quality Improvements--
Physician Quality Reporting System
I. Electronic Health Record (EHR) Incentive Program
J. Medicare Shared Savings Program
K. Value-Based Payment Modifier and Physician Feedback Program
L. Updating Existing Standards for E-Prescribing Under Medicare
Part D
M. Discussion of Budget Neutrality for the Chiropractic Services
Demonstration
IV. Collection of Information Requirements
V. Response to Comments
VI. Regulatory Impact Analysis
Regulatory Text

Acronyms

In addition, because of the many organizations and terms to which
we refer by acronym in this proposed rule, we are listing these
acronyms and their corresponding terms in alphabetical order below:

AMA RUC American Medical Association/[Specialty Society] Relative
[Value] Update Committee
ATRA American Taxpayer Relief Act (Pub. L. 112-240)
BBA Balanced Budget Act of 1997 (Pub. L. 105-33)
BBRA [Medicare, Medicaid and State Child Health Insurance Program]
Balanced Budget Refinement Act of 1999 (Pub. L. 106-113)
CAH Critical access hospital
CF Conversion factor
CPT [Physicians] Current Procedural Terminology (CPT codes,
descriptions and other data only are copyright 2012 American Medical
Association. All rights reserved.)
CY Calendar year
DRA Deficit Reduction Act of 2005 (Pub. L. 109-171)
eRx Electronic prescribing
FFS Fee-for-service
FR Federal Register
GPCI Geographic practice cost index
HCPCS Healthcare Common Procedure Coding System
MCTRJCA Middle Class Tax Relief and Job Creation Act of 2012 (Pub.
L. 112-96)
MedPAC Medicare Payment Advisory Commission
MEI Medicare Economic Index
MFP Multi-Factor Productivity
MIEA-TRHCA The Medicare Improvements and Extension Act, Division B
of the Tax Relief and Health Care Act (Pub. L. 109-432)
MIPPA Medicare Improvements for Patients and Providers Act (Pub. L.
110-275)
MP Malpractice
MPPR Multiple procedure payment reduction
MMEA Medicare and Medicaid Extenders Act (Pub. L. 111-309)
MMSEA Medicare, Medicaid, and State Children's Health Insurance
Program Extension Act (Pub. L. 110-73)
NPP Nonphysician practitioner
OBRA '89 Omnibus Budget Reconciliation Act of 1989
OBRA '90 Omnibus Budget Reconciliation Act of 1990
PC Professional component
PE Practice expense
PE/HR Practice expense per hour
PFS Physician Fee Schedule
PQRS Physician Quality Reporting System
RFA Regulatory Flexibility Act
RIA Regulatory impact analysis
RVU Relative value unit
SGR Sustainable growth rate
TAP Technical Advisory Panel
TC Technical component
TPTCCA Temporary Payroll Tax Cut Continuation Act (Pub. L. 112-78)
VBP Value-based purchasing

Addenda Available Only Through the Internet on the CMS Web Site

The PFS Addenda along with other supporting documents and tables
referenced in this proposed rule with comment period are available
through the Internet on the CMS Web site at http://www.cms.gov/PhysicianFeeSched/. Click on the link on the left side of the screen
titled, ``PFS Federal Regulations Notices'' for a chronological list of
PFS Federal Register and other related documents. For the CY 2014 PFS
proposed rule, refer to item CMS-1600-P. Readers who experience any
problems accessing any of the Addenda or other documents referenced in
this proposed rule and posted on the CMS Web site identified above
should contact Elliot Isaac at (410) 786-4735.

CPT (Current Procedural Terminology) Copyright Notice

Throughout this proposed rule, we use CPT codes and descriptions to
refer to a variety of services. We note that CPT codes and descriptions
are copyright 2012 American Medical Association. All Rights Reserved.
CPT is a registered trademark of the American Medical Association
(AMA). Applicable Federal Acquisition Regulations (FAR) and Defense
Federal Acquisition Regulations (DFAR) apply.

I. Executive Summary and Background

A. Executive Summary

1. Purpose
This major proposed rule would revise payment polices under the
Medicare Physician Fee Schedule (PFS) and make other policy changes
related to Medicare Part B payment. These changes would be applicable
to services furnished in CY 2014.
2. Summary of the Major Provisions
The Social Security Act (Act) requires us to establish payments
under the PFS based on national uniform relative value units (RVUs)
that account for the relative resources used in furnishing a service.
The Act requires that RVUs be established for three categories of
resources: work, practice expense (PE); and malpractice (MP) expense;
and that we establish by regulation each year payment amounts for all
physicians' services, incorporating geographic adjustments to reflect
the variations in the costs of furnishing services in different
geographic areas. In this major proposed rule, we propose RVUs for CY
2014 for the PFS and other Medicare Part B payment policies to ensure
that our payment systems are updated to reflect changes in medical
practice and the relative value of services, as well as changes in the
statute. In addition, this proposed rule includes discussions and
proposals regarding:
Misvalued PFS Codes.
Telehealth Services.
Applying Therapy Caps to Outpatient Therapy Services
Furnished by CAHs.
Requiring the Compliance with State law as a Condition of
Payment for Services Furnished Incident to Physician and Other
Practitioner Services.
Revising the MEI based on MEI TAP Recommendations.

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Updating the Ambulance Fee Schedule regulations.
Updating the--
++ Physician Compare Web site.
++ Physician Quality Reporting System.
++ Electronic Health Record (EHR) Incentive Program.
++ Medicare Shared Savings Program.
Budget Neutrality for the Chiropractic Services
Demonstration.
Physician Value-Based Payment Modifier and the Physician
Feedback Reporting Program.
3. Summary of Costs and Benefits
The Act requires that annual adjustments to PFS RVUs not cause
annual estimated expenditures to differ by more than $20 million from
what they would have been had the adjustments not been made. If
adjustments to RVUs would cause expenditures to change by more than $20
million, we must make adjustments to preserve budget neutrality. These
adjustments can affect the distribution of Medicare expenditures across
specialties. In addition, several proposed changes would affect the
specialty distribution of Medicare expenditures. For most specialties
the projected impacts are a small percentage change in Medicare
payments under the PFS. For a few specialties a larger impact is
projected. Diagnostic Testing Facilities, Independent Laboratory,
Pathology, Radiation Oncology, and Radiation Therapy Centers are
projected to have a change of 5 percent or more.

B. Background

Since January 1, 1992, Medicare has paid for physicians' services
under section 1848 of the Act, ``Payment for Physicians' Services.''
The system relies on national relative values that are established for
work, PE, and MP, which are then adjusted for geographic cost
variations. These values are multiplied by a conversion factor (CF) to
convert the RVUs into payment rates. The concepts and methodology
underlying the PFS were enacted as part of the Omnibus Budget
Reconciliation Act of 1989 (OBRA '89) (Pub. L. 101-239, enacted on
December 19, 1989), and the Omnibus Budget Reconciliation Act of 1990
(OBRA '90 (Pub. L. 101-508, enacted on November 5, 1990). The final
rule published on November 25, 1991 (56 FR 59502) set forth the first
fee schedule used for payment for physicians' services.
We note that throughout this proposed rule, unless otherwise noted,
the term ``practitioner'' is used to describe both physicians and
nonphysician practitioners who are permitted to bill Medicare under the
PFS for services furnished to Medicare beneficiaries.
1. Development of the Relative Values
a. Work RVUs
The physician work RVUs established for the implementation of the
fee schedule in January 1992 were developed with extensive input from
the physician community. A research team at the Harvard School of
Public Health developed the original physician work RVUs for most codes
under a cooperative agreement with the Department of Health and Human
Services (HHS). In constructing the code-specific vignettes used in
determining the original physician work RVUs, Harvard worked with
panels of experts, both inside and outside the federal government, and
obtained input from numerous physician specialty groups.
We establish work RVUs for new and revised codes based, in part, on
our review of recommendations received from the American Medical
Association/Specialty Society Relative Value Update Committee (AMA
RUC).
b. Practice Expense RVUs
Initially, only the work RVUs were resource-based, and the PE and
MP RVUs were based on average allowable charges. Section 121 of the
Social Security Act Amendments of 1994 (Pub. L. 103-432, enacted on
October 31, 1994), amended section 1848(c)(2)(C)(ii) of the Act and
required us to develop resource-based PE RVUs for each physicians'
service beginning in 1998. We were required to consider general
categories of expenses (such as office rent and wages of personnel, but
excluding malpractice expenses) comprising PEs. Originally, this new
method was to be used beginning in 1998, but section 4505(a) of the
Balanced Budget Act of 1997 (BBA) (Pub. L. 105-33, enacted on August 5,
1997) delayed implementation of the resource-based PE RVU system until
January 1, 1999. In addition, section 4505(b) of the BBA provided for a
4-year transition period from the charge-based PE RVUs to the resource-
based PE RVUs.
We established the resource-based PE RVUs for each physicians'
service in a final rule, published November 2, 1998 (63 FR 58814),
effective for services furnished in CY 1999. Based on the requirement
to transition to a resource-based system for PE over a 4-year period,
payment rates were not fully based upon resource-based PE RVUs until CY
2002. This resource-based system was based on two significant sources
of actual PE data: the Clinical Practice Expert Panel (CPEP) data and
the AMA's Socioeconomic Monitoring System (SMS) data. (These data
sources are described in greater detail in the CY 2012 final rule with
comment period (76 FR 73033).)
Separate PE RVUs are established for services furnished in facility
settings, such as a hospital outpatient department (HOPD) or an
ambulatory surgical center (ASC), and in nonfacility settings, such as
a physician's office. The nonfacility RVUs reflect all of the direct
and indirect PEs involved in furnishing a service described by a
particular HCPCS code. The difference, if any, in these PE RVUs
generally results in a higher payment in the nonfacility setting
because in the facility settings some costs are borne by the facility.
Medicare's payment to the facility (such as the OPPS payment to the
HOPD) would reflect costs typically incurred by the facility. Thus,
payment associated with those facility resources is not made under the
PFS.
Section 212 of the Balanced Budget Refinement Act of 1999 (BBRA)
(Pub. L. 106-113, enacted on November 29, 1999) directed the Secretary
of Health and Human Services (the Secretary) to establish a process
under which we accept and use, to the maximum extent practicable and
consistent with sound data practices, data collected or developed by
entities and organizations to supplement the data we normally collect
in determining the PE component. On May 3, 2000, we published the
interim final rule (65 FR 25664) that set forth the criteria for the
submission of these supplemental PE survey data. The criteria were
modified in response to comments received, and published in the Federal
Register (65 FR 65376) as part of a November 1, 2000 final rule. The
PFS final rules published in 2001 and 2003, respectively, (66 FR 55246
and 68 FR 63196) extended the period during which we would accept these
supplemental data through March 1, 2005.
In the CY 2007 PFS final rule with comment period (71 FR 69624), we
revised the methodology for calculating direct PE RVUs from the top-
down to the bottom-up methodology beginning in CY 2007. We adopted a 4-
year transition to the new PE RVUs. This transition was completed for
CY 2010. In the CY 2010 PFS final rule with comment period, we updated
the practice expense per hour (PE/HR) data that are used in the
calculation of PE RVUs for most specialties (74 FR 61749). In CY 2010,
we began a 4-year

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transition to the new PE RVUs using the updated PE/HR data, which was
completed for CY 2013.
c. Malpractice RVUs
Section 4505(f) of the BBA amended section 1848(c) of the Act to
require that we implement resource-based MP RVUs for services furnished
on or after CY 2000. The resource-based MP RVUs were implemented in the
PFS final rule with comment period published November 2, 1999 (64 FR
59380). The MP RVUs are based on malpractice insurance premium data
collected from commercial and physician-owned insurers from all the
states, the District of Columbia, and Puerto Rico.
d. Refinements to the RVUs
Section 1848(c)(2)(B)(i) of the Act requires that we review all
RVUs no less often than every 5 years. Prior to CY 2013, we conducted
periodic reviews of work RVUs and PE RVUs independently. We completed
Five-Year Reviews of Work RVUs that were effective for calendar years
1997, 2002, 2007, and 2012.
While refinements to the direct PE inputs initially relied heavily
on input from the AMA RUC Practice Expense Advisory Committee (PEAC),
the shifts to the bottom-up PE methodology in CY 2007 and to the use of
the updated PE/HR data in CY 2010 have resulted in significant
refinements to the PE RVUs in recent years.
In the CY 2012 PFS final rule with comment period (76 FR 73057), we
finalized a proposal to consolidate reviews of work and PE RVUs under
section 1848(c)(2)(B) of the Act and reviews of potentially misvalued
codes under section 1848(c)(2)(K) of the Act into one annual process.
With regard to MP RVUs, we completed Five-Year Reviews of MP that
were effective in CY 2005 and CY 2010.
In addition to the Five-Year Reviews, beginning for CY 2009, CMS
and the AMA RUC have identified and reviewed a number of potentially
misvalued codes on an annual basis based on various identification
screens. This annual review of work and PE RVUs for potentially
misvalued codes was supplemented by the amendments to section 1848 of
the Act, as enacted by section 3134 of the Affordable Care Act, which
requires the agency to periodically identify, review and adjust values
for potentially misvalued codes with an emphasis on seven specific
categories (see section II.B.2. of this proposed rule).
e. Application of Budget Neutrality to Adjustments of RVUs
As described in section VI.C.1. of this proposed rule, in
accordance with section 1848(c)(2)(B)(ii)(II) of the Act, if revisions
to the RVUs would cause expenditures for the year to change by more
than $20 million, we make adjustments to ensure that expenditures do
not increase or decrease by more than $20 million.
2. Calculation of Payments Based on RVUs
To calculate the payment for each physicians' service, the
components of the fee schedule (work, PE, and MP RVUs) are adjusted by
geographic practice cost indices (GPCIs) to reflect the variations in
the costs of furnishing the services. The GPCIs reflect the relative
costs of physician work, PE, and MP in an area compared to the national
average costs for each component. (See section II.E.2 of this proposed
rule for more information about GPCIs.)
RVUs are converted to dollar amounts through the application of a
CF, which is calculated based on a statutory formula by CMS's Office of
the Actuary (OACT). The CF for a given year is calculated using (a) the
productivity-adjusted increase in the Medicare Economic Index (MEI) and
(b) the Update Adjustment Factor (UAF), which is calculated by taking
into account the Medicare Sustainable Growth Rate (SGR), an annual
growth rate intended to control growth in aggregate Medicare
expenditures for physicians' services, and the allowed and actual
expenditures for physicians' services. A more detailed discussion of
the calculation of the CF, the SGR, and the MEI appears in the PFS
final rule with comment period for each calendar year (the most recent
begins on 77 FR 69131).
The formula for calculating the Medicare fee schedule payment
amount for a given service and fee schedule area can be expressed as:

Payment = [(RVU work x GPCI work) + (RVU PE x GPCI PE) + (RVU MP x GPCI
MP)] x CF
3. Separate Fee Schedule Methodology for Anesthesia Services
Section 1848(b)(2)(B) of the Act specifies that the fee schedule
amounts for anesthesia services are to be based on a uniform relative
value guide, with appropriate adjustment of an anesthesia conversion
factor, in a manner to assure that fee schedule amounts for anesthesia
services are consistent with those for other services of comparable
value. Therefore, there is a separate fee schedule methodology for
anesthesia services. Specifically, we establish a separate conversion
factor for anesthesia services and we utilize the uniform relative
value guide, or base units, as well as time units, to calculate the fee
schedule amounts for anesthesia services. Since anesthesia services are
not valued using RVUs, a separate methodology for locality adjustments
is also necessary. This involves an adjustment to the national
anesthesia CF for each payment locality.
4. Most Recent Changes to the Fee Schedule
The CY 2013 PFS final rule with comment period (77 FR 68892)
implemented changes to the PFS and other Medicare Part B payment
policies. It also finalized many of the CY 2012 interim RVUs and
established interim RVUs for new and revised codes for CY 2013 to
ensure that our payment system is updated to reflect changes in medical
practice, coding changes, and the relative values of services. It also
implemented certain statutory provisions including provisions of the
Affordable Care Act (Pub. L. 111-148) and the Middle Class Tax Relief
and Jobs Creation Act (MCTRJCA) (Pub. L. 112-96), including claims-
based data reporting requirements for therapy services.
In the CY 2013 PFS final rule with comment period, we announced the
following for CY 2013: The total PFS update of -26.5 percent; the
initial estimate for the sustainable growth rate (SGR) of -19.7
percent; and the CY 2013 CF of $25.0008. These figures were calculated
based on the statutory provisions in effect on November 1, 2012, when
the CY 2013 PFS final rule with comment period was issued.
On January 2, 2013, the American Taxpayer Relief Act (ATRA) of 2012
(Pub. L. 112-240) was signed into law. Section 601(a) of the ATRA
specified a zero percent update to the PFS CF for CY 2013. As a result,
the CY 2013 PFS conversion factor was revised to $34.0320. In addition,
the ATRA extended and added several provisions affecting Medicare
services furnished in CY 2013, including:
Section 602--extending the 1.0 floor on the work
geographic practice cost index through CY 2013;
Section 603--extending the exceptions process for
outpatient therapy caps through CY 2013, extending the application of
the cap and manual medical review threshold to services furnished in
the hospital outpatient department (OPD) through CY 2013, and requiring
the counting of a proxy amount for therapy services

[[Page 43286]]

furnished in a Critical Access Hospital (CAH) toward the cap and
threshold during CY 2013.

In addition to the changes effective for CY 2013, section 635 of ATRA
revised the equipment utilization rate assumption for advanced imaging
services furnished on or after January 1, 2014.
On March 5, 2013, we submitted to the Medicare Payment Advisory
Committee (MedPAC) an estimate of the SGR and CF applicable to Medicare
payments for physicians' services for CY 2014, as required by section
1848(d)(1)(E) of the Act. The actual values used to compute physician
payments for CY 2014 will be based on later data and are scheduled to
be published by November 1, 2013 as part of the CY 2014 PFS final rule
with comment period.

II. Provisions of the Proposed Rule for PFS

A. Resource-Based Practice Expense (PE) Relative Value Units (RVUs)

1. Overview
Practice expense (PE) is the portion of the resources used in
furnishing a service that reflects the general categories of physician
and practitioner expenses, such as office rent and personnel wages, but
excluding malpractice expenses, as specified in section 1848(c)(1)(B)
of the Act. Section 121 of the Social Security Amendments of 1994 (Pub.
L. 103-432), enacted on October 31, 1994, amended section
1848(c)(2)(C)(ii) of the Act to require us to develop a methodology for
a resource-based system for determining PE RVUs for each physician's
service. We develop PE RVUs by looking at the direct and indirect
physician practice resources involved in furnishing each service.
Direct expense categories include clinical labor, medical supplies, and
medical equipment. Indirect expenses include administrative labor,
office expense, and all other expenses. The sections that follow
provide more detailed information about the methodology for translating
the resources involved in furnishing each service into service-specific
PE RVUs. In addition, we note that section 1848(c)(2)(B)(ii)(II) of the
Act provides that adjustments in RVUs for a year may not cause total
PFS payments to differ by more than $20 million from what they would
have otherwise been if the adjustments were not made. Therefore, if
revisions to the RVUs cause expenditures to change by more than $20
million, we make adjustments to ensure that expenditures do not
increase or decrease by more than $20 million. We refer readers to the
CY 2010 PFS final rule with comment period (74 FR 61743 through 61748)
for a more detailed explanation of the PE methodology.
2. Practice Expense Methodology
a. Direct Practice Expense
We determine the direct PE for a specific service by adding the
costs of the direct resources (that is, the clinical staff, equipment,
and supplies) typically involved with furnishing that service. The
costs of the resources are calculated using the refined direct PE
inputs assigned to each CPT code in our PE database, which are based on
our review of recommendations received from the AMA RUC. For a detailed
explanation of the direct PE methodology, including examples, we refer
readers to the Five-Year Review of Work Relative Value Units Under the
PFS and Proposed Changes to the Practice Expense Methodology proposed
notice (71 FR 37242) and the CY 2007 PFS final rule with comment period
(71 FR 69629).
b. Indirect Practice Expense per Hour Data
We use survey data on indirect PEs incurred per hour worked in
developing the indirect portion of the PE RVUs. Prior to CY 2010, we
primarily used the practice expense per hour (PE/HR) by specialty that
was obtained from the AMA's Socioeconomic Monitoring Surveys (SMS). The
AMA administered a new survey in CY 2007 and CY 2008, the Physician
Practice Expense Information Survey (PPIS). The PPIS is a
multispecialty, nationally representative, PE survey of both physicians
and nonphysician practitioners (NPPs) paid under the PFS using a survey
instrument and methods highly consistent with those used for the SMS
and the supplemental surveys. The PPIS gathered information from 3,656
respondents across 51 physician specialty and health care professional
groups. We believe the PPIS is the most comprehensive source of PE
survey information available. We used the PPIS data to update the PE/HR
data for the CY 2010 PFS for almost all of the Medicare-recognized
specialties that participated in the survey.
When we began using the PPIS data in CY 2010, we did not change the
PE RVU methodology itself or the manner in which the PE/HR data are
used in that methodology. We only updated the PE/HR data based on the
new survey. Furthermore, as we explained in the CY 2010 PFS final rule
with comment period (74 FR 61751), because of the magnitude of payment
reductions for some specialties resulting from the use of the PPIS
data, we transitioned its use over a 4-year period (75 percent old/25
percent new for CY 2010, 50 percent old/50 percent new for CY 2011, 25
percent old/75 percent new for CY 2012, and 100 percent new for CY
2013) from the previous PE RVUs to the PE RVUs developed using the new
PPIS data. As provided in the CY 2010 PFS final rule with comment
period (74 FR 61751), the transition to the PPIS data was complete in
CY 2013. Therefore, the CY 2014 PE RVUs are developed based entirely on
the PPIS data, except as noted in this section.
Section 1848(c)(2)(H)(i) of the Act requires us to use the medical
oncology supplemental survey data submitted in 2003 for oncology drug
administration services. Therefore, the PE/HR for medical oncology,
hematology, and hematology/oncology reflects the continued use of these
survey data.
Supplemental survey data on independent labs from the College of
American Pathologists were implemented for payments in CY 2005.
Supplemental survey data from the National Coalition of Quality
Diagnostic Imaging Services (NCQDIS), representing independent
diagnostic testing facilities (IDTFs), were blended with supplementary
survey data from the American College of Radiology (ACR) and
implemented for payments in CY 2007. Neither IDTFs, nor independent
labs, participated in the PPIS. Therefore, we continue to use the PE/HR
that was developed from their supplemental survey data.
Consistent with our past practice, the previous indirect PE/HR
values from the supplemental surveys for these specialties were updated
to CY 2006 using the MEI to put them on a comparable basis with the
PPIS data.
We also do not use the PPIS data for reproductive endocrinology and
spine surgery since these specialties currently are not separately
recognized by Medicare, nor do we have a method to blend the PPIS data
with Medicare-recognized specialty data.
We do not use the PPIS data for sleep medicine since there is not a
full year of Medicare utilization data for that specialty given the
specialty code was only available beginning in October 1, 2012. We
anticipate using the PPIS data to create PE/HR for sleep medicine for
CY 2015 when we will have a full year of data to make the calculations.
Previously, we established PE/HR values for various specialties
without SMS or supplemental survey data by crosswalking them to other
similar specialties to estimate a proxy PE/HR. For specialties that
were part of the PPIS

[[Page 43287]]

for which we previously used a crosswalked PE/HR, we instead used the
PPIS-based PE/HR. We continue previous crosswalks for specialties that
did not participate in the PPIS. However, beginning in CY 2010 we
changed the PE/HR crosswalk for portable x-ray suppliers from radiology
to IDTF, a more appropriate crosswalk because these specialties are
more similar to each other with respect to physician time.
For registered dietician services, the resource-based PE RVUs have
been calculated in accordance with the final policy that crosswalks the
specialty to the ``All Physicians'' PE/HR data, as adopted in the CY
2010 PFS final rule with comment period (74 FR 61752) and discussed in
more detail in the CY 2011 PFS final rule with comment period (75 FR
73183).
c. Allocation of PE to Services
To establish PE RVUs for specific services, it is necessary to
establish the direct and indirect PE associated with each service.
(1) Direct Costs
The relative relationship between the direct cost portions of the
PE RVUs for any two services is determined by the relative relationship
between the sum of the direct cost resources (that is, the clinical
staff, equipment, and supplies) typically involved with furnishing each
of the services. The costs of these resources are calculated from the
refined direct PE inputs in our PE database. For example, if one
service has a direct cost sum of $400 from our PE database and another
service has a direct cost sum of $200, the direct portion of the PE
RVUs of the first service would be twice as much as the direct portion
of the PE RVUs for the second service.
(2) Indirect Costs
Section II.A.2.b. of this proposed rule describes the current data
sources for specialty-specific indirect costs used in our PE
calculations. We allocated the indirect costs to the code level on the
basis of the direct costs specifically associated with a code and the
greater of either the clinical labor costs or the physician work RVUs.
We also incorporated the survey data described earlier in the PE/HR
discussion. The general approach to developing the indirect portion of
the PE RVUs is described as follows:
For a given service, we use the direct portion of the PE
RVUs calculated as previously described and the average percentage that
direct costs represent of total costs (based on survey data) across the
specialties that furnish the service to determine an initial indirect
allocator. In other words, the initial indirect allocator is calculated
so that the direct costs equal the average percentage of direct costs
of those specialties furnishing the service. For example, if the direct
portion of the PE RVUs for a given service is 2.00 and direct costs, on
average, represented 25 percent of total costs for the specialties that
furnished the service, the initial indirect allocator would be
calculated so that it equals 75 percent of the total PE RVUs. Thus, in
this example the initial indirect allocator would equal 6.00, resulting
in a total PE RVUs of 8.00 (2.00 is 25 percent of 8.00 and 6.00 is 75
percent of 8.00).
Next, we add the greater of the work RVUs or clinical
labor portion of the direct portion of the PE RVUs to this initial
indirect allocator. In our example, if this service had work RVUs of
4.00 and the clinical labor portion of the direct PE RVUs was 1.50, we
would add 4.00 (since the 4.00 work RVUs are greater than the 1.50
clinical labor portion) to the initial indirect allocator of 6.00 to
get an indirect allocator of 10.00. In the absence of any further use
of the survey data, the relative relationship between the indirect cost
portions of the PE RVUs for any two services would be determined by the
relative relationship between these indirect cost allocators. For
example, if one service had an indirect cost allocator of 10.00 and
another service had an indirect cost allocator of 5.00, the indirect
portion of the PE RVUs of the first service would be twice as great as
the indirect portion of the PE RVUs for the second service.
Next, we incorporate the specialty-specific indirect PE/HR
data into the calculation. In our example, if based on the survey data,
the average indirect cost of the specialties furnishing the first
service with an allocator of 10.00 was half of the average indirect
cost of the specialties furnishing the second service with an indirect
allocator of 5.00, the indirect portion of the PE RVUs of the first
service would be equal to that of the second service.
d. Facility and Nonfacility Costs
For procedures that can be furnished in a physician's office, as
well as in a hospital or facility setting, we establish two PE RVUs:
facility and nonfacility. The methodology for calculating PE RVUs is
the same for both the facility and nonfacility RVUs, but is applied
independently to yield two separate PE RVUs. Because in calculating the
PE RVUs for services furnished in a facility, we do not include
resources that would generally not be provided by physicians when
furnishing the service in a facility, the facility PE RVUs are
generally lower than the nonfacility PE RVUs. Medicare makes a separate
payment to the facility for its costs of furnishing a service.
e. Services With Technical Components (TCs) and Professional Components
(PCs)
Diagnostic services are generally comprised of two components: a
professional component (PC); and a technical component (TC). The PC and
TC may be furnished independently or by different providers, or they
may be furnished together as a ``global'' service. When services have
PC and TC components that can be billed separately, the payment for the
global service equals the sum of the payment for the TC and PC. This is
a result of using a weighted average of the ratio of indirect to direct
costs across all the specialties that furnish the global service, TCs,
and PCs; that is, we apply the same weighted average indirect
percentage factor to allocate indirect expenses to the global service,
PCs, and TCs for a service. (The direct PE RVUs for the TC and PC sum
to the global under the bottom-up methodology.)
f. PE RVU Methodology
For a more detailed description of the PE RVU methodology, we refer
readers to the CY 2010 PFS final rule with comment period (74 FR 61745
through 61746).
(1) Setup File
First, we create a setup file for the PE methodology. The setup
file contains the direct cost inputs, the utilization for each
procedure code at the specialty and facility/nonfacility place of
service level, and the specialty-specific PE/HR data calculated from
the surveys.
(2) Calculate the Direct Cost PE RVUs
Sum the costs of each direct input.
Step 1: Sum the direct costs of the inputs for each service. Apply
a scaling adjustment to the direct inputs.
Step 2: Calculate the current aggregate pool of direct PE costs.
This is the product of the current aggregate PE (aggregate direct and
indirect) RVUs, the CF, and the average direct PE percentage from the
survey data.
Step 3: Calculate the aggregate pool of direct costs. This is the
sum of the product of the direct costs for each service from Step 1 and
the utilization data for that service. For CY 2014, we adjusted the
direct cost pool to match the new PE share of the MEI, as discussed in
section II.D. of this rule.

[[Page 43288]]

Step 4: Using the results of Step 2 and Step 3 calculate a direct
PE scaling adjustment so that the aggregate direct cost pool does not
exceed the current aggregate direct cost pool and apply it to the
direct costs from Step 1 for each service.
Step 5: Convert the results of Step 4 to an RVU scale for each
service. To do this, divide the results of Step 4 by the CF. Note that
the actual value of the CF used in this calculation does not influence
the final direct cost PE RVUs, as long as the same CF is used in Step 2
and Step 5. Different CFs will result in different direct PE scaling
factors, but this has no effect on the final direct cost PE RVUs since
changes in the CFs and changes in the associated direct scaling factors
offset one another.
(3) Create the Indirect Cost PE RVUs
Create indirect allocators.
Step 6: Based on the survey data, calculate direct and indirect PE
percentages for each physician specialty.
Step 7: Calculate direct and indirect PE percentages at the service
level by taking a weighted average of the results of Step 6 for the
specialties that furnish the service. Note that for services with TCs
and PCs, the direct and indirect percentages for a given service do not
vary by the PC, TC, and global service.
Step 8: Calculate the service level allocators for the indirect PEs
based on the percentages calculated in Step 7. The indirect PEs are
allocated based on the three components: the direct PE RVUs; the
clinical PE RVUs; and the work RVUs. For most services the indirect
allocator is: Indirect percentage * (direct PE RVUs/direct percentage)
+ work RVUs.
There are two situations where this formula is modified:
If the service is a global service (that is, a service
with global, professional, and technical components), then the indirect
allocator is: Indirect percentage (direct PE RVUs/direct percentage) +
clinical PE RVUs + work RVUs.
If the clinical labor PE RVUs exceed the work RVUs (and
the service is not a global service), then the indirect allocator is:
Indirect percentage (direct PE RVUs/direct percentage) + clinical PE
RVUs.

Note: For global services, the indirect allocator is based on
both the work RVUs and the clinical labor PE RVUs. We do this to
recognize that, for the PC service, indirect PEs will be allocated
using the work RVUs, and for the TC service, indirect PEs will be
allocated using the direct PE RVUs and the clinical labor PE RVUs.
This also allows the global component RVUs to equal the sum of the
PC and TC RVUs.

For presentation purposes in the examples in Table 5, the formulas
were divided into two parts for each service.
The first part does not vary by service and is the
indirect percentage (direct PE RVUs/direct percentage).
The second part is either the work RVU, clinical labor PE
RVU, or both depending on whether the service is a global service and
whether the clinical PE RVUs exceed the work RVUs (as described earlier
in this step).
Apply a scaling adjustment to the indirect allocators.
Step 9: Calculate the current aggregate pool of indirect PE RVUs by
multiplying the current aggregate pool of PE RVUs by the average
indirect PE percentage from the survey data.
Step 10: Calculate an aggregate pool of indirect PE RVUs for all
PFS services by adding the product of the indirect PE allocators for a
service from Step 8 and the utilization data for that service. For CY
2014, we adjusted the indirect cost pool to match the new PE share of
the MEI, as discussed in section II.D. of this rule.
Step 11: Using the results of Step 9 and Step 10, calculate an
indirect PE adjustment so that the aggregate indirect allocation does
not exceed the available aggregate indirect PE RVUs and apply it to
indirect allocators calculated in Step 8.
Calculate the indirect practice cost index.
Step 12: Using the results of Step 11, calculate aggregate pools of
specialty-specific adjusted indirect PE allocators for all PFS services
for a specialty by adding the product of the adjusted indirect PE
allocator for each service and the utilization data for that service.
Step 13: Using the specialty-specific indirect PE/HR data,
calculate specialty-specific aggregate pools of indirect PE for all PFS
services for that specialty by adding the product of the indirect PE/HR
for the specialty, the physician time for the service, and the
specialty's utilization for the service across all services furnished
by the specialty.
Step 14: Using the results of Step 12 and Step 13, calculate the
specialty-specific indirect PE scaling factors.
Step 15: Using the results of Step 14, calculate an indirect
practice cost index at the specialty level by dividing each specialty-
specific indirect scaling factor by the average indirect scaling factor
for the entire PFS.
Step 16: Calculate the indirect practice cost index at the service
level to ensure the capture of all indirect costs. Calculate a weighted
average of the practice cost index values for the specialties that
furnish the service. (Note: For services with TCs and PCs, we calculate
the indirect practice cost index across the global service, PCs, and
TCs. Under this method, the indirect practice cost index for a given
service (for example, echocardiogram) does not vary by the PC, TC, and
global service.)
Step 17: Apply the service level indirect practice cost index
calculated in Step 16 to the service level adjusted indirect allocators
calculated in Step 11 to get the indirect PE RVUs.
(4) Calculate the Final PE RVUs
Step 18: Add the direct PE RVUs from Step 6 to the indirect PE RVUs
from Step 17 and apply the final PE budget neutrality (BN) adjustment
and the MEI revision adjustment.
The final PE BN adjustment is calculated by comparing the results
of Step 18 to the current pool of PE RVUs (prior to the MEI revision
adjustment and the OPPS/ASC cap redistribution). This final BN
adjustment is required to redistribute RVUs from step 18 to all PE RVUs
in the PFS, and because certain specialties are excluded from the PE
RVU calculation for ratesetting purposes, but all specialties are
included for purposes of calculating the final BN adjustment. (See
``Specialties excluded from ratesetting calculation'' later in this
section.) As discussed in section II.D. of this proposed rule, we are
revising the Medicare Economic Index (MEI) for CY 2014.
Step 19: Consistent with the proposed policy addressed in section
II.A.4. of this proposed rule, apply the OPPS/ASC cap to codes subject
to the cap and redistribute the RVU reduction to the PE RVUs for all
other services.
(5) Setup File Information
Specialties excluded from ratesetting calculation: For the
purposes of calculating the PE RVUs, we exclude certain specialties,
such as certain nonphysician practitioners paid at a percentage of the
PFS and low-volume specialties, from the calculation. These specialties
are included for the purposes of calculating the BN adjustment. They
are displayed in Table 1.

[[Page 43289]]

Table 1--Specialties Excluded From Ratesetting Calculation
------------------------------------------------------------------------
Specialty code Specialty description
------------------------------------------------------------------------
49.................... Ambulatory surgical center.
50.................... Nurse practitioner.
51.................... Medical supply company with certified orthotist.
52.................... Medical supply company with certified
prosthetist.
53.................... Medical supply company with certified
prosthetist[dash]orthotist.
54.................... Medical supply company not included in 51, 52,
or 53.
55.................... Individual certified orthotist.
56.................... Individual certified prosthestist.
57.................... Individual certified prosthetist[dash]orthotist.
58.................... Individuals not included in 55, 56, or 57.
59.................... Ambulance service supplier, e.g., private
ambulance companies, funeral homes, etc.
60.................... Public health or welfare agencies.
61.................... Voluntary health or charitable agencies.
73.................... Mass immunization roster biller.
74.................... Radiation therapy centers.
87.................... All other suppliers (e.g., drug and department
stores).
88.................... Unknown supplier/provider specialty.
89.................... Certified clinical nurse specialist.
95.................... Competitive Acquisition Program (CAP) Vendor.
96.................... Optician.
97.................... Physician assistant.
A0.................... Hospital.
A1.................... SNF.
A2.................... Intermediate care nursing facility.
A3.................... Nursing facility, other.
A4.................... HHA.
A5.................... Pharmacy.
A6.................... Medical supply company with respiratory
therapist.
A7.................... Department store.
1..................... Supplier of oxygen and/or oxygen related
equipment.
2..................... Pedorthic personnel.
3..................... Medical supply company with pedorthic personnel.
------------------------------------------------------------------------

Crosswalk certain low volume physician specialties:
Crosswalk the utilization of certain specialties with relatively low
PFS utilization to the associated specialties.
Physical therapy utilization: Crosswalk the utilization
associated with all physical therapy services to the specialty of
physical therapy.
Identify professional and technical services not
identified under the usual TC and 26 modifiers: Flag the services that
are PC and TC services, but do not use TC and 26 modifiers (for
example, electrocardiograms). This flag associates the PC and TC with
the associated global code for use in creating the indirect PE RVUs.
For example, the professional service, CPT code 93010
(Electrocardiogram, routine ECG with at least 12 leads; interpretation
and report only), is associated with the global service, CPT code 93000
(Electrocardiogram, routine ECG with at least 12 leads; with
interpretation and report).
Payment modifiers: Payment modifiers are accounted for in
the creation of the file consistent with current payment policy as
implemented in claims processing. For example, services billed with the
assistant at surgery modifier are paid 16 percent of the PFS amount for
that service; therefore, the utilization file is modified to only
account for 16 percent of any service that contains the assistant at
surgery modifier. Similarly, for those services to which volume
adjustments are made to account for the payment modifiers, time
adjustments are applied as well. For time adjustments to surgical
services, the intraoperative portion in the physician time file is
used; where it is not present, the intraoperative percentage from the
payment files used by contractors to process Medicare claims is used
instead. Where neither is available, we use the payment adjustment
ratio to adjust the time accordingly. Table 2 details the manner in
which the modifiers are applied.

Table 2--Application of Payment Modifiers to Utilization Files
----------------------------------------------------------------------------------------------------------------
Modifier Description Volume adjustment Time adjustment
----------------------------------------------------------------------------------------------------------------
80, 81, 82........................... Assistant at Surgery... 16%.................... Intraoperative portion.
AS................................... Assistant at Surgery-- 14% (85% * 16%)........ Intraoperative portion.
Physician Assistant.
50 or LT and RT...................... Bilateral Surgery...... 150%................... 150% of physician time.
51................................... Multiple Procedure..... 50%.................... Intraoperative portion.
52................................... Reduced Services....... 50%.................... 50%.
53................................... Discontinued Procedure. 50%.................... 50%.
54................................... Intraoperative Care Preoperative + Preoperative +
only. Intraoperative Intraoperative
Percentages on the portion.
payment files used by
Medicare contractors
to process Medicare
claims.

[[Page 43290]]

55................................... Postoperative Care only Postoperative Postoperative portion.
Percentage on the
payment files used by
Medicare contractors
to process Medicare
claims.
62................................... Co-surgeons............ 62.5%.................. 50%.
66................................... Team Surgeons.......... 33%.................... 33%.
----------------------------------------------------------------------------------------------------------------

We also make adjustments to volume and time that correspond to
other payment rules, including special multiple procedure endoscopy
rules and multiple procedure payment reductions (MPPR). We note that
section 1848(c)(2)(B)(v) of the Act exempts certain reduced payments
for multiple imaging procedures and multiple therapy services from the
BN calculation under section 1848(c)(2)(B)(ii)(II) of the Act. These
MPPRs are not included in the development of the RVUs.
For anesthesia services, we do not apply adjustments to volume
since the average allowed charge is used when simulating RVUs, and
therefore, includes all adjustments. A time adjustment of 33 percent is
made only for medical direction of two to four cases since that is the
only situation where time units are duplicative.
Work RVUs: The setup file contains the work RVUs from this
proposed rule with comment period.
(6) Equipment Cost per Minute
The equipment cost per minute is calculated as:

(1/(minutes per year * usage)) * price * ((interest rate/(1-(1/((1 +
interest rate)[caret] life of equipment)))) + maintenance)

Where:
minutes per year = maximum minutes per year if usage were continuous
(that is, usage = 1); generally 150,000 minutes.
usage = variable, see discussion below.
price = price of the particular piece of equipment.
life of equipment = useful life of the particular piece of
equipment.
maintenance = factor for maintenance; 0.05.
interest rate = variable, see discussion below.

Usage: We currently use an equipment utilization rate assumption of
50 percent for most equipment, with the exception of expensive
diagnostic imaging equipment. For expensive diagnostic imaging
equipment, which is equipment priced at over $1 million (for example,
computed tomography (CT) and magnetic resonance imaging (MRI)
scanners), we use an equipment utilization rate assumption of 75
percent. Section 1848(b)(4)(C) of the Act, as modified by section 635
of the America Taxpayer Relief Act of 2012 (Pub. L. 112-240, enacted on
January 2, 2013) (ATRA), requires that for fee schedules established
for CY 2014 and subsequent years, in the methodology for determining PE
RVUs for expensive diagnostic imaging equipment, the Secretary shall
use a 90 percent assumption. The provision also requires that the
reduced expenditures attributable to this change in the utilization
rate for CY 2014 and subsequent years shall not be taken into account
when applying the BN limitation on annual adjustments described in
section 1848(c)(2)(B)(ii)(II) of the Act. We are applying the 90
percent utilization rate assumption in CY 2014 to all of the services
to which the 75 percent equipment utilization rate assumption applied
in CY 2013. These services are listed in a file called ``CY 2014 CPT
Codes Subject to 90 Percent Usage Rate,'' available on the CMS Web site
under downloads for the CY 2014 PFS proposed rule at http://www.cms.gov/physicianfeesched/downloads/. These codes are also
displayed in Table 3.

Table 3--CPT Codes Subject to 90 Percent Equipment Utilization Rate
Assumption
------------------------------------------------------------------------
CPT code Short descriptor
------------------------------------------------------------------------
70336............................ Mri, temporomandibular joint(s).
70450............................ Ct head/brain w/o dye.
70460............................ Ct head/brain w/dye.
70470............................ Ct head/brain w/o & w/dye.
70480............................ Ct orbit/ear/fossa w/o dye.
70481............................ Ct orbit/ear/fossa w/dye.
70482............................ Ct orbit/ear/fossa w/o & w/dye.
70486............................ Ct maxillofacial w/o dye.
70487............................ Ct maxillofacial w/dye.
70488............................ Ct maxillofacial w/o & w/dye.
70490............................ Ct soft tissue neck w/o dye.
70491............................ Ct soft tissue neck w/dye.
70492............................ Ct soft tissue neck w/o & w/dye.
70496............................ Ct angiography, head.
70498............................ Ct angiography, neck.
70540............................ Mri orbit/face/neck w/o dye.
70542............................ Mri orbit/face/neck w/dye.
70543............................ Mri orbit/face/neck w/o & w/dye.
70544............................ Mr angiography head w/o dye.
70545............................ Mr angiography head w/dye.
70546............................ Mr angiography head w/o & w/dye.
70547............................ Mr angiography neck w/o dye.
70548............................ Mr angiography neck w/dye.
70549............................ Mr angiography neck w/o & w/dye.
70551............................ Mri brain w/o dye.
70552............................ Mri brain w/dye.
70553............................ Mri brain w/o & w/dye.
70554............................ Fmri brain by tech.
71250............................ Ct thorax w/o dye.
71260............................ Ct thorax w/dye.
71270............................ Ct thorax w/o & w/dye.
71275............................ Ct angiography, chest.
71550............................ Mri chest w/o dye.
71551............................ Mri chest w/dye.
71552............................ Mri chest w/o & w/dye.
71555............................ Mri angio chest w/or w/o dye.
72125............................ CT neck spine w/o dye.
72126............................ Ct neck spine w/dye.
72127............................ Ct neck spine w/o & w/dye.
72128............................ Ct chest spine w/o dye.
72129............................ Ct chest spine w/dye.
72130............................ Ct chest spine w/o & w/dye.
72131............................ Ct lumbar spine w/o dye.
72132............................ Ct lumbar spine w/dye.
72133............................ Ct lumbar spine w/o & w/dye.
72141............................ Mri neck spine w/o dye.
72142............................ Mri neck spine w/dye.
72146............................ Mri chest spine w/o dye.
72147............................ Mri chest spine w/dye.
72148............................ Mri lumbar spine w/o dye.
72149............................ Mri lumbar spine w/dye.
72156............................ Mri neck spine w/o & w/dye.
72157............................ Mri chest spine w/o & w/dye.
72158............................ Mri lumbar spine w/o & w/dye.
72159............................ Mr angio spone w/o&w/dye.
72191............................ Ct angiography, pelv w/o & w/dye.
72192............................ Ct pelvis w/o dye.
72193............................ Ct pelvis w/dye.
72194............................ Ct pelvis w/o & w/dye.
72195............................ Mri pelvis w/o dye.
72196............................ Mri pelvis w/dye.
72197............................ Mri pelvis w/o &w/dye.
72198............................ Mri angio pelvis w/or w/o dye.
73200............................ Ct upper extremity w/o dye.
73201............................ Ct upper extremity w/dye.
73202............................ Ct upper extremity w/o & w/dye.
73206............................ Ct angio upper extr w/o & w/dye.
73218............................ Mri upper extr w/o dye.
73219............................ Mri upper extr w/dye.
73220............................ Mri upper extremity w/o & w/dye.
73221............................ Mri joint upper extr w/o dye.
73222............................ Mri joint upper extr w/dye.
73223............................ Mri joint upper extr w/o & w/dye.
73225............................ Mr angio upr extr w/o&w/dye.
73700............................ Ct lower extremity w/o dye.
73701............................ Ct lower extremity w/dye.

[[Page 43291]]

73702............................ Ct lower extremity w/o & w/dye.
73706............................ Ct angio lower ext w/o & w/dye.
73718............................ Mri lower extremity w/o dye.
73719............................ Mri lower extremity w/dye.
73720............................ Mri lower ext w/& w/o dye.
73721............................ Mri joint of lwr extre w/o dye.
73722............................ Mri joint of lwr extr w/dye.
73723............................ Mri joint of lwr extr w/o & w/dye.
73725............................ Mr angio lower ext w or w/o dye.
74150............................ Ct abdomen w/o dye.
74160............................ Ct abdomen w/dye.
74170............................ Ct abdomen w/o & w/dye.
74174............................ Ct angiography, abdomen and pelvis w/
o & w/dye.
74175............................ Ct angiography, abdom w/o & w/dye.
74176............................ Ct abdomen and pelvis w/o dye.
74177............................ Ct abdomen and pelvis w/dye.
74178............................ Ct abdomen and pelvis w/and w/o dye.
74181............................ Mri abdomen w/o dye.
74182............................ Mri abdomen w/dye.
74183............................ Mri abdomen w/o and w/dye.
74185............................ Mri angio, abdom w/or w/o dye.
74261............................ Ct colonography, w/o dye.
74262............................ Ct colonography, w/dye.
75557............................ Cardiac mri for morph.
75559............................ Cardiac mri w/stress img.
75561............................ Cardiac mri for morph w/dye.
75563............................ Cardiac mri w/stress img & dye.
75565............................ Card mri vel flw map add-on.
75571............................ Ct hrt w/o dye w/ca test.
75572............................ Ct hrt w/3d image.
75573............................ Ct hrt w/3d image, congen.
75574............................ Ct angio hrt w/3d image.
75635............................ Ct angio abdominal arteries.
76380............................ CAT scan follow up study.
77058............................ Mri, one breast.
77059............................ Mri, broth breasts.
77078............................ Ct bone density, axial.
77084............................ Magnetic image, bone marrow.
------------------------------------------------------------------------

Interest Rate: In the CY 2013 final rule with comment period (77 FR
68902), we updated the interest rates used in developing an equipment
cost per minute calculation. The interest rate was based on the Small
Business Administration (SBA) maximum interest rates for different
categories of loan size (equipment cost) and maturity (useful life).
The interest rates are listed in Table 4. See 77 FR 68902 for a
thorough discussion of this issue.

Table 4--SBA Maximum Interest Rates
------------------------------------------------------------------------
Interest
Price Useful life rate
(percent)
------------------------------------------------------------------------
<$25K.............................. <7 Years.............. 7.50
$25K to $50K....................... <7 Years.............. 6.50
>$50K.............................. <7 Years.............. 5.50
<$25K.............................. 7+ Years.............. 8.00
$25K to $50K....................... 7+ Years.............. 7.00
>$50K.............................. 7+ Years.............. 6.00
------------------------------------------------------------------------
See 77 FR 68902 for a thorough discussion of this issue.

[[Page 43292]]

Table 5--Calculation of PE RVUs Under Methodology for Selected Codes
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
99213 33533
Office CABG, 71020 71020-TC 71020-26 93000 ECG, 93005 ECG, 93010 ECG,
Step Source Formula visit, est arterial, Chest x- Chest x- Chest x- complete tracing report non-
non- single ray non- ray non- ray non- non- non- facility
facility facility facility facility facility facility facility
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
(1) Labor cost (Lab)............. Step 1............. AMA................ ................... 13.32 77.52 5.74 5.74 0.00 6.12 6.12 0.00
(2) Supply cost (Sup)............ Step 1............. AMA................ ................... 2.98 0.00 3.39 3.39 0.00 1.19 1.19 0.00
(3) Equipment cost (Eqp)......... Step 1............. AMA................ ................... 0.17 0.58 7.24 7.24 0.00 0.11 0.11 0.00
(4) Direct cost (Dir)............ Step 1............. ................... =(1)+(2)+(3)....... 16.48 78.10 16.38 16.38 0.00 7.42 7.42 0.00
(5) Direct adjustment (Dir. Adj.) Steps 2-4.......... See footnote*...... ................... 0.5427 0.5427 0.5427 0.5427 0.5427 0.5427 0.5427 0.5427
(6) Adjusted Labor............... Steps 2-4.......... =Labor * Dir Adj... =(1)*(5)........... 7.23 42.07 3.11 3.11 0.00 3.32 3.32 0.00
(7) Adjusted Supplies............ Steps 2-4.......... =Eqp * Dir Adj..... =(2)*(5)........... 1.62 0.00 1.84 1.84 0.00 0.65 0.65 0.00
(8) Adjusted Equipment........... Steps 2-4.......... =Sup * Dir Adj..... =(3)*(5)........... 0.09 0.32 3.93 3.93 0.00 0.06 0.06 0.00
(9) Adjusted Direct.............. Steps 2-4.......... ................... =(6)+(7)+(8)....... 8.94 42.39 8.89 8.89 0.00 4.03 4.03 0.00
(10) Conversion Factor (CF)...... Step 5............. PFS................ ................... 34.0230 34.0230 34.0230 34.0230 34.0230 34.0230 34.0230 34.0230
(11) Adj. labor cost converted... Step 5............. =(Lab * Dir Adj)/CF =(6)/(10).......... 0.21 1.24 0.09 0.09 0.00 0.10 0.10 0.00
(12) Adj. supply cost converted.. Step 5............. =(Sup * Dir Adj)/CF =(7)/(10).......... 0.05 0.00 0.05 0.05 0.00 0.02 0.02 0.00
(13) Adj. equipment cost Step 5............. =(Eqp * Dir Adj)/CF =(8)/(10).......... 0.00 0.01 0.12 0.12 0.00 0.00 0.00 0.00
converted.
(14) Adj. direct cost converted.. Step 5............. ................... =(11)+(12)+(13).... 0.26 1.25 0.26 0.26 0.00 0.12 0.12 0.00
(15) Work RVU.................... Setup File......... PFS................ ................... 0.97 33.75 0.22 0.00 0.22 0.17 0.00 0.17
(16) Dir--pct.................... Steps 6,7.......... Surveys............ ................... 0.31 0.18 0.31 0.31 0.31 0.31 0.31 0.31
(17) Ind--pct.................... Steps 6,7.......... Surveys............ ................... 0.69 0.82 0.69 0.69 0.69 0.69 0.69 0.69
(18) Ind. Alloc. Formula (1st Step 8............. See Step 8......... ................... ((14)/ ((14)/ ((14)/ ((14)/ ((14)/ ((14)/ ((14)/ ((14)/
part). (16)*(17) (16)*(17) (16)*(17) (16)*(17) (16)*(17) (16)*(17) (16)*(17) (16)*(17)
(19) Ind. Alloc.(1st part)....... Step 8............. ................... See 18............. 0.79 5.87 0.64 0.64 0.00 0.29 0.29 0.00
(20) Ind. Alloc. Formula (2nd Step 8............. See Step 8......... ................... (15) (15) (15+11) (11) (15) (15+11) (11) (15)
part).
(21) Ind. Alloc.(2nd part)....... Step 8............. ................... See 20............. 0.97 33.75 0.31 0.09 0.22 0.27 0.10 0.17
(22) Indirect Allocator (1st + Step 8............. ................... =(19)+(21)......... 1.76 39.62 0.95 0.73 0.22 0.56 0.39 0.17
2nd).
(23) Indirect Adjustment (Ind. Steps 9-11......... See Footnote**..... ................... 0.3826 0.3826 0.3826 0.3826 0.3826 0.3826 0.3826 0.3826
Adj.).
(24) Adjusted Indirect Allocator. Steps 9-11......... =Ind Alloc * Ind ................... 0.67 15.16 0.36 0.28 0.08 0.21 0.15 0.07
Adj.
(25) Ind. Practice Cost Index Steps 12-16........ ................... ................... 1.08 0.77 0.93 0.93 0.93 0.91 0.91 0.91
(IPCI).
(26) Adjusted Indirect........... Step 17............ = Adj.Ind Alloc * =(24)*(25)......... 0.73 11.60 0.34 0.26 0.08 0.19 0.14 0.06
PCI.
(27) Pre-Cap PE RVU.............. Step 18............ =(Adj Dir + Adj =((14)+(26)) * 0.98 12.78 0.61 0.53 0.08 0.32 0.26 0.06
Ind) * Other Adj. Other Adj)***.
(28) OPPS/ASC Cap Adj............ Step 19............ PFS................ ................... 1.016 1.016 1.016 1.016 1.016 1.016 1.016 1.016
(29) Final PE RVU................ Step 19............ PE RVU * OPPS/ASC (27)*(28).......... 1.00 12.99 0.62 0.54 0.08 0.32 0.26 0.06
Cap Adj.
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Note: PE RVUs in Table 5, row 28, may not match Addendum B due to rounding.
* The direct adj = [current PE RVUs * CF * avg dir pct]/[sum direct inputs] = [Step 2]/[Step 3]
** The indirect adj = [current PE RVUs * avg ind pct]/[sum of ind allocators] = [Step 9]/[Step 10]
*** The other adjustment includes adjustments for the changes in the equipment utilization rate for certain services and the MEI revisions.
Note: The use of any particular conversion factor (CF) in Table 5 to illustrate the PE calculation has no effect on the resulting RVUs.

[[Page 43293]]

3. Changes to Direct PE Inputs for Specific Services
In this section, we discuss other CY 2014 proposals and revisions
related to direct PE inputs for specific services. The proposed
revisions are included in the proposed rule CY 2014 direct PE database,
which is available on the CMS Web site under the supporting data files
for the CY 2014 PFS proposed rule with comment period at www.cms.gov/PhysicianFeeSched/.
a. Anomalous Supply Inputs
In the CY 2013 PFS final rule with comment period, we established
interim final direct PE inputs based on acceptance, with refinement, of
recommendations submitted by the AMA RUC. Although we generally address
public comments on the prior year's interim final direct PE inputs in
the following year's final rule with comment period, several commenters
raised an issue regarding anomalous supply items that we believe is
best addressed through proposed revisions to the direct PE inputs.
For the CY 2013 interim final direct PE inputs for a series of
codes that describe six levels of surgical pathology services (CPT
codes 88300, 88302, 88304, 88305, 88307, 88309), we did not accept the
AMA RUC recommendation to create two new direct PE supply inputs
because we did not consider these items to be disposable supplies (77
FR 69074). The recommended new items were called ``specimen, solvent,
and formalin disposal cost,'' and ``courier transportation costs.'' In
the CY 2013 PFS final rule with comment period, we explained that
neither the specimen and supply disposal nor courier costs for
transporting specimens are appropriately considered disposable medical
supplies. Instead, we stated these costs are incorporated into the PE
RVUs for these services through the indirect PE allocation. We also
noted that the current direct PE inputs for these and similar services
across the PFS do not include these kinds of costs as disposable
supplies.
Several commenters noted that, contrary to our assertion in the
final rule with comment period, there are a few items incorporated in
the direct PE input database as ``supplies'' that are no more
disposable supplies than the new items recommended by the AMA RUC for
the surgical pathology codes. These commenters identified seven supply
inputs in particular that they believe are analogous to the items that
we did not accept in establishing CY 2013 interim final direct PE
inputs. These items and their associated HCPCS codes are listed in
Table 6.

Table 6--Items Identified by Commenters
------------------------------------------------------------------------
CMS supply code Item description Associated CPT codes
------------------------------------------------------------------------
SK106............... device shipping cost.... 93271, 93229, 93268.
SK112............... Federal Express cost 64650, 88363, 64653.
(average across all
zones).
SK113............... communication, wireless 93229.
per service.
SK107............... fee, usage, cycletron/ 77423, 77422.
accelerator,
gammaknife, Lincac SRS
System.
SK110............... fee, image analysis..... 96102, 96101, 99174.
SK111............... fee, licensing, 96102, 96101, 96103,
computer, psychology. 96120.
SD140............... bag system, 1000ml (for 93451, 93452, 93453,
angiography waste 93454, 93455, 93456,
fluids). 93457, 93458, 93459,
93460, 93461.
------------------------------------------------------------------------

We reviewed each of these items for consistency with the general
principles of the PE methodology regarding the consistent
categorization of all costs. Within the PE methodology, all costs other
than clinical labor, disposable supplies, and medical equipment are
considered indirect costs. For six of the items contained in Table 6,
we agree with the commenters that the items should not be considered
disposable supplies. We believe that these items are more appropriately
categorized as indirect PE costs, which are reflected in the allocation
of indirect PE RVUs rather than direct PE. Therefore, we are proposing
to remove the following six items from the direct PE input database for
CY 2014: ``device shipping cost'' (SK106); ``Federal Express cost
(average across all zones)'' (SK112); ``communication, wireless per
service'' (SK113); ``fee, usage, cycletron/accelerator, gammaknife,
Lincac SRS System'' (SK107); ``fee, image analysis'' (SK110); and
``fee, licensing, computer, psychology'' (SK111). The CY 2014 proposed
direct PE input database and Addendum B of this proposed rule reflect
these proposed revisions.
In the case of the supply item called ``bag system, 1000ml (for
angiography waste fluids)'' (SD140), we do not agree with the
commenters that this item is analogous to the specimen disposal costs
recommended for the surgical pathology codes. This supply input
represents only the costs of the disposable material items associated
with the removal of waste fluids that typically result from a
particular procedure. In contrast, the item recommended by the AMA RUC
for surgical pathology consisted of an amortized portion of a specimen
disposal contract that includes costs for resources such as labor and
transportation. Furthermore, we do not believe that the specimen
disposal contract is attributable to individual procedures within the
established PE methodology. We believe that a disposable supply is one
that is attributable, in its entirety, to an individual patient for a
particular service. An amortized portion of a specimen disposal
contract does not meet these criteria. Accordingly, as stated in the CY
2013 final rule with comment period, we did not accept the AMA RUC
recommendation to create a new supply item related to specimen disposal
costs. We believe that many physician offices and other nonfacility
settings where Medicare beneficiaries receive services incur costs
related to waste management or other service contracts, but none of
these costs are currently incorporated into the PE methodology as
disposable supplies. Instead, these costs are appropriately categorized
as indirect costs and are reflected in the PE RVUs through the
allocation of indirect PE. We are clarifying that we believe that
supply costs related to specimen disposal attributable to individual
services may be appropriately categorized as disposable supplies, but
that specimen disposal costs related to an allocated portion of service
contracts that cannot be attributed to individual services should not
be incorporated into the direct PE input database as disposable
supplies.

[[Page 43294]]

Moreover, because do not agree with commenters that the ``bag
system, 1000ml (for angiography waste fluids)'' (SD140) is analogous to
a specimen disposal contract for the reasons state above, we continue
to believe that SD140 is a direct expense. Accordingly, we are not
removing SD140 from the direct PE input database. Additionally, we
anticipate responding to these and other aspects of the comments
regarding the direct PE inputs for the surgical pathology services in
the CY 2014 PFS final rule with comment period.
b. Direct PE Input Refinements based on Routine Data Review
In reviewing the direct PE input database, we have identified
several discrepancies that we believe should be addressed for CY 2014.
In the following paragraphs, we identify the nature of these
discrepancies, the affected codes, and the refinements displayed in the
CY 2014 proposed direct PE input database. As part of our internal
review of information in the direct PE input database, we identified
supply items that appeared without quantities for CPT code 51710
(Change of cystostomy tube; complicated). Upon reviewing these items we
believe that the codes should include the items at the quantities
listed in Table 7.

Table 7--Supply Items and Quantities for CPT Code 51710
------------------------------------------------------------------------
NF
Supply code Description of supply item quantity
------------------------------------------------------------------------
SA069...................... tray, suturing................... 1.0
SB007...................... drape, sterile barrier 16in x 1.0
29in.
SC029...................... needle, 18-27g................... 1.0
SC051...................... syringe 10-12ml.................. 1.0
SD024...................... catheter, Foley.................. 1.0
SD088...................... Guidewire........................ 1.0
SF036...................... suture, nylon, 3-0 to 6-0, c..... 1.0
SG055...................... gauze, sterile 4in x 4in......... 1.0
SG079...................... tape, surgical paper 1in 6.0
(Micropore).
SH075...................... water, sterile inj............... 3.0
SJ032...................... lubricating jelly (K-Y) (5gm uou) 1.0
SJ041...................... povidone soln (Betadine)......... 20.0
------------------------------------------------------------------------

Upon reviewing the direct PE inputs for CPT code 51710 and the
related code 51705 (Change of cystostomy tube; simple), we also noted
that the direct PE input database includes an anomalous 0.5 minutes of
clinical labor time in the post-service period. We believe that this
small portion of clinical labor time is the result of a rounding error
in our data and should be removed from the direct PE input database.
During our review of the data, we noted an invalid supply code
(SM037) that appears in the direct PE input database for CPT codes
88312 and 88313. Upon review of the code, we believe that the supply
item called ``wipes, lens cleaning (per wipe) (Kimwipe)'' (SM027)
should be included in the code instead of the invalid code. The CY 2014
proposed direct PE input database reflects these proposed revisions.
Additionally, we conducted a routine review of the codes valued in
the nonfacility setting for which moderate sedation is inherent in the
procedure. Consistent with the standard moderate sedation package
finalized in the CY 2012 PFS final rule with comment period (76 FR
73043), we have made minor adjustments to the nurse time and equipment
time of 18 of these codes. These codes appear in Table 8, and the CY
2014 proposed direct PE input database reflects the proposed refined
inputs for moderation sedation.

Table 8--Codes With Minor Adjustments to Moderate Sedation Inputs
------------------------------------------------------------------------
CPT code Descriptor
------------------------------------------------------------------------
31629............................. Bronchoscopy/needle bx each.
31645............................. Bronchoscopy clear airways.
31646............................. Bronchoscopy reclear airway.
32405............................. Percut bx lung/mediastinum.
32550............................. Insert pleural cath.
35471............................. Repair arterial blockage.
37183............................. Remove hepatic shunt (tips).
37210............................. Embolization uterine fibroid.
43453............................. Dilate esophagus.
43458............................. Dilate esophagus.
44394............................. Colonoscopy w/snare.
45340............................. Sig w/balloon dilation.
47000............................. Needle biopsy of liver.
47525............................. Change bile duct catheter.
49411............................. Ins mark abd/pel for rt perq.
50385............................. Change stent via transureth.
50386............................. Remove stent via transureth.
57155............................. Insert uteri tandem/ovoids.
93312............................. Echo transesophageal.
93314............................. Echo transesophageal.
G0341............................. Percutaneous islet celltrans.
------------------------------------------------------------------------

c. Adjustments to Pre-Service Clinical Labor Minutes
We recently received a recommendation from the AMA RUC regarding
appropriate pre-service clinical labor minutes in the facility setting
for codes with 000 day global periods. In general, the AMA RUC has
recommended that codes with 000 day global period include a maximum of
30 minutes of clinical labor time in the pre-service period in the
facility setting. The AMA RUC identified 48 codes that currently
include more clinical labor time than this recommended maximum and
provided us with recommended pre-service clinical labor minutes in the
facility setting of 30 minutes or fewer for these 48 codes. We reviewed
the AMA RUC's recommendation and agree that the recommended reductions
would be appropriate to maintain relativity with other 000 day global
codes. Therefore, we propose to amend the pre-service clinical labor
minutes for the codes listed in Table 9, consistent with the AMA RUC
recommendation. The proposed CY 2014 direct PE input database reflects
this proposal.

Table 9--000-Day Global Codes with Proposed Changes to Pre-Service CL
Time
------------------------------------------------------------------------
Existing CL
pre-service Proposed CL pre-service
CPT code Short descriptor facility facility minutes (AMA
minutes RUC recommendation)
------------------------------------------------------------------------
20900........ Removal of bone 60 30
for graft.
20902........ Removal of bone 60 30
for graft.
33224........ Insert pacing 35 30
lead & connect.
33226........ Reposition l 35 30
ventric lead.
36800........ Insertion of 60 0
cannula.
36861........ Cannula 37 0
declotting.
37202........ Transcatheter 45 0
therapy infuse.
50953........ Endoscopy of 60 30
ureter.

[[Page 43295]]

50955........ Ureter endoscopy 60 30
& biopsy.
51726........ Complex 41 30
cystometrogram.
51785........ Anal/urinary 34 30
muscle study.
52250........ Cystoscopy and 37 30
radiotracer.
52276........ Cystoscopy and 32 30
treatment.
52277........ Cystoscopy and 37 30
treatment.
52282........ Cystoscopy 31 30
implant stent.
52290........ Cystoscopy and 31 30
treatment.
52300........ Cystoscopy and 36 30
treatment.
52301........ Cystoscopy and 36 30
treatment.
52334........ Create passage 31 30
to kidney.
52341........ Cysto w/ureter 42 30
stricture tx.
52342........ Cysto w/up 42 30
stricture tx.
52343........ Cysto w/renal 42 30
stricture tx.
52344........ Cysto/uretero 55 30
stricture tx.
52345........ Cysto/uretero w/ 55 30
up stricture.
52346........ Cystouretero w/ 55 30
renal strict.
52351........ Cystouretero & 45 30
or pyeloscope.
52352........ Cystouretero w/ 50 30
stone remove.
52353........ Cystouretero w/ 50 30
lithotripsy.
52354........ Cystouretero w/ 50 30
biopsy.
52355........ Cystouretero w/ 50 30
excise tumor.
54100........ Biopsy of penis. 33 30
61000........ Remove cranial 60 15
cavity fluid.
61001........ Remove cranial 60 15
cavity fluid.
61020........ Remove brain 60 15
cavity fluid.
61026........ Injection into 60 15
brain canal.
61050........ Remove brain 60 15
canal fluid.
61055........ Injection into 60 15
brain canal.
61070........ Brain canal 60 15
shunt procedure.
62268........ Drain spinal 36 30
cord cyst.
67346........ Biopsy eye 42 30
muscle.
68100........ Biopsy of eyelid 32 30
lining.
93530........ Rt heart cath 35 30
congenital.
93531........ R & l heart cath 35 30
congenital.
93532........ R & l heart cath 35 30
congenital.
93533........ R & l heart cath 35 30
congenital.
93580........ Transcath 35 30
closure of asd.
93581........ Transcath 35 30
closure of vsd.
------------------------------------------------------------------------

d. Price Adjustment for Laser Diode
It has come to our attention that the price associated with the
equipment item called ``laser, diode, for patient positioning (Probe)''
(ER040) in the direct PE input database is $7,678 instead of $18,160 as
listed in the CY 2013 PFS final rule with comment period (77 FR 68922).
The CY 2014 proposed direct PE input database reflects the updated
price for the equipment item.
e. Direct PE Inputs for Stereotactic Radiosurgery (SRS) Services (CPT
Codes 77372 and 77373)
Since 2001, Medicare has used HCPCS G-codes, in addition to the CPT
codes, for stereotactic radiosurgery (SRS) to distinguish robotic and
non-robotic methods of delivery. Based on our review of the current SRS
technology, it is our understanding that most services currently
furnished with linac-based SRS technology, including services currently
billed using the non-robotic codes, incorporate some type of robotic
feature. Therefore, we believe that it is no longer necessary to
continue to distinguish robotic versus non-robotic linac-based SRS
through the HCPCS G-codes. For purposes of the hospital outpatient
prospective payment system (OPPS), CMS is proposing to replace the
existing four SRS HCPCS G-codes G0173 (Linear accelerator based
stereotactic radiosurgery, complete course of therapy in one session),
G0251 (Linear accelerator based stereotactic radiosurgery, delivery
including collimator changes and custom plugging, fractionated
treatment, all lesions, per session, maximum five sessions per course
of treatment), G0339 (Image-guided robotic linear accelerator-based
stereotactic radiosurgery, complete course of therapy in one session or
first session of fractionated treatment), and G0340 (Image-guided
robotic linear accelerator-based stereotactic radiosurgery, delivery
including collimator changes and custom plugging, fractionated
treatment, all lesions, per session, second through fifth sessions,
maximum five sessions per course of treatment), with the SRS CPT codes
77372 (Radiation treatment delivery, stereotactic radiosurgery (SRS),
complete course of treatment of cranial lesion(s) consisting of 1
session; linear accelerator based) and 77373 (Stereotactic body
radiation therapy, treatment delivery, per fraction to 1 or more
lesions, including image guidance, entire course not to exceed 5
fractions) that do not distinguish between robotic and non-robotic
methods of delivery. We refer readers to section II.C.3 of the CY 2014
OPPS proposed rule for more discussion of that proposal. We also refer
readers to the CY 2007 OPPS final rule (71 FR 68023 through 68026) for
a

[[Page 43296]]

detailed discussion of the history of the SRS codes.
Two of the four current SRS G-codes are paid in the nonfacility
setting through the PFS. These two codes, G0339 and G0340, describe
robotic SRS treatment delivery and are contractor-priced. CPT codes
77372 and 77373, which describe SRS treatment delivery without regard
to the method of delivery, are currently paid in the nonfacility
setting based on resource-based RVUs developed through the standard PE
methodology. If the CY 2014 OPPS proposal is implemented, it would
appear that there would no longer be a need for G-codes to describe
robotic SRS treatment and delivery. Prior to eliminating the
contractor-priced G-codes and using the existing CPT code for PFS
payment of services previously reported using G-codes, we believe that
it would be appropriate to ensure that the direct PE inputs used to
develop PE RVUs for CPT codes 77372 and 77373 accurately reflect the
typical resources used in furnishing the services that would be
reported in the non-facility setting in the absence of the robotic G-
codes. Therefore, for CY 2014, we are not proposing to replace the
contractor-priced G-codes for PFS payment. We are seeking comment from
the public and stakeholders, including the AMA RUC, regarding whether
or not the direct PE inputs for CPT codes 77372 and 77373 would
continue to accurately estimate the resources used in furnishing
typical SRS delivery were there no coding distinction between robotic
and non-robotic methods of delivery.
3. Using OPPS and ASC Rates in Developing PE RVUs
As we explain in section II.A.2.d of this proposed rule, we
typically establish two PE RVUs for procedures that can be furnished in
either a nonfacility setting, like a physician's office, or facility
setting, like a hospital. The nonfacility RVUs reflect all of the
direct and indirect practice expenses of providing a particular service
when the entire service is furnished in a nonfacility setting. The
facility RVUs are designed to reflect the direct and indirect practice
expenses typically associated with furnishing a particular service in a
setting, such as a hospital or ASC where those facilities incur a
portion or all of the costs. Thus, the difference between the facility
and nonfacility RVUs is because Medicare makes a separate payment to
the facility for its costs of furnishing a service when a service is
furnished in a facility.
When services are furnished in the facility setting, such as a
hospital outpatient department (OPD) or an ambulatory surgical center
(ASC), the total Medicare payment (made to the facility and the
professional combined) typically exceeds the Medicare payment made for
the same service when furnished in the physician office or other
nonfacility setting. We believe that this payment difference generally
reflects the greater costs that facilities incur than those incurred by
practitioners furnishing services in offices and other non-facility
settings. For example, hospitals incur higher overhead costs because
they maintain the capability to furnish services 24 hours a day and 7
days per week, furnish services to higher acuity patients than those
who receive services in physician offices, and have additional legal
obligations such as complying with the Emergency Medical Treatment and
Active Labor Act (EMTALA). Additionally, hospitals and ASCs must meet
Medicare conditions of participation and conditions for coverage,
respectively.
However, we have found that for some services, the total Medicare
payment when the service is furnished in the physician office setting
exceeds the total Medicare payment when the service is furnished in an
OPD or an ASC. When this occurs, we believe it is not the result of
appropriate payment differentials between the services furnished in
different settings. Rather, we believe it is due to anomalies in the
data we use under the PFS and in the application of our resource-based
PE methodology to the particular services.
The PFS PE RVUs rely heavily on the voluntary submission of
information by individuals furnishing the service and who are paid at
least in part based on the data provided. Currently, we have little
means to validate whether the information is accurate or reflects
typical resource costs. Furthermore, in the case of certain direct
costs, like the price of high-cost disposable supplies and expensive
capital equipment, even voluntary information has been very difficult
to obtain. In some cases the PE RVUs are based upon single price quotes
or one paid invoice. We have addressed these issues extensively in
previous rulemaking (75 FR 73252) and again in section II.A.3.e of this
proposed rule. Such incomplete, small sample, potentially biased or
inaccurate resource input costs may distort the resources used to
develop nonfacility PE RVUs used in calculating PFS payment rates for
individual services.
In addition to the accuracy issues with some of the physician PE
resource inputs, the data used in the PFS PE methodology can often be
outdated. As we have previously noted (77 FR 68921) there is no
practical means for CMS or stakeholders to engage in a complete
simultaneous review of the input resource costs for all HCPCS codes
paid under the PFS on an annual or even regular basis. Thus, the
information used to estimate PE resource costs for PFS services is not
routinely updated. Instead, we strive to maintain relativity by
reviewing the work RVUs, physician time, and direct PE inputs for a
code at the same time and reviewing all codes within families where
appropriate. Nonetheless, outdated resource input costs may distort
RVUs used to develop nonfacility PFS payment rates for individual
services. In the case of new medical devices for which high growth in
volume of a service as it diffuses into clinical practice may lead to a
decrease in the cost of expensive items, outdated price inputs can
result in significant overestimation of resource costs.
Such inaccurate resource input costs may distort the nonfacility PE
RVUs used to calculate PFS payment rates for individual services. As we
have previously noted, OPPS payment rates are based on auditable
hospital data and are updated annually. Given the differences in the
validity of the data used to calculate payments under the PFS and OPPS,
we believe that the nonfacility PFS payment rates for procedures that
exceed those for the same procedure when in a facility result from
inadequate or inaccurate direct PE inputs, especially in price or time
assumptions, as compared to the more accurate OPPS data. On these
bases, we are proposing a change in the PE methodology beginning in CY
2014 and subsequent years. To improve the accuracy of PFS nonfacility
payment rates for each calendar year, we are proposing to use the
current year OPPS or ASC rates as a point of comparison in establishing
PE RVUs for services under the PFS. In setting PFS rates, we would
compare the PFS payment rate for a service furnished in an office
setting to the total Medicare payment to practitioners and facilities
for the same service when furnished in a hospital outpatient setting.
For services on the ASC list, we would make the same comparison except
we would use the ASC rate as the point of comparison instead of the
OPPS rate.
We are proposing to limit the nonfacility PE RVUs for individual
codes so that the total nonfacility PFS payment amount would not exceed
the total combined amount Medicare would pay for the same code in the
facility setting. That is, if the nonfacility PE RVUs for a code would
result in a higher payment than the corresponding

[[Page 43297]]

OPPS or ASC payment rate and PFS facility PE RVUs (when applicable) for
the same code, we would reduce the nonfacility PE RVU rate so that the
total nonfacility payment does not exceed the total Medicare payment
made for the service in the facility setting. To maintain the greatest
consistency and transparency possible, we are proposing to use the
current year PFS conversion factor, as reflected in Figure B1.
Similarly, we are proposing to use current year OPPS or ASC rates in
the comparison.
[GRAPHIC] [TIFF OMITTED] TP19JY13.000

For services with no work RVUs, we are proposing to compare the
total nonfacility PFS payment to the OPPS payment rates directly since
no PFS payment is made for these services when furnished in the
facility setting.
We are proposing to exempt the following services from this policy:
Services Without Separate OPPS Payment rates: We are proposing to
exclude services without separately payable OPPS rates from this
methodical change since there would be no OPPS rate to which we could
compare the PFS nonfacility PE RVUs. We note that there would also be
no ASC rate for these services since ASCs are only approved to furnish
a subset of OPPS services.
Codes Subject to the DRA Imaging Cap: We are proposing to exclude
services capped at the OPPS payment rate by the Deficit Reduction Act
of 2005 (DRA) (Pub. L. 109-171) from this policy. The DRA provision
limits PFS payment for most imaging procedures to the amount paid under
the OPPS system. This policy applies to the technical component of
imaging services, including X-ray, ultrasound, nuclear medicine, MRI,
CT, and fluoroscopy services. Screening and diagnostic mammograms are
exempt. Since payment for these procedures is capped by statute we are
excluding them from this policy.
Codes with Low Volume in the OPPS or ASC: We are proposing to
exclude any service for which 5% percent or less of the total number of
services are furnished in the OPPS setting relative to the total number
of PFS/OPPS allowed services.
Codes with ASC Rates Based on PFS Payment Rates: To avoid issues of
circularity, we are proposing to exclude ASC services subject to the
``office-based'' procedure payment policies for which payment rates are
based on the PFS nonfacility PE RVUs. We direct interested readers to
the CY 2013 OPPS final rule (77 FR 68444) for additional information
regarding this payment policy.
Codes Paid in the Facility at Nonfacility PFS Rates: To avoid
issues of circularity, we are also proposing to exclude services that
are paid in the facility setting at nonfacility payment rates. This
would include certain professional-only services where the resource
costs for practitioners are assumed to be similar in both settings.
Codes with PE RVUs Developed Outside the PE Methodology: We are
also proposing to exclude services with PE RVUs established outside the
PE Methodology through notice and comment rulemaking.
Addendum B of this proposed rule with comment period displays the
PE RVUs that would result from implementation of this proposed change
in the PE methodology.
In discussing resource input issues, some stakeholders have
previously suggested that the direct costs (for example, clinical
labor, disposable supplies and medical equipment) involved in
furnishing a service are similar in both the nonfacility and facility
settings. Others have suggested that facilities, like hospitals, have
greater purchasing power for medical equipment and disposable supplies
so that the direct costs for a facility to furnish a service can be
lower than costs for a physician practice furnishing the same service.
This proposed policy does not assume that the direct costs to furnish a
service in the nonfacility setting are always lower than in the
facility setting. Medicare payment methodologies, including both OPPS
and the PFS PE methodology, incorporate both direct and indirect costs
(administrative labor, office expenses, and all other expenses). This
proposed policy is premised on the idea that there are significantly
greater indirect resource costs that are carried by facilities even in
the event that the direct costs involved in furnishing a service in the
office and facility settings are comparable.
We believe this proposal provides a reliable means for Medicare to
set upper payment limits for office-based procedures based on
relatively more

[[Page 43298]]

reliable cost information available for the same procedures when
furnished in a facility setting where the cost structure would be
expected to be somewhat, if not significantly, higher than the office
setting. We believe that the current basis for estimating the resource
costs involved in furnishing a PFS service is significantly encumbered
by our current inability to obtain accurate information regarding
supply and equipment prices, as well as procedure time assumptions. We
believe that this policy will mitigate the negative impact of these
difficulties on both the appropriate relativity of PFS services and
overall Medicare spending. A wide range of stakeholders and public
commenters have pointed to the nonfacility setting as the most cost-
effective location for services. Given the significantly higher cost
structure of facilities (as discussed above) we believe that this
presumption is accurate. In its March 2012 report to Congress, MedPAC
recommended that Medicare should seek to pay similar amounts for
similar services across payment settings, taking into account
differences in the definitions of services and patient severity.
(MedPAC March 2012 Report to Congress, page 46) We believe that the
proposed change to our PFS PE methodology will more appropriately
reflect resource costs in the nonfacility setting.
b. Ultrasound Equipment Recommendations
In the CY 2012 PFS proposed rule (76 FR 42796), we asked the AMA
RUC to review the ultrasound equipment described in the direct PE input
database. We specifically asked for review of the ultrasound equipment
items described in the direct PE input database and whether the
ultrasound equipment listed for specific procedure codes is clinically
necessary.
In response, the AMA RUC recommended creating several new equipment
inputs in addition to the revision of current equipment inputs for
ultrasound services. The AMA RUC also forwarded pricing information for
new and existing equipment items from certain medical specialty
societies that represent the practitioners who furnish these services.
In the following paragraphs, we summarize the AMA RUC recommendations,
address our review of the provided information, and describe proposed
changes to the direct PE inputs used in developing PE RVUs for these
services.
(1) Equipment Rooms
The AMA RUC made a series of recommendations regarding the
ultrasound equipment items included in direct PE input equipment
packages called ``rooms.'' Specifically, the AMA RUC recommended adding
several new equipment items to the equipment packages called ``room,
ultrasound, general'' (EL015) and ``room, ultrasound, vascular''
(EL016). The AMA RUC also recommended creating a similar direct PE
input equipment package called ``room, ultrasound, cardiovascular.'' In
considering these recommendations, we identified a series of new
concerns regarding the makeup of these equipment packages and because
there are several different ways to handle these concerns, we are
seeking public comment from additional stakeholders prior to proposing
to implement any of these recommended changes through future
rulemaking.
We note that the existing ``rooms'' for ultrasound technology
include a greater number of individual items than the ``rooms'' for
other kinds of procedures. For example, the equipment package for the
``room, basic radiology'' (EL012) contains only two items: An x-ray
machine and a camera. Ordinarily under the PFS, direct PE input
packages for ``rooms'' include only equipment items that are typically
used in furnishing every service in that room. When equipment items
beyond those included in a ``room'' are typically used in furnishing a
particular procedure, the additional equipment items for that procedure
are separately reflected in the direct PE input database in addition to
the ``room'' rather than being included in the room. When handled in
this way, the room includes only those inputs that are common to all
services furnished in that room type, and thus the direct PE inputs are
appropriate for the typical case of each particular service. When
additional equipment items are involved in furnishing a particular
service, they are included as an individual PE input only for that
particular service.
In contrast, the equipment items currently included in the ``room,
ultrasound, general'' are: the ultrasound system, five different
transducers, two probe starter kits, two printers, a table, and various
other items. We do not believe that it is likely that all of these
items would be typically used in furnishing each service. For example,
we do not believe that the typical ultrasound study would require the
use of five different ultrasound transducers. However, the costs of all
of these items are incorporated into the resource inputs for every
service for which the ultrasound room is a direct PE input, regardless
of whether each of those items is typically used in furnishing the
particular service. This increases the resource cost for every service
that uses the room regardless of whether or not each of the individual
items is typically used in furnishing a particular procedure.
Instead of incorporating the AMA RUC's recommendation to add more
equipment items to these ultrasound equipment ``room'' packages, we
believe that we should continue to consider the appropriateness of the
full number of items in the ultrasound ``rooms'' in the context of
maintaining appropriate relativity with other services across the PFS.
We seek comment from stakeholders, including the AMA RUC, on the items
included in the ultrasound rooms, especially as compared to the items
included in other equipment ``rooms.'' We believe that it would be
appropriate to consider these comments in future rulemaking.
Specifically we seek comment on whether equipment packages called
``rooms'' should include all of the items that might be included in an
actual room, just the items typically used for every service in such a
room, or all of the items typically used in typical services furnished
in the room. We believe that it would be most appropriate to propose
changes to the ``room, ultrasound, general'' (EL015) and ``room,
ultrasound, vascular'' (EL016) in the context of considering comments
on this broader issue. We also believe that consideration of the
broader issue will help determine whether it would be appropriate to
create a ``room, ultrasound, cardiovascular,'' and if so, what items
would be included in this equipment package.
In addition to the concerns regarding the contents of the
ultrasound ``room'' packages, we are also concerned about the pricing
information submitted through the AMA RUC to support its recommendation
to add equipment to the ultrasound room packages. The highest-price
item used in pricing the existing equipment input called ``room,
ultrasound, general'' (EL015), is a ``GE Logic 9 ultrasound system,''
currently priced at $220,000. As part of a current AMA RUC
recommendation, a medical specialty society recommended increasing the
price of that item to $314,500. However, that recommendation did not
include documentation to support the pricing level, such as a copy of a
paid invoice for the equipment. Furthermore, the recommended price
conflicts with certain publicly available information. For example, the
Milwaukee Sentinel-Journal reported in a February 9, 2013 article that
the price for GE ultrasound equipment ranges from ``$7,900 for a hand-
held ultrasound to $200,000 for its

[[Page 43299]]

most advanced model.'' The same article points to an item called the
``Logiq E9'' as the ultrasound machine most used by radiologists and
priced from $150,000 to $200,000. http://www.jsonline.com/business/ge-sees-strong-future-with-its-ultrasound-business-uj8mn79-190533061.html
At this time, are unsure how to best reconcile the information
disclosed by the manufacturer to the press and the prices submitted by
the medical specialty society for use in updating the direct PE input
prices. We believe discrepancies, such as these, exemplify the
potential problem with updating prices for particular items based
solely on price quotes or information other than copies of paid
invoices. However, copies of paid invoices must also be evaluated
carefully. The information presented in the article regarding the price
for hand-held ultrasound devices raises questions about the adequacy of
paid invoices, too, in determining appropriate input costs. The direct
PE input described in the database as ``ultrasound unit, portable''
(EQ250) is currently priced at $29,999 based on a submitted invoice,
while the article cites that GE sells a portable unit for as low as
$7,900. We are seeking comment on the appropriate price to use as the
typical cost for portable ultrasound units.
Additionally, we are not proposing to revise the equipment items,
or to change the prices of items, included in these rooms. Instead,
pending our receipt and consideration of additional information, the
proposed direct PE input database continues to include the current
prices for the ``room, ultrasound, general'' (EL015), ``room,
ultrasound, vascular'' (EL016), and ``ultrasound unit, portable''
(EQ250).
(2) New Equipment Inputs and Price Updates
Ultrasound Unit, portable, breast procedures. The AMA RUC
recommended that a new direct PE input, ``ultrasound unit, portable,
breast procedures,'' be created for breast procedures that are
performed in a surgeon's office and where ultrasound imaging is
included in the code descriptor. These services are described by CPT
codes 19105 (Ablation, cryosurgical, of fibroadenoma, including
ultrasound guidance, each fibroadenoma), 19296 (Placement of
radiotherapy afterloading expandable catheter (single or multichannel)
into the breast for interstitial radioelement application following
partial mastectomy, includes imaging guidance; on date separate from
partial mastectomy), and 19298 (Placement of radiotherapy afterloading
brachytherapy catheters (multiple tube and button type) into the breast
for interstitial radioelement application following (at the time of or
subsequent to) partial mastectomy, includes imaging guidance). We are
creating this input. The pricing information submitted for this item is
a paid invoice and two price quotes. As we have previously stated, we
believe that copies of paid invoices are more likely to reflect actual
resource costs associated with equipment and supply items than quotes
or other information. Therefore, we are proposing a price of $33,930,
which reflects the price displayed on the submitted copy of the paid
invoice. We are not using the quotes as we do not believe that quotes
provide reliable information about the prices that are actually paid
for medical equipment.
Endoscopic Ultrasound Processor. The AMA RUC recommended creating a
new direct PE input called ``endoscopic ultrasound processor,'' for use
in furnishing the service described by CPT code 31620 (Endobronchial
ultrasound (EBUS) during bronchoscopic diagnostic or therapeutic
intervention(s) (List separately in addition to code for primary
procedure[s])). We are creating this equipment item to use as an input
in the proposed direct PE input database. The price associated with the
``endoscopic ultrasound processor'' will be $59,925, which reflects the
price documented on the copy of the paid invoice submitted with the
recommendation.
Bronchofibervideoscope. The AMA RUC recommended creating a new
direct PE input called ``Bronchofibervideoscope,'' for use in
furnishing the service described by CPT code 31620 (Endobronchial
ultrasound (EBUS) during bronchoscopic diagnostic or therapeutic
intervention(s) (List separately in addition to code for primary
procedure[s])). We are creating this new equipment item to use as an
input in the proposed direct PE input database. However, this item has
no price associated with it in the proposed direct PE input database
because we did not receive any information that would allow us to price
the item accurately. Consequently, we seek copies of paid invoices for
this equipment item so that we can price the item accurately in the
future.
Endoscope, ultrasound probe, drive (ES015). The AMA RUC forwarded
pricing information to us regarding the existing input called
``endoscope, ultrasound probe, drive'' (ES015). This information
included a copy of a paid invoice. Based on this information, we are
proposing to change the price associated with ES015 to $13,256.25,
which reflects the price documented on the submitted copy of the paid
invoice.
(3) Ultrasound Equipment Input Recommendations for Particular Services
The AMA RUC made recommendations regarding the typical ultrasound
items used in furnishing particular services. In general, the AMA RUC
recommended that the existing equipment items accurately described the
typical equipment used in furnishing particular services. However, for
some CPT codes the AMA RUC recommended changing the associated
equipment inputs that appear in the direct PE input database. Based on
our review of these recommendations, we have generally agreed with the
AMA RUC regarding these recommended changes, and these changes are
reflected in the proposed direct PE input database. Table 10 displays
the codes with proposed changes to ultrasound equipment. However, for
certain codes we do not agree with the recommendations of the AMA RUC.
The following paragraphs address the changes we are proposing that
differ from the recommendations of the AMA RUC.
For a series of cardiovascular services that include ultrasound
technology, the AMA RUC recommended removing certain equipment items
and replacing those items with a new item called ``room, ultrasound,
cardiovascular.'' As we described in the preceding paragraphs, we are
not proposing to create the ``room, ultrasound, cardiovascular'' and
therefore will not propose to add this ``room'' an input for these
services. However, we note that the newly recommended equipment package
incorporates many of the same kinds of items as the currently existing
``room, ultrasound, vascular'' (EL016). We agree with the AMA RUC's
suggestion that the existing equipment inputs for the relevant services
listed in Table 10 do not reflect typical resource costs of furnishing
the services. We believe that, pending our further consideration of the
ultrasound ``room'' equipment packages, it would be appropriate to use
the existing ``room, ultrasound, vascular'' (EL016) as a proxy for
resource costs for these services. Therefore, the proposed direct PE
input database reflects this proposed change.
In the case of CPT code 76942 (Ultrasonic guidance for needle
placement (eg, biopsy, aspiration, injection, localization device),
imaging supervision and interpretation), we agree with the AMA RUC's

[[Page 43300]]

recommendation to replace the current equipment input of the ``room,
ultrasound, general'' (EL015) with ``ultrasound unit, portable''
(EQ250). We note that this service is typically reported with other
codes that describe the needle placement procedures and that the
recommended change in equipment from a room to a portable device
reflects a change in the typical kinds of procedures reported with this
image guidance service. Given this change, we believe that it is
appropriate to reconsider the procedure time assumption currently used
in establishing the direct PE inputs for this code is 45 minutes, which
we believe is inaccurate. We reviewed the services reported with CPT
code 76942 to identify the most common procedures furnished with this
image guidance. The code most frequently reported with CPT code 76942
is CPT 20610 (Arthrocentesis, aspiration and/or injection; major joint
or bursa (eg, shoulder, hip, knee joint, subacromial bursa). The
assumed procedure time for this service is five minutes. The vast
majority of other procedures frequently reported with CPT code 76942
range in procedure time assumptions from 5 to 20 minutes. Therefore, in
addition to proposing the recommended change in equipment inputs
associated with the code, we are also proposing to change the procedure
time assumption used in establishing direct PE inputs for the service
from 45 to 10 minutes, based on our analysis of thirty needle placement
procedures most frequently reported with CPT code 76942. We note that
this will reduce the clinical labor and equipment minutes associated
with the code from 58 to 23 minutes. This change is reflected in the
proposed direct PE input database. We also note that this code has been
proposed as a potentially misvalued code in section II.B.3.b.1.

Table 10--Codes With Proposed Changes to Ultrasound Equipment for CY 2014
----------------------------------------------------------------------------------------------------------------
Proposed CY 2014 Proposed CY 2014
CPT code Descriptor CY 2013 CMS CY 2013 Equipment Equipment CMS Equipment
Equipment code description code description
----------------------------------------------------------------------------------------------------------------
19105........... Cryosurg ablate fa EQ250 ultrasound unit, NEW ultrasound unit,
each. portable. portable, breast
procedures.
19296........... Place po breast EL015 room, ultrasound, NEW ultrasound unit,
cath for rad. general. portable, breast
procedures.
19298........... Place breast rad EL015 room, ultrasound, NEW ultrasound unit,
tube/caths. general. portable, breast
procedures.
---------------------------------------------------------------------------
31620........... Endobronchial us n/a NEW Bronchofibervideos
add-on. cope.
---------------------------------------------------------------------------
n/a NEW Endoscopic
ultrasound
processor.
---------------------------------------------------------------------------
52649........... Prostate laser EQ255 ultrasound, EQ250 ultrasound unit,
enucleation. noninvasive portable.
bladder scanner w-
cart.
-------------------------------------
76376........... 3d render w/o EL015 room, ultrasound, Remove input.
postprocess. general.
-------------------------------------
76775........... Us exam abdo back EL015 room, ultrasound, EQ250 ultrasound unit,
wall lim. general. portable.
76820........... Umbilical artery EQ249 ultrasound color EL015 room, ultrasound,
echo. doppler, general.
transducers and
vaginal probe.
76857........... Us exam pelvic EL015 room, ultrasound, EQ250 ultrasound unit,
limited. general. portable.
76870........... Us exam scrotum... EL015 room, ultrasound, EQ250 ultrasound unit,
general. portable.
76872........... Us transrectal.... EL015 room, ultrasound, EQ250 ultrasound unit,
general. portable.
76942........... Echo guide for EL015 room, ultrasound, EQ250 ultrasound unit,
biopsy. general. portable.
93303........... Echo guide for EQ253 ultrasound, EL016 room, ultrasound,
biopsy. echocardiography vascular.
digital
acquisition (Novo
Microsonics,
TomTec).
EQ254 ultrasound,
echocardiography
w-4 transducers
(Sequoia C256).
EQ252 ultrasound,
echocardiography
analyzer software
(ProSolv).
93304........... Echo transthoracic EQ252 ultrasound, EL016 room, ultrasound,
echocardiography vascular.
analyzer software
(ProSolv).
EQ253 ultrasound,
echocardiography
digital
acquisition (Novo
Microsonics,
TomTec).
EQ254 ultrasound,
echocardiography
w-4 transducers
(Sequoia C256).
93306........... Tte w/doppler EQ253 ultrasound, EL016 room, ultrasound,
complete. echocardiography vascular.
digital
acquisition (Novo
Microsonics,
TomTec).
EQ254 ultrasound,
echocardiography
w-4 transducers
(Sequoia C256).
EQ252 ultrasound,
echocardiography
analyzer software
(ProSolv).
93307........... Tte w/o doppler EQ252 ultrasound, EL016 room, ultrasound,
complete. echocardiography vascular.
analyzer software
(ProSolv).
EQ253 ultrasound,
echocardiography
digital
acquisition (Novo
Microsonics,
TomTec).

[[Page 43301]]

EQ254 ultrasound,
echocardiography
w-4 transducers
(Sequoia C256).
93308........... Tte f-up or lmtd.. EQ252 ultrasound, EL016 room, ultrasound,
echocardiography vascular.
analyzer software
(ProSolv).
EQ253 ultrasound,
echocardiography
digital
acquisition (Novo
Microsonics,
TomTec).
EQ254 ultrasound,
echocardiography
w-4 transducers
(Sequoia C256).
93312........... Echo EQ253 ultrasound, EL016 room, ultrasound,
transesophageal. echocardiography vascular.
digital
acquisition (Novo
Microsonics,
TomTec).
EQ252 ultrasound,
echocardiography
analyzer software
(ProSolv).
EQ256 ultrasound,
transducer (TEE
Omniplane II).
EQ254 ultrasound,
echocardiography
w-4 transducers
(Sequoia C256).
93314........... Echo EQ254 ultrasound, EL016 room, ultrasound,
transesophageal. echocardiography vascular.
w-4 transducers
(Sequoia C256).
EQ256 ultrasound,
transducer (TEE
Omniplane II).
EQ252 ultrasound,
echocardiography
analyzer software
(ProSolv).
EQ253 ultrasound,
echocardiography
digital
acquisition (Novo
Microsonics,
TomTec).
93320........... Doppler echo exam EQ252 ultrasound, EL016 room, ultrasound,
heart. echocardiography vascular.
analyzer software
(ProSolv).
EQ253 ultrasound,
echocardiography
digital
acquisition (Novo
Microsonics,
TomTec).
EQ254 ultrasound,
echocardiography
w-4 transducers
(Sequoia C256).
93321........... Doppler echo exam EQ252 ultrasound, EL016 room, ultrasound,
heart. echocardiography vascular.
analyzer software
(ProSolv).
EQ254 ultrasound,
echocardiography
w-4 transducers
(Sequoia C256).
93325........... Doppler color flow EQ252 ultrasound, EL016 room, ultrasound,
add-on. echocardiography vascular.
analyzer software
(ProSolv).
EQ253 ultrasound,
echocardiography
digital
acquisition (Novo
Microsonics,
TomTec).
EQ254 ultrasound,
echocardiography
w-4 transducers
(Sequoia C256).
93350........... Stress tte only... EQ252 ultrasound, EL016 room, ultrasound,
echocardiography vascular.
analyzer software
(ProSolv).
EQ253 ultrasound,
echocardiography
digital
acquisition (Novo
Microsonics,
TomTec).
EQ254 ultrasound,
echocardiography
w-4 transducers
(Sequoia C256).
93351........... Stress tte EQ254 ultrasound, EL016 room, ultrasound,
complete. echocardiography vascular.
w-4 transducers
(Sequoia C256).
93980........... Penile vascular EL015 room, ultrasound, EQ249 ultrasound color
study. general. doppler,
transducers and
vaginal probe.
93981........... Penile vascular EL015 room, ultrasound, EQ249 ultrasound color
study. general. doppler,
transducers and
vaginal probe.
----------------------------------------------------------------------------------------------------------------

4. Collecting Data on Services Furnished in Off-Campus Hospital
Provider-Based Departments
In recent years, the research literature and popular press have
documented the increased trend toward hospital acquisition of physician
practices, integration of those practices as a department of the
hospital, and the resultant increase in the furnishing of physicians'
services in a hospital outpatient setting (for example, see Ostrom,
Carol M. ``Why you might pay twice for one visit to a doctor,'' Seattle
Times. November 3, 2012, and O'Malley, Ann, Amelia M. Bond, and Robert
Berenson. Rising hospital employment of physicians: better quality,
higher costs? Issue Brief No. 136, Center for Studying Health System
Change. August 2011). When a Medicare

[[Page 43302]]

beneficiary receives outpatient services in a hospital, Medicare
generally pays more in total than when the beneficiary receives those
same services in a freestanding clinic or physician office. As more
physician practices become hospital-based, news articles have
highlighted beneficiary liability for the additional coinsurance for
the ``facility fee,'' which is the payment in addition to the physician
payment when services are furnished in a hospital. MedPAC has
questioned the appropriateness of increased Medicare payment and
beneficiary cost-sharing when physician offices become hospital
outpatient departments, and has recommended that Medicare pay selected
hospital outpatient services at physician fee schedule rates (MedPAC
March 2012 Report to Congress).
The total l payment (including both Medicare program payment and
beneficiary cost-sharing) generally is higher when outpatient services
are furnished in the hospital outpatient setting rather than a
physician office. Both the PFS and the hospital outpatient prospective
payment system (OPPS) establish payment based on the relative resources
involved in furnishing a service. As described in section II.B.1.b. of
this proposed rule, the relative values for services furnished in the
physician office setting under the PFS reflect not only payment for the
practitioner's work, but also the direct expenses (clinical labor,
medical equipment, and medical supplies) and the indirect expenses
(administrative labor, office expense, and all other expenses)
typically involved in furnishing the service. Under section 1833(t) of
the Act, Medicare provides separate payment through the OPPS to
hospitals for certain items and services furnished to registered
hospital outpatients that are based on the relativity of the resource
costs (labor and capital) involved in furnishing those hospital
services. In general, we expect hospitals to have higher overall
resource requirements than physician offices because hospitals are
required to meet conditions of participation, to maintain standby
capacity for emergency situations, and to be available to address a
wide variety of complex medical needs in a community. When services are
furnished in the hospital setting, such as in off-campus provider based
departments, Medicare pays the physician under the PFS at a typically
lower facility payment rate but then also pays the hospital under the
OPPS for the facility resources required to furnish the service. The
beneficiary pays coinsurance for both the physician PFS payment and the
hospital OPPS payment. The term ``facility fee'' refers to this
additional hospital outpatient payment.
Upon acquisition of a physician practice, hospitals frequently
treat the practice locations as off-campus provider-based departments
of the hospital and bill Medicare for services furnished at those
locations under the OPPS (for further information on the provider-based
regulations at Sec. 413.65, see http://www.gpo.gov/fdsys/pkg/CFR-2010-title42-vol2/pdf/CFR-2010-title42-vol2-sec413-65.pdf). Since October 1,
2002, we have not required hospitals to seek from CMS a determination
of provider-based status for a facility that is located off campus. We
also do not have a formal process for gathering information on the
frequency, type, and payment for services furnished in off-campus
provider-based departments of the hospital.
To better understand the growing trend toward hospital acquisition
of physician offices and subsequent treatment of those locations as
off-campus provider-based outpatient departments, we are considering
collecting information that would allow us to analyze the frequency,
type, and payment for services furnished in off-campus provider-based
hospital departments. We have considered several potential methods.
Claims-based approaches could include (1) creating a new place of
service code for off-campus departments of a provider under 42 CFR
413.65(g)(2) as part of item 24B of the CMS-1500 claim form, comparable
to current place of service codes such as ``22 Outpatient'' and ``23
Emergency Room-Hospital'' when physician services are furnished in an
off-campus provider-based department, or (2) creating a HCPCS modifier
that could be reported with every code for services furnished in an
off-campus provider-based department of a hospital on the CMS-1500
claim form for physician services and the UB-04 (CMS form 1450) for
hospital outpatient claims. In addition, we also have considered asking
hospitals to break out the costs and charges for their provider-based
departments as outpatient service cost centers on the Medicare hospital
cost report, form 2552-10. We note that some hospitals already break
out these costs voluntarily or because of cost reporting requirements
for the 340B Drug Discount program but this practice is not consistent
or standardized. We welcome public comment on the best means for
collecting information on the frequency, type, and payment for services
furnished in off-campus provider-based departments of hospitals.

B. Misvalued Codes

1. Valuing Services Under the PFS
Section 1848(c) of the Act requires the Secretary to determine
relative values for physicians' services based on three components:
work; PE; and malpractice. Section 1848(c)(1)(A) of the Act defines the
work component to include ``the portion of the resources used in
furnishing the service that reflects physician time and intensity in
furnishing the service.'' In addition, section 1848(c)(2)(C)(i) of the
Act specifies that ``the Secretary shall determine a number of work
relative value units (RVUs) for the service based on the relative
resources incorporating physician time and intensity required in
furnishing the service.'' Section 1848(c)(1)(B) of the Act defines the
PE component as ``the portion of the resources used in furnishing the
service that reflects the general categories of expenses (such as
office rent and wages of personnel, but excluding malpractice expenses)
comprising practice expenses.'' (See section I.A.2. for more detail on
the PE component.) Section 1848(c)(1)(C) of the Act defines the
malpractice component as ``the portion of the resources used in
furnishing the service that reflects malpractice expenses in furnishing
the service.'' Sections 1848 (c)(2)(C)(ii) and (iii) of the Act specify
that PE and malpractice expense RVUs shall be determined based on the
relative PE/malpractice expense resources involved in furnishing the
service.
Section 1848(c)(2)(B) of the Act directs the Secretary to conduct a
periodic review, not less often than every 5 years, of the RVUs
established under the PFS. Section 3134(a) of the Affordable Care Act
added a new section 1848(c)(2)(K) to the Act, which requires the
Secretary to periodically identify potentially misvalued services using
certain criteria and to review and make appropriate adjustments to the
relative values for those services. Section 3134(a) of the Affordable
Care Act also added a new section 1848(c)(2)(L) to the Act which,
requires the Secretary to develop a process to validate the RVUs of
certain potentially misvalued codes under the PFS, identified using the
same criteria used to identify potentially misvalued codes, and to make
appropriate adjustments.
As discussed in section II.A.1. of this proposed rule, each year we
develop and propose appropriate adjustments to the RVUs, taking into
account the recommendations provided by the

[[Page 43303]]

American Medical Association/Specialty Society Relative Value Scale
Update Committee (AMA RUC), the Medicare Payment Advisory Commission
(MedPAC), and others. For many years, the AMA RUC has provided us with
recommendations on the appropriate relative values for new, revised,
and potentially misvalued PFS services. We review these recommendations
on a code-by-code basis and consider these recommendations in
conjunction with analyses of other data, such as claims data, to inform
the decision-making process as authorized by the law. We may also
consider analyses of physician time, work RVUs, or direct PE inputs
using other data sources, such as Department of Veteran Affairs (VA),
National Surgical Quality Improvement Program (NSQIP), the Society for
Thoracic Surgeons (STS) National Database, and the Physician Quality
Reporting Initiative (PQRI) databases. In addition to considering the
most recently available data, we also assess the results of physician
surveys and specialty recommendations submitted to us by the AMA RUC.
We conduct a clinical review to assess the appropriate RVUs in the
context of contemporary medical practice. We note that section
1848(c)(2)(A)(ii) of the Act authorizes the use of extrapolation and
other techniques to determine the RVUs for physicians' services for
which specific data are not available in addition to taking into
account the results of consultations with organizations representing
physicians. In accordance with section 1848(c) of the Act, we determine
appropriate adjustments to the RVUs, explain the basis of these
adjustments, and respond to public comments in the PFS proposed and
final rules.
2. Identifying, Reviewing, and Validating the RVUs of Potentially
Misvalued Services
a. Background
In its March 2006 Report to the Congress, MedPAC noted that
``misvalued services can distort the price signals for physicians'
services as well as for other health care services that physicians
order, such as hospital services.'' In that same report MedPAC
postulated that physicians' services under the PFS can become misvalued
over time. MedPAC stated, ``when a new service is added to the
physician fee schedule, it may be assigned a relatively high value
because of the time, technical skill, and psychological stress that are
often required to furnish that service. Over time, the work required
for certain services would be expected to decline as physicians become
more familiar with the service and more efficient in furnishing it.''
We believe services can also become overvalued when PEs decline. This
can happen when the costs of equipment and supplies fall, or when
equipment is used more frequently than is estimated in the PE
methodology, reducing its cost per use. Likewise, services can become
undervalued when physician work increases or PEs rise. In the ensuing
years since MedPAC's 2006 report, additional groups of potentially
misvalued services have been identified by the Congress, CMS, MedPAC,
the AMA RUC, and other stakeholders.
In recent years, CMS and the AMA RUC have taken increasingly
significant steps to identify and address potentially misvalued codes.
As MedPAC noted in its March 2009 Report to Congress, in the
intervening years since MedPAC made the initial recommendations, ``CMS
and the AMA RUC have taken several steps to improve the review
process.'' Most recently, section 1848(c)(2)(K)(ii) of the Act (as
added by section 3134(a) of the Affordable Care Act) directed the
Secretary to specifically examine, as determined appropriate,
potentially misvalued services in the following seven categories:
Codes and families of codes for which there has been the
fastest growth;
Codes and families of codes that have experienced
substantial changes in PEs;
Codes that are recently established for new technologies
or services;
Multiple codes that are frequently billed in conjunction
with furnishing a single service;
Codes with low relative values, particularly those that
are often billed multiple times for a single treatment;
Codes which have not been subject to review since the
implementation of the RBRVS (the so-called `Harvard-valued codes'); and
Other codes determined to be appropriate by the Secretary.
Section 1848(c)(2)(K)(iii) of the Act also specifies that the
Secretary may use existing processes to receive recommendations on the
review and appropriate adjustment of potentially misvalued services. In
addition, the Secretary may conduct surveys, other data collection
activities, studies, or other analyses, as the Secretary determines to
be appropriate, to facilitate the review and appropriate adjustment of
potentially misvalued services. This section also authorizes the use of
analytic contractors to identify and analyze potentially misvalued
codes, conduct surveys or collect data, and make recommendations on the
review and appropriate adjustment of potentially misvalued services.
Additionally, this section provides that the Secretary may coordinate
the review and adjustment of any RVU with the periodic review described
in section 1848(c)(2)(B) of the Act. Finally, section
1848(c)(2)(K)(iii)(V) of the Act specifies that the Secretary may make
appropriate coding revisions (including using existing processes for
consideration of coding changes) that may include consolidation of
individual services into bundled codes for payment under the physician
fee schedule.
b. Progress in Identifying and Reviewing Potentially Misvalued Codes
To fulfill our statutory mandate, we have identified and reviewed
numerous potentially misvalued codes in all seven of the categories
specified in section 1848(c)(2)(K)(ii) of the Act, and we plan to
continue our work examining potentially misvalued codes in these areas
over the upcoming years. In the current process, we identify
potentially misvalued codes for review, and request recommendations
from the AMA RUC and other public commenters on revised work RVUs and
direct PE inputs for those codes. The AMA RUC, through its own
processes, also identifies potentially misvalued codes for review.
Through our public nomination process for potentially misvalued codes
established in the CY 2012 PFS final rule with comment period, other
individuals and stakeholder groups submit nominations for review of
potentially misvalued codes as well.
Since CY 2009, as a part of the annual potentially misvalued code
review and Five-Year Review process, we have reviewed more than 1,000
potentially misvalued codes to refine work RVUs and direct PE inputs.
We have adopted appropriate work RVUs and direct PE inputs for these
services as a result of these reviews. A more detailed discussion of
the extensive prior reviews of potentially misvalued codes is included
in the CY 2012 PFS final rule with comment period (76 FR 73052 through
73055). In the CY 2012 PFS proposed rule, we proposed to identify and
review potentially misvalued codes in the category of ``Other codes
determined to be appropriate by the Secretary,'' referring to a list of
the highest PFS expenditure services, by specialty, that had not been
recently reviewed (76 FR 73059 through 73068).
In the CY 2012 final rule with comment period, we finalized our
policy to consolidate the review of physician work and PE at the same
time

[[Page 43304]]

(76 FR 73055 through 73958), and established a process for the annual
public nomination of potentially misvalued services.
One of the priority categories for review of potentially misvalued
codes is services that have not been subject to review since the
implementation of the PFS (the so-called ``Harvard-valued codes''). In
the CY 2009 PFS proposed rule, we requested that the AMA RUC engage in
an ongoing effort to review the remaining Harvard-valued codes,
focusing first on the high-volume, low intensity codes (73 FR 38589).
For the Fourth Five-Year Review (76 FR 32410), we requested that the
AMA RUC review services that have not been reviewed since the original
implementation of the PFS with annual utilization greater than 30,000
(Harvard-valued--Utilization > 30,000). In the CY 2013 final rule with
comment period, we identify for review the potentially misvalued codes
for Harvard-valued services with annual allowed charges that total at
least $10,000,000 (Harvard-valued--Allowed charges >=$10,000,000).
In addition to the Harvard-valued codes, in the same rule we
finalized for review a list of potentially misvalued codes that have
stand-alone PE (codes with physician work and no listed physician time
and codes with no physician work and have listed physician time).
c. Validating RVUs of Potentially Misvalued Codes
In addition to identifying and reviewing potentially misvalued
codes, section 3134(a) of the Affordable Care Act added section
1848(c)(2)(L) of the Act, which specifies that the Secretary shall
establish a formal process to validate RVUs under the PFS. The
validation process may include validation of work elements (such as
time, mental effort and professional judgment, technical skill and
physical effort, and stress due to risk) involved with furnishing a
service and may include validation of the pre-, post-, and intra-
service components of work. The Secretary is directed, as part of the
validation, to validate a sampling of the work RVUs of codes identified
through any of the seven categories of potentially misvalued codes
specified by section 1848(c)(2)(K)(ii) of the Act. Furthermore, the
Secretary may conduct the validation using methods similar to those
used to review potentially misvalued codes, including conducting
surveys, other data collection activities, studies, or other analyses
as the Secretary determines to be appropriate to facilitate the
validation of RVUs of services.
In the CY 2011 PFS proposed rule (75 FR 40068) and CY 2012 PFS
proposed rule (76 FR 42790), we solicited public comments on possible
approaches, methodologies, and data sources that we should consider for
a validation process. A summary of the comments along with our
responses are included in the CY 2011 PFS final rule with comment
period (75 FR 73217) and the CY 2012 PFS final rule with comment period
(73054 through 73055).
We have entered into two contracts with outside entities to develop
validation models for RVUs. During a 2-year project, the RAND
Corporation will use available data to build a validation model to
predict work RVUs and the individual components of work RVUs, time and
intensity. The model design will be informed by the statistical
methodologies and approach used to develop the initial work RVUs and to
identify potentially misvalued procedures under current CMS and AMA RUC
processes. RAND will use a representative set of CMS-provided codes to
test the model. RAND will consult with a technical expert panel on
model design issues and the test results.
The second contract is with the Urban Institute. Given the central
role of time in establishing work RVUs and the concerns that have been
raised about the current time values, a key focus of the project is
collecting data from several practices for services selected by the
contractor. The data will be used to develop time estimates. Urban
Institute will use a variety of approaches to develop objective time
estimates, depending on the type of service, which will be a very
resource-intensive part of the project. Objective time estimates will
be compared to the current time values used in the fee schedule. The
project team will then convene groups of physicians from a range of
specialties to review the new time data and their potential
implications for work and the ratio of work to time.
3. CY 2014 Identification and Review of Potentially Misvalued Services
a. Public Nomination of Potentially Misvalued Codes
In the CY 2012 PFS final rule with comment period, we finalized a
process for the public to nominate potentially misvalued codes (76 FR
73058). The public and stakeholders may nominate potentially misvalued
codes for review by submitting the code with supporting documentation
during the 60-day public comment period following the release of the
annual PFS final rule with comment period. Supporting documentation for
codes nominated for the annual review of potentially misvalued codes
may include the following:
Documentation in the peer reviewed medical literature or
other reliable data that there have been changes in physician work due
to one or more of the following: technique; knowledge and technology;
patient population; site-of-service; length of hospital stay; and
physician time.
An anomalous relationship between the code being proposed
for review and other codes.
Evidence that technology has changed physician work, that
is, diffusion of technology.
Analysis of other data on time and effort measures, such
as operating room logs or national and other representative databases.
Evidence that incorrect assumptions were made in the
previous valuation of the service, such as a misleading vignette,
survey, or flawed crosswalk assumptions in a previous evaluation.
Prices for certain high cost supplies or other direct PE
inputs that are used to determine PE RVUs are inaccurate and do not
reflect current information.
Analyses of physician time, work RVU, or direct PE inputs
using other data sources (for example, Department of Veteran Affairs
(VA) National Surgical Quality Improvement Program (NSQIP), the Society
for Thoracic Surgeons (STS) National Database, and the Physician
Quality Reporting System (PQRS) databases).
National surveys of physician time and intensity from
professional and management societies and organizations, such as
hospital associations.
After we receive the nominated codes during the 60-day comment
period following the release of the annual PFS final rule with comment
period, we evaluate the supporting documentation and assess whether the
nominated codes appear to be potentially misvalued codes appropriate
for review under the annual process. In the following year's PFS
proposed rule, we publish the list of nominated codes and indicate
whether we are proposing each nominated code as a potentially misvalued
code.
We did not receive publicly nominated potentially misvalued codes
for inclusion in this proposed rule. We look forward to receiving new
code nominations for inclusion in the CY 2015 proposed rule to continue
with our efforts to identify potentially misvalued codes.

[[Page 43305]]

b. Potentially Misvalued Codes
(1) Contractor Medical Director Identified Potentially Misvalued Codes
After publishing the CY final rule with comment period, we began
considering additional ways to broaden participation in the process of
identifying potentially misvalued codes. We solicited the input of
Medicare contractor medical directors (CMDs) in developing a list of
potentially misvalued codes. CMDs offer a unique perspective on the
Medicare program. Medicare Administrative Contractors administer the
Medicare program in their assigned geographic area and each has at
least one CMD that serves as its director. As a group, CMDs represent a
variety of medical specialties, which makes them a diverse group of
physicians capable of providing opinions across the vast scope of
services covered under the PFS. In addition to being physicians, they
are on the front line of administering the Medicare program; and their
offices often serve as the first point of contact for any provider with
questions regarding coverage, coding and claims processing. CMDs spend
a significant amount of time communicating directly with providers and
the health care industry discussing more than just the broad aspects of
the Medicare program but also engaging in and facilitating specific
discussions around individual services. Through their development of
evidence-based local coverage determinations (LCDs), CMDs also have
experience developing policy based on research. In consultation with
our CMDs, we have identified the following list of codes that we are
proposing as potentially misvalued. We include a brief discussion of
the reasons for proposing these codes as potentially misvalued.

Table 11--Codes Identified in Consultation With CMDs as Potentially
Misvalued
------------------------------------------------------------------------
CPT code Short descriptor
------------------------------------------------------------------------
17311............................. Mohs 1 stage h/n/hf/g.
17313............................. Mohs 1 stage t/a/l.
21800............................. Treatment of rib fracture.
22035............................. Closed tx spine process fx.
27193............................. Treat pelvic ring fracture.
33960............................. External circulation assist.
33961............................. External circulation assist, each
subsequent day.
47560............................. Laparoscopy w/cholangio.
47562............................. Laparoscopic cholecystectomy.
47563............................. Laparo cholecystectomy/graph.
55845............................. Extensive prostate surgery.
55866............................. Laparo radical prostatectomy.
64566............................. Neuroeltrd stim post tibial.
76942............................. Echo guide for biopsy.
------------------------------------------------------------------------

CPT codes 17311 (Mohs micrographic technique, including removal of
all gross tumor, surgical excision of tissue specimens, mapping, color
coding of specimens, microscopic examination of specimens by the
surgeon, and histopathologic preparation, head, neck, hands, feet
genitalia, or any location with surgery directly involving muscle,
cartilage, bone, tendon, major nerves, or vessels; first stage, up to 5
tissue blocks) and 17313 (Mohs micrographic technique, including
removal of all gross tumor, surgical excision of tissue specimens,
mapping, color coding of specimens, microscopic examination of
specimens by the surgeon, and histpathologic preparation including
routine stains(s) of the trunk, arms, or legs; first stage, up to 5
tissue blocks) are proposed as potentially misvalued codes because
based on CMD comments, we believe that the code may be overvalued.
CPT codes 21800 (Closed treatment of rib fracture, uncomplicated,
each), 22305 (Closed treatment of vertebral process fracture(s)) and
27193 (Closed treatment of pelvic ring fracture, dislocation, diastasis
or subluxation, without manipulation) is proposed for review. We are
considering the appropriateness of having a 90-day global surgical
package for a procedure that is performed in settings other than the
inpatient setting 33 percent of the time. We believe it is unlikely
that it is appropriate for a procedure performed outside of the
inpatient hospital setting at this frequency to have such a long global
period. CPT codes 33960 (Prolonged extracorporeal circulation for
cardiopulmonary insufficiency; initial day) and 33961 (Each subsequent
day) are being proposed for review because CMDs were concerned about
their current valuation of physician work. The CMD comment states that
the service was originally valued when it was used primarily in
premature neonates; but the service is now being furnished to adults
with severe influenza, pneumonia and respiratory distress syndrome. We
are concerned that, while the code currently includes 523 minutes of
total physician time with 133 minutes of intraservice time, physicians
are not typically furnishing the service over that entire time
interval; rather, hospital-employed pump technicians are furnishing
much of the work.
CPT codes 47560 (Laparoscopy, surgical; with guided transhepatic
cholangiography, without biopsy), 47562 (Cholecystectomy) and 47563
(Cholecystectomy with cholangiography) we are proposing these codes as
potentially misvalued because the more extensive code has lower work
RVUs than the less extensive codes.
CPT codes 55845 (Prostatectomy, retropubic radical with or without
nerve sparing with bilateral pelvic lymphadenectomy, including external
iliac, hypogastric, and obturator nodes) and 55866 (Laparoscopy,
surgical prostatectomy, retropubic radial, including nerve sparing,
includes robotic assistance when performed) we are proposing as
potentially misvalued because the RVUs for the laparoscopic procedure
are higher than for the open procedure and, in general, a laparascopic
procedure would not require greater resources than the open procedure.
We are proposing CPT 64566 (Posterior tibial neurostimulation,
percutaneous needle electrode, single treatment, includes programming)
as a potentially misvalued code because we think that the procedure
typically is furnished by support staff with supervision as opposed to
being furnished by the physician. We are concerned that the current
valuation is based on the procedure being furnished by a physician.
We are proposing CPT code 76942 (Ultrasonic guidance for needle
placement (for example, biopsy, aspiration, injection, localization
device), imaging supervision and interpretation) as a potentially
misvalued code because of the high frequency with which it is billed
with CPT code 20610 (Arthrocentesis aspiration and/or injection; major
joint or bursa (for example, shoulder, hip, knee joint, subacromial
bursa) in the CMD's geographic region. The CMD noted that some
providers within the contractor's geographic area bill CPT code 76942
with every injection or aspiration of the knee. One CMD suggests that
the payment for CPT code 76942 and CPT code 20610 should be combined to
reduce the incentive for providers to always provide and bill
separately for ultrasound guidance. We note that we are making a
proposal regarding the direct PE inputs for CPT code 76942. Our claims
data show that the procedure time assumption for CPT code 76942 is
longer than the typical procedure with which the code is billed (for
example, CPT code 20610). The proposed changes relating to CPT code
76942 are addressed in detail in section II.A.4.b.3. of this proposed
rule. We believe that the discrepancy in procedure times and the
resulting potentially inaccurate payment raises a fundamental concern
regarding the incentive to furnish ultrasound guidance. However, we
believe this

[[Page 43306]]

concern spans more than just an individual code for ultrasound
guidance. Accordingly, we have proposed additional ultrasound guidance
codes as potentially misvalued in Table 12. We are seeking public
comment on including these codes as potentially misvalued codes. We are
also seeking public comment on any similar codes that should be
included on this list.

Table 12--CPT Codes for Ultrasound Guidance
------------------------------------------------------------------------
CPT code Short descriptor
------------------------------------------------------------------------
76930............................. Echo guide cardiocentesis.
76932............................. Echo guide for heart biopsy.
76936............................. Echo guide for artery repair.
76940............................. US guide tissue ablation.
76948............................. Echo guide ova aspiration.
76950............................. Echo guidance radiotherapy.
76965............................. Echo guidance radiotherapy.
------------------------------------------------------------------------

(2) Improving the Valuation of the Global Surgical Package, Measuring
Post-Operative Work
In the CY 2013 proposed rule, we sought comments on methods of
obtaining accurate and current data on E/M services furnished as part
of a global surgical package. Commenters provided a variety of
suggestions including setting the all surgical services to a 0-day
global period, requiring all E/M services to be separately billed,
validating the global surgical packages with the hospital Diagnosis-
Related Group length of stay data, and setting documentation standards
for post-operative E/M services that could be audited. In addition to
receiving the broader comments on measuring post-operative work, we
also received a comment from the AMA RUC noting that the hospital and
discharge day management services included in the global period for
many surgical procedures may have been inadvertently removed from the
time file in 2007. With its comment letter, the AMA RUC sent us a time
file with updated post-operative visits for the services that arguably
we incorrectly displayed with zero visits in the CMS time file. We said
in the CY 2013 final rule with comment period that we would review this
file and, if appropriate, propose modifications to the physician time
file in the CY 2014 PFS proposed rule. We noted in the CY 2013 final
rule with comment period that if time had been removed from the
physician time file inadvertently, it would not have affected the
physician work RVUs or direct PE inputs for these services. It would
have a small impact on the indirect allocation of PE at the specialty
level, which we would review when we explore this potential time file
change.
After extensive review, we believe that the data were deleted from
the time file due to an inadvertent error as noted by the AMA RUC.
Thus, we are proposing to replace the missing post-operative hospital
E/M visit information and time for the 117 codes that were identified
by the AMA-RUC and displayed in Table 13. We believe this proposal
would populate the physician time file with data that, absent the
inadvertent error, would have been present in the time file.

Table 13--Proposed Physician Time Changes for CY 2014 Potentially Misvalued Codes
----------------------------------------------------------------------------------------------------------------
AMA RUC-recommended visits AMA RUC-
CPT code Short descriptor ------------------------------------ CY 2013 recommended
99231 99232 99238 99291 physician time physician time
----------------------------------------------------------------------------------------------------------------
19368............... Breast reconstruction. 4 ....... 1 ....... 712 770
19369............... Breast reconstruction. 3 ....... 1 ....... 657 690
20100............... Explore wound neck.... 2 ....... 1 ....... 218 266
20816............... Replantation digit 5 ....... 1 ....... 671 697
complete.
20822............... Replantation digit 3 ....... 1 ....... 587 590
complete.
20824............... Replantation thumb 5 ....... 1 ....... 646 690
complete.
20827............... Replantation thumb 4 ....... 1 ....... 610 625
complete.
20838............... Replantation foot 8 ....... 1 ....... 887 986
complete.
20955............... Fibula bone graft 6 ....... 1 1 867 957
microvasc.
20969............... Bone/skin graft 8 ....... 1 ....... 1,018 1,048
microvasc.
20970............... Bone/skin graft iliac 8 ....... 1 ....... 958 988
crest.
20973............... Bone/skin graft great 5 ....... 1 ....... 1,018 988
toe.
21139............... Reduction of forehead. 1 ....... 1 ....... 400 466
21151............... Reconstruct midface 2 ....... 1 1 567 686
lefort.
21154............... Reconstruct midface 3 ....... 1 2 664 853
lefort.
21155............... Reconstruct midface 2 ....... 1 2 754 939
lefort.
21175............... Reconstruct orbit/ ....... 1 1 2 549 767
forehead.
21182............... Reconstruct cranial ....... 1 1 2 619 856
bone.
21188............... Reconstruction of 1 ....... 1 ....... 512 572
midface.
22100............... Remove part of neck 2 ....... 1 ....... 397 372
vertebra.
22101............... Remove part thorax 3 ....... 1 ....... 392 387
vertebra.
22110............... Remove part of neck 6 ....... 1 ....... 437 479
vertebra.
22112............... Remove part thorax 7 ....... 1 ....... 507 530
vertebra.
22114............... Remove part lumbar 7 ....... 1 ....... 517 530
vertebra.
22210............... Revision of neck spine 7 ....... 1 ....... 585 609
22212............... Revision of thorax 7 ....... 1 ....... 610 640
spine.
22214............... Revision of lumbar 7 ....... 1 ....... 585 624
spine.
22220............... Revision of neck spine 7 ....... 1 ....... 565 585
22222............... Revision of thorax 8 ....... 1 ....... 630 651
spine.
22224............... Revision of lumbar 8 ....... 1 ....... 620 666
spine.
22315............... Treat spine fracture.. 1 ....... 1 ....... 257 252
22325............... Treat spine fracture.. 6 ....... 1 ....... 504 528
22326............... Treat neck spine 6 ....... 1 ....... 452 480
fracture.
22327............... Treat thorax spine 9 ....... 1 ....... 505 604
fracture.
22548............... Neck spine fusion..... 8 ....... 1 1 532 673
22556............... Thorax spine fusion... 3 ....... 1 1 525 557
22558............... Lumbar spine fusion... 2 ....... 1 1 502 525

[[Page 43307]]

22590............... Spine & skull spinal 3 ....... 1 ....... 532 501
fusion.
22595............... Neck spinal fusion.... 6 ....... 1 ....... 492 521
22600............... Neck spine fusion..... 6 ....... 1 ....... 437 490
22610............... Thorax spine fusion... 8 ....... 1 ....... 468 549
22630............... Lumbar spine fusion... 3 ....... 1 ....... 501 487
22800............... Fusion of spine....... 7 ....... 1 ....... 517 571
22802............... Fusion of spine....... 4 ....... 1 ....... 552 538
22804............... Fusion of spine....... 5 ....... 1 ....... 630 595
22808............... Fusion of spine....... 5 ....... 1 ....... 553 530
22810............... Fusion of spine....... 5 ....... 1 ....... 613 595
22812............... Fusion of spine....... 8 ....... 1 ....... 666 700
31582............... Revision of larynx.... 8 ....... 1 ....... 489 654
32650............... Thoracoscopy w/ 2 ....... 1 ....... 322 290
pleurodesis.
32656............... Thoracoscopy w/ 3 ....... 1 ....... 419 377
pleurectomy.
32658............... Thoracoscopy w/sac fb 1 ....... 1 ....... 362 330
remove.
32659............... Thoracoscopy w/sac 2 ....... 1 ....... 414 357
drainage.
32661............... Thoracoscopy w/ 1 ....... 1 ....... 342 300
pericard exc.
32664............... Thoracoscopy w/th nrv 1 ....... 1 ....... 362 330
exc.
32820............... Reconstruct injured 4 ....... 1 5 631 854
chest.
33236............... Remove electrode/ 4 ....... 1 ....... 258 346
thoracotomy.
33237............... Remove electrode/ 5 ....... 1 ....... 378 456
thoracotomy.
33238............... Remove electrode/ 5 ....... 1 ....... 379 472
thoracotomy.
33243............... Remove eltrd/ 5 ....... 1 ....... 504 537
thoracotomy.
33321............... Repair major vessel... 8 ....... 1 ....... 751 754
33332............... Insert major vessel 8 ....... 1 ....... 601 604
graft.
33401............... Valvuloplasty open.... 8 ....... 1 ....... 830 661
33403............... Valvuloplasty w/cp 8 ....... 1 ....... 890 638
bypass.
33417............... Repair of aortic valve 3 ....... 1 3 740 750
33472............... Revision of pulmonary 1 ....... 1 5 665 780
valve.
33502............... Coronary artery 3 ....... 1 3 710 688
correction.
33503............... Coronary artery graft. 6 ....... 1 3 890 838
33504............... Coronary artery graft. 5 ....... 1 3 740 789
33600............... Closure of valve...... 6 ....... 1 ....... 800 628
33602............... Closure of valve...... 6 ....... 1 ....... 770 628
33606............... Anastomosis/artery- 8 ....... 1 ....... 860 728
aorta.
33608............... Repair anomaly w/ 5 ....... 1 ....... 800 668
conduit.
33690............... Reinforce pulmonary 3 ....... 1 3 620 636
artery.
33702............... Repair of heart 1 ....... 1 4 663 751
defects.
33722............... Repair of heart defect 5 ....... 1 ....... 770 608
33732............... Repair heart-vein 5 ....... 1 ....... 710 578
defect.
33735............... Revision of heart 3 ....... 1 4 740 770
chamber.
33736............... Revision of heart 5 ....... 1 ....... 710 548
chamber.
33750............... Major vessel shunt.... 2 ....... 1 3 680 722
33764............... Major vessel shunt & 2 ....... 1 4 710 750
graft.
33767............... Major vessel shunt.... 5 ....... 1 ....... 800 608
33774............... Repair great vessels 1 ....... 1 7 845 998
defect.
33788............... Revision of pulmonary 3 ....... 1 3 770 736
artery.
33802............... Repair vessel defect.. 3 ....... 1 2 558 556
33803............... Repair vessel defect.. 3 ....... 1 2 618 586
33820............... Revise major vessel... 1 ....... 1 1 430 414
33824............... Revise major vessel... 1 ....... 1 3 588 615
33840............... Remove aorta 2 ....... 1 3 588 639
constriction.
33845............... Remove aorta 1 ....... 1 3 710 726
constriction.
33851............... Remove aorta 2 ....... 1 3 603 700
constriction.
33852............... Repair septal defect.. 2 ....... 1 3 663 719
33853............... Repair septal defect.. 8 ....... 1 ....... 800 668
33917............... Repair pulmonary 5 ....... 1 ....... 740 608
artery.
33920............... Repair pulmonary 6 ....... 1 ....... 800 658
atresia.
33922............... Transect pulmonary 5 ....... 1 ....... 618 546
artery.
33974............... Remove intra-aortic 1 ....... 1 ....... 406 314
balloon.
34502............... Reconstruct vena cava. 6 ....... 1 ....... 793 741
35091............... Repair defect of 11 ....... 1 2 597 790
artery.
35694............... Arterial transposition 2 ....... 1 ....... 468 456
35901............... Excision graft neck... 4 ....... 1 ....... 484 482
35903............... Excision graft 3 ....... 1 ....... 408 416
extremity.
47135............... Transplantation of 23 ....... 1 ....... 1,501 1,345
liver.
47136............... Transplantation of 28 ....... 1 ....... 1,301 1,329
liver.
49422............... Remove tunneled ip 1 ....... 1 ....... 154 182
cath.
49429............... Removal of shunt...... 6 ....... 1 ....... 249 317
50320............... Remove kidney living 4 ....... 1 ....... 480 524
donor.

[[Page 43308]]

50845............... Appendico-vesicostomy. 5 ....... 1 ....... 685 613
56632............... Extensive vulva 7 ....... 1 ....... 835 683
surgery.
60520............... Removal of thymus 2 ....... 1 2 406 474
gland.
60521............... Removal of thymus 5 ....... 1 ....... 457 445
gland.
60522............... Removal of thymus 7 ....... 1 ....... 525 533
gland.
61557............... Incise skull/sutures.. 3 ....... 1 ....... 529 510
63700............... Repair of spinal 3 ....... 1 ....... 399 401
herniation.
63702............... Repair of spinal 3 ....... 1 ....... 469 463
herniation.
63704............... Repair of spinal 8 ....... 1 ....... 534 609
herniation.
63706............... Repair of spinal 8 ....... 1 ....... 602 679
herniation.
----------------------------------------------------------------------------------------------------------------

(3) Codes With Higher Total Medicare Payments in Office Than in
Hospital or ASC
We are proposing to address nearly 200 codes that we believe have
misvalued resource inputs. These are codes for which the total PFS
payment when furnished in an office or other nonfacility setting would
exceed the total Medicare payment (the combined payment to the facility
and the professional) when the service is furnished in a facility,
either a hospital outpatient department or an ASC.
For services furnished in a facility setting we would generally
expect the combined payment to the facility and the practitioner to
exceed the PFS payment made to the professional when the service is
furnished in the nonfacility setting. This payment differential is
expected because it reflects the greater costs we would expect to be
incurred by facilities relative to physicians furnishing services in
offices and other non-facility settings. These greater costs are due to
higher overhead resulting from differences in regulatory requirements
and for facilities, such as hospitals, maintaining the capacity to
furnish services 24 hours per day and 7 days per week. However, when we
analyzed such payments, we identified nearly 300 codes that would
result in greater Medicare payment in the nonfacility setting than in
the facility setting. We believe these anomalous site-of-service
payment differentials are the result of inaccurate resource input data
used to establish rates under the PFS.
In this proposed rule, we are proposing to address these misvalued
codes. Specifically, we are proposing to refine the PE methodology to
limit the nonfacility PE RVUs for individual codes so that the total
nonfacility PFS payment amount would not exceed the total combined
payment under the PFS and the OPPS (or the ASC payment system) when the
service is furnished in the facility setting. We believe this is an
efficient way to address these significant anomalies within the PE
methodology and more appropriately value these services. We discuss
this proposal in more detail in section II.A.4.b.3.
4. The Multiple Procedure Payment Reduction Policy
Medicare has long employed multiple procedure payment reduction
(MPPR) policies to adjust payment to more appropriately reflect reduced
resources involved with furnishing services that are frequently
furnished together. Under these policies, we reduce payment for the
second and subsequent services within the same MPPR category furnished
in the same session or same day. These payment reductions reflect
efficiencies that typically occur in either the PE or professional work
or both when services are furnished together. With the exception of a
few codes that are always reported with another code, the PFS values
services independently to recognize relative resources involved when
the service is the only one furnished in a session. Although some of
our MPPR policies precede the Affordable Care Act, MPPRs can address
the fourth category of potentially misvalued codes identified in
section 1848(c)(2)(K) of the Act, as added by the Affordable Care Act,
which is ``multiple codes that are frequently billed in conjunction
with furnishing a single service'' (see 75 FR 73216). We are not
proposing any new MPPRs in this proposed rule, but the following
sections describe the history of MPPRs and the services currently
covered by MPPRs.
a. Background
Medicare has a longstanding policy to reduce payment by 50 percent
for the second and subsequent surgical procedures furnished to the same
beneficiary by a single physician, or physicians in the same group
practice, on the same day, largely based on the presence of
efficiencies in the PE and pre- and post-surgical physician work.
Effective January 1, 1995, the MPPR policy, with this same percentage
reduction, was extended to nuclear medicine diagnostic procedures (CPT
codes 78306, 78320, 78802, 78803, 78806, and 78807). In the CY 1995 PFS
final rule with comment period (59 FR 63410), we indicated that we
would consider applying the policy to other diagnostic tests in the
future.
Consistent with recommendations of MedPAC in its March 2005 Report
to the Congress on Medicare Payment Policy, for CY 2006 PFS, we
extended the MPPR policy to the TC of certain diagnostic imaging
procedures furnished on contiguous areas of the body in a single
session (70 FR 70261). This MPPR policy recognizes that for the second
and subsequent imaging procedures furnished in the same session, there
are some efficiencies in clinical labor, supplies, and equipment time.
In particular, certain clinical labor activities and supplies are not
duplicated for subsequent imaging services in the same session and,
because equipment time and indirect costs are allocated based on
clinical labor time, we also reduced those accordingly.
The imaging MPPR policy originally applied to computed tomography
(CT) and computed tomographic angiography (CTA), magnetic resonance
imaging (MRI) and magnetic resonance angiography (MRA), and ultrasound
services within 11 families of codes based on imaging modality and body
region, and only applied to procedures furnished in a single session
involving contiguous body areas within a family of codes. Additionally,
this MPPR policy originally applied to TC-only services and to the TC
of global services, but not to professional component (PC) services.
There have been several revisions to this policy since it was
originally adopted. Under the current imaging

[[Page 43309]]

MPPR policy, full payment is made for the TC of the highest paid
procedure, and payment for the TC is reduced by 50 percent for each
additional procedure subject to this MPPR policy. We originally planned
to phase in the imaging MPPR policy over a 2-year period, with a 25
percent reduction in CY 2006 and a 50 percent reduction in CY 2007 (70
FR 70263). However, section 5102(b) of the Deficit Reduction Act of
2005 (DRA) (Pub. L. 109-171, enacted on December 20, 2006) amended the
statute to place a cap on the PFS payment amount for most imaging
procedures at the amount paid under the hospital outpatient prospective
payment system (OPPS). In view of this new OPPS payment cap, we decided
in the CY 2006 PFS final rule with comment period that it would be
prudent to retain the imaging MPPR at 25 percent while we continued to
examine the appropriate payment levels (71 FR 69659). The DRA also
exempted reduced expenditures attributable to the imaging MPPR policy
from the PFS budget neutrality provision. Effective July 1, 2010,
section 1848(b)(4)(C) of the Act increased the MPPR on the TC of
imaging services under the policy established in the CY 2006 PFS final
rule with comment period from 25 to 50 percent. Section
1848(c)(2)(B)(v)(IV) of the Act exempted the reduced expenditures
attributable to this further change from the PFS budget neutrality
provision.
In the July 2009 U.S. Government Accountability Office (GAO) report
entitled, Medicare Physician Payments: Fees Could Better Reflect
Efficiencies Achieved when Services are Provided Together, the GAO
recommended that we take further steps to ensure that fees for services
paid under the PFS reflect efficiencies that occur when services are
furnished by the same physician to the same beneficiary on the same
day. The GAO report recommended the following: (1) Expanding the
existing imaging MPPR policy for certain services to the PC to reflect
efficiencies in physician work for certain imaging services; and (2)
expanding the MPPR to reflect PE efficiencies that occur when certain
nonsurgical, nonimaging services are furnished together. The GAO report
also encouraged us to focus on service pairs that have the most impact
on Medicare spending.
In its March 2010 report, MedPAC noted its concerns about
mispricing of services under the PFS. MedPAC indicated that it would
explore whether expanding the unit of payment through packaging or
bundling would improve payment accuracy and encourage more efficient
use of services. In the CY 2009 and CY 2010 PFS proposed rules (73 FR
38586 and 74 FR 33554, respectively), we stated that we planned to
analyze nonsurgical services commonly furnished together (for example,
60 to 75 percent of the time) to assess whether an expansion of the
MPPR policy could be warranted. MedPAC encouraged us to consider
duplicative physician work, as well as PE, in any expansion of the MPPR
policy.
Section 1848(c)(2)(K) of the Act specifies that the Secretary shall
identify potentially misvalued codes by examining multiple codes that
are frequently billed in conjunction with furnishing a single service,
and review and make appropriate adjustments to their relative values.
As a first step in applying this provision, in the CY 2010 final rule
with comment period, we implemented a limited expansion of the imaging
MPPR policy to additional combinations of imaging services.
Effective January 1, 2011, the imaging MPPR applies regardless of
code family; that is, the policy applies to multiple imaging services
furnished within the same family of codes or across families. This
policy is consistent with the standard PFS MPPR policy for surgical
procedures that does not group procedures by body region. The current
imaging MPPR policy applies to CT and CTA, MRI and MRA, and ultrasound
procedures furnished to the same beneficiary in the same session,
regardless of the imaging modality, and is not limited to contiguous
body areas.
As we noted in the CY 2011 PFS final rule with comment period (75
FR 73228), although section 1848(c)(2)(B)(v)(VI) of the Act specifies
that reduced expenditures attributable to the increase in the imaging
MPPR from 25 to 50 percent (effective for fee schedules established
beginning with 2010 and for services furnished on or after July 1,
2010) are excluded from the PFS budget neutrality adjustment, it does
not apply to reduced expenditures attributable to our policy change
regarding additional code combinations across code families
(noncontiguous body areas) that are subject to budget neutrality under
the PFS. The complete list of codes subject to the CY 2011 MPPR policy
for diagnostic imaging services is included in Addendum F.
As a further step in applying the provisions of section
1848(c)(2)(K) of the Act, on January 1, 2011, we implemented an MPPR
for therapy services. The MPPR applies to separately payable ``always
therapy'' services, that is, services that are only paid by Medicare
when furnished under a therapy plan of care. As we explained in the CY
2011 PFS final rule with comment period (75 FR 73232), the therapy MPPR
does not apply to contractor-priced codes, bundled codes, or add-on
codes.
This MPPR for therapy services was first proposed in the CY 2011
proposed rule (75 FR 44075) as a 50 percent payment reduction to the PE
component of the second and subsequent therapy services for multiple
``always therapy'' services furnished to a single beneficiary in a
single day. It applies to services furnished by an individual or group
practice or ``incident to'' a physician's service. However, in response
to public comments, in the CY 2011 PFS final rule with comment period
(75 FR 73232), we adopted a 25 percent payment reduction to the PE
component of the second and subsequent therapy services for multiple
``always therapy'' services furnished to a single beneficiary in a
single day.
Subsequent to publication of the CY 2011 PFS final rule with
comment period, section 3 of the Physician Payment and Therapy Relief
Act of 2010 (PPTRA) (Pub. L. 111-286) revised the payment reduction
percentage from 25 percent to 20 percent for therapy services for which
payment is made under a fee schedule under section 1848 of the Act
(which are services furnished in office settings, or non-institutional
services). The payment reduction percentage remained at 25 percent for
therapy services furnished in institutional settings. Section 4 of the
PPTRA exempted the reduced expenditures attributable to the therapy
MPPR policy from the PFS budget neutrality provision. Section 633 of
the ATRA revised the reduction to 50 percent of the PE component for
all settings, effective April 1, 2013. Therefore, full payment is made
for the service or unit with the highest PE and payment for the PE
component for the second and subsequent procedures or additional units
of the same service is reduced by 50 percent for both institutional and
non-institutional services.
This MPPR policy applies to multiple units of the same therapy
service, as well as to multiple different ``always therapy'' services,
when furnished to the same beneficiary on the same day. The MPPR
applies when multiple therapy services are billed on the same date of
service for one beneficiary by the same practitioner or facility under
the same National Provider Identifier (NPI), regardless of whether the
services are furnished in one therapy discipline or multiple
disciplines, including physical therapy, occupational therapy, or
speech-language pathology.

[[Page 43310]]

The MPPR policy applies in all settings where outpatient therapy
services are paid under Part B. This includes both services that are
furnished in the office setting and paid under the PFS, as well as
institutional services that are furnished by outpatient hospitals, home
health agencies, comprehensive outpatient rehabilitation facilities
(CORFs), and other entities that are paid for outpatient therapy
services at rates based on the PFS.
In its June 2011 Report to Congress, MedPAC highlighted continued
growth in ancillary services subject to the in-office ancillary
services exception. The in-office ancillary exception to the general
prohibition under section 1877 of the Act as amended by the Ethics in
Patient Referrals Act, also known as the Stark law, allows physicians
to refer Medicare beneficiaries for designated health services,
including imaging, radiation therapy, home health care, durable medical
equipment, clinical laboratory tests, and physical therapy, to entities
with which they have a financial relationship under specific
conditions. MedPAC recommended that we apply a MPPR to the PC of
diagnostic imaging services furnished by the same practitioner in the
same session as one means to curb excess self-referral for these
services. The GAO already had made a similar recommendation in its July
2009 report.
In continuing to apply the provisions of section 1848(c)(2)(K) of
the Act regarding potentially misvalued codes that result from
``multiple codes that are frequently billed in conjunction with
furnishing a single service,'' in the CY 2012 final rule (76 FR 73071),
we expanded the MPPR to the PC of Advanced Imaging Services (CT, MRI,
and Ultrasound), that is, the same list of codes to which the MPPR on
the TC of advanced imaging already applied. Thus, this MPPR policy now
applies to the PC and the TC of certain diagnostic imaging codes.
Specifically, we expanded the payment reduction currently applied to
the TC to apply also to the PC of the second and subsequent advanced
imaging services furnished by the same physician (or by two or more
physicians in the same group practice) to the same beneficiary in the
same session on the same day. However, in response to public comments,
in the CY 2012 PFS final rule with comment period, we adopted a 25
percent payment reduction to the PC component of the second and
subsequent imaging services.
Under this policy, full payment is made for the PC of the highest
paid advanced imaging service, and payment is reduced by 25 percent for
the PC for each additional advanced imaging service furnished to the
same beneficiary in the same session. This policy was based on the
expected efficiencies in furnishing multiple services in the same
session due to duplication of physician work, primarily in the pre- and
post-service periods, but with some efficiencies in the intraservice
period.
This policy is consistent with the statutory requirement for the
Secretary to identify, review, and adjust the relative values of
potentially misvalued services under the PFS as specified by section
1848(c)(2)(K) of the Act. This policy is also consistent with our
longstanding policies on surgical and nuclear medicine diagnostic
procedures, under which we apply a 50 percent payment reduction to
second and subsequent procedures. Furthermore, it was responsive to
continued concerns about significant growth in imaging spending, and to
MedPAC (March 2010 and June 2011) and GAO (July 2009) recommendations
regarding the expansion of MPPR policies under the PFS to account for
additional efficiencies.
In the CY 2013 final rule (77 FR 68933), we expanded the MPPR to
the TC of certain cardiovascular and ophthalmology diagnostic tests.
Although we proposed a 25 percent reduction for both diagnostic
cardiovascular and ophthalmology services, we adopted a 20 percent
reduction for ophthalmology services in the final rule with comment
period (77 FR 68941) in response to public comments. For diagnostic
cardiovascular services, full payment is made for the procedure with
the highest TC payment, and payment is reduced by 25 percent for the TC
for each additional procedure furnished to the same patient on the same
day. For diagnostic ophthalmology services, full payment is made for
the procedure with the highest TC payment, and payment is reduced by 20
percent for the TC for each additional procedure furnished to the same
patient on the same day.
Although we are not proposing any new MPPR policies for CY 2014, we
continue to look at expanding the MPPR based on efficiencies when
multiple procedures are furnished together. Any specific proposals
would be presented in future rulemaking and subject to further public
comment.''
The complete list of services subject to the MPPRs on diagnostic
imaging services, therapy services, diagnostic cardiovascular services
and diagnostic ophthalmology services is shown in Addenda F through J.

C. Malpractice RVUs

Section 1848(c) of the Act requires that each service paid under
the PFS be composed of three components: Work, PE, and malpractice.
From 1992 to 1999, malpractice RVUs were charge-based, using weighted
specialty-specific malpractice expense percentages and 1991 average
allowed charges. Malpractice RVUs for new codes after 1991 were
extrapolated from similar existing codes or as a percentage of the
corresponding work RVU. Section 4505(f) of the BBA, which amended
section 1848(c) of the Act, required us to implement resource-based
malpractice RVUs for services furnished beginning in 2000. Therefore,
initial implementation of resource-based malpractice RVUs occurred in
2000.
The statute also requires that we review and, if necessary, adjust
RVUs no less often than every 5 years. The first review and update of
resource-based malpractice RVUs was addressed in the CY 2005 PFS final
rule with comment period (69 FR 66263). Minor modifications to the
methodology were addressed in the CY 2006 PFS final rule with comment
period (70 FR 70153). In the CY 2010 PFS final rule with comment
period, we implemented the second review and update of malpractice
RVUs. For a discussion of the second review and update of malpractice
RVUs, see the CY 2010 PFS proposed rule (74 FR 33537) and final rule
with comment period (74 FR 61758).
As explained in the CY 2011 PFS final rule with comment period (75
FR 73208), malpractice RVUs for new and revised codes effective before
the next five-year review of malpractice RVUs (for example, effective
CY 2011 through CY 2014, assuming that the next review of malpractice
RVUs occurs for CY 2015) are determined either by a direct crosswalk
from a similar source code or by a modified crosswalk to account for
differences in work RVUs between the new/revised code and the source
code. For the modified crosswalk approach, we adjust (or ``scale'') the
malpractice RVU for the new/revised code to reflect the difference in
work RVU between the source code and the new/revised work value (or, if
greater, the clinical labor portion of the fully implemented PE RVU)
for the new code. For example, if the proposed work RVU for a revised
code is 10 percent higher than the work RVU for its source code, the
malpractice RVU for the revised code would be increased by 10 percent
over the source code malpractice RVU. This approach presumes the same
risk factor for the new/revised code and source code but

[[Page 43311]]

uses the work RVU for the new/revised code to adjust for the difference
in risk attributable to the variation in work between the two services.
For CY 2014, we will continue our current approach for determining
malpractice RVUs for new/revised codes. We will publish a list of new/
revised codes and the malpractice crosswalks used for determining their
malpractice RVUs in the final rule with comment period. The CY 2014
malpractice RVUs for new/revised codes will be implemented in the CY
2014 PFS final rule with comment period. These RVUs will be subject to
public comment. They will then be finalized in the CY 2015 PFS final
rule with comment period.

D. Medicare Economic Index (MEI)

1. Revising of the Medicare Economic Index (MEI)
a. Background
The Medicare Economic Index (MEI) is authorized under section
1842(b)(3) of the Act, which states that prevailing charge levels
beginning after June 30, 1973 may not exceed the level from the
previous year except to the extent that the Secretary finds, on the
basis of appropriate economic index data, that such higher level is
justified by year-to-year economic changes. Beginning July 1, 1975, and
continuing through today, the MEI has met this requirement by
reflecting the weighted-average annual price change for various inputs
involved in furnishing physicians' services. The MEI is a fixed-weight
input price index, with an adjustment for the change in economy-wide,
private nonfarm business multifactor productivity. This index is
comprised of two broad categories: (1) Physicians' own time; and (2)
physicians' practice expense (PE).
The current form of the MEI was described in the November 25, 1992
Federal Register (57 FR 55896) and was based in part on the
recommendations of a Congressionally-mandated meeting of experts held
in March 1987. Since that time, the MEI has been updated or revised on
four instances. First, the MEI was rebased in 1998 (63 FR 58845), which
moved the cost structure of the index from 1992 data to 1996 data.
Second, the methodology for the productivity adjustment was revised in
the CY 2003 PFS final rule with comment period (67 FR 80019) to reflect
the percentage change in the 10-year moving average of economy-wide
private nonfarm business multifactor productivity. Third, the MEI was
rebased in 2003 (68 FR 63239), which moved the cost structure of the
index from 1996 data to 2000 data. Fourth, the MEI was rebased in 2011
(75 FR 73262), which moved the cost structure of the index from 2000
data to 2006 data.
The terms ``rebasing'' and ``revising'', while often used
interchangeably, actually denote different activities. Rebasing refers
to moving the base year for the structure of costs of an input price
index, while revising relates to other types of changes such as
changing data sources, cost categories, or price proxies used in the
input price index. For CY 2014, we are proposing to revise the MEI
based on the recommendations of the MEI Technical Advisory Panel (TAP).
We are not rebasing the MEI and will continue to use the data from 2006
to estimate the cost weights, since these are the most recently
available, relevant, and complete data we have available to develop
these weights. In the following sections of this proposed rule, we
detail our proposals regarding reorganization of cost categories, our
rationale for selecting the price proxies in the MEI, and the results
of the proposed revisions to the MEI based on the MEI TAP
recommendations.
b. MEI Technical Advisory Panel (TAP) Recommendations
In the CY 2011 PFS final rule (77 FR 68892), we proposed to convene
a MEI TAP that would review all aspects of the MEI, including the
inputs, input weights, price-measurement proxies, and productivity
adjustment. The MEI TAP was to assess the relevance and accuracy of
these inputs to current physician practices. The MEI TAP's analysis and
recommendations would be considered in future rulemaking to ensure that
the MEI accurately and appropriately meets its intended statutory
purpose.
The MEI TAP was established by the Secretary under 42 U.S.C. 217a
and was governed by the provisions of the Federal Advisory Committee
Act (FACA) (Pub. L. 92-463, enacted on October 6, 1972), as amended, 5
U.S.C. App. The Panel's deliberations were made in accordance with the
FACA, which means that the meetings were conducted in public and
stakeholders were given the opportunity to share their evidence and
views with panel members.
The MEI TAP consisted of five members and held three meetings in
2012: May 21; June 25; and July 11. It produced 8 findings and 13
recommendations for consideration by CMS. Background on the MEI TAP
members, meeting transcripts for all three meetings, and the MEI TAP's
final report, including all findings and recommendations are available
at http://www.cms.gov/Regulations-and-Guidance/Guidance/FACA/MEITAP.html. It is possible to implement some of the recommendations
immediately, while more in-depth research is required to implement
several of the recommendations.
For CY 2014, we are proposing to implement 10 of the 13
recommendations made by the MEI TAP. These proposed changes only
involve revising the MEI categories, cost shares, and price proxies.
Again, we are not proposing to rebase the MEI at this time since the
MEI TAP concluded that there is not a reliable, ongoing source of data
to maintain the MEI. After acknowledging that there are no additional
data to support further rebasing of the MEI at this time, the MEI TAP
recommended that CMS' Office of the Actuary (OACT) identify and
evaluate additional data sources that may allow for more frequent
updates to the MEI's cost categories and their respective weights. Some
of the possible data sources the MEI TAP suggested we consider are:
The Medical Group Management Association's (MGMA) Cost
Survey
The Bureau of the Census Services Annual Survey (SAS)
Pending feasibility, a CMS survey, possibly conducted
jointly with the American Medical Association, that focuses exclusively
on physician expenses as they relate to the MEI. The Panel notes that
the lead time to conceive, develop, fund, and administer such a survey
would likely be considerable.
Alternatively, and again pending feasibility, CMS could
obtain more robust data by means of detailed formal cost reports based
on a methodologically sound sample of physician practices. Whether the
degree of improvement in the MEI would warrant the cost associated with
the process would be an important consideration.
As such, we will continue to investigate possible data sources,
including an assessment of whether using self-employed physician data
for the MEI cost weights, continues to be the most appropriate
approach.
c. Overview of Proposed Revisions
The MEI was last rebased and revised in the CY 2011 PFS final rule
with comment period (75 FR 73262-73275). The current base year for the
MEI is 2006, which means that the cost weights in the index reflect
physicians' expenses in 2006. The details of the methodology used to
determine the 2006 cost shares were provided in the CY 2011 PFS

[[Page 43312]]

proposed rule and finalized in the CY 2011 PFS final rule with comment
period (75 FR 40087 and 75 FR 73262, respectively). We are proposing to
make the following revisions to the 2006-based MEI:
(1) Reclassify and Revise Certain Cost Categories
Reclassify expenses for non-physician clinical personnel
that can bill independently from non-physician compensation to
physician compensation.
Revise the physician wage and benefit split so that the
cost weights are more in line with the definitions of the price proxies
used for each category.
Add an additional subcategory under non-physician
compensation for health-related workers.
Create a new cost category called ``All Other Professional
Services'' that includes expenses covered in the current MEI
categories: ``All Other Services'' and ``Other Professional Expenses.''
The proposed ``All Other Professional Services'' category would be
further disaggregated into appropriate occupational subcategories.
Create an aggregate cost category called ``Miscellaneous
Office Expenses'' that would include the expenses for ``Rubber and
Plastics,'' ``Chemicals,'' ``All Other Products,'' and ``Paper.''
(2) Revise Price Proxies
Revise the price proxy for physician wages and salaries
from the Average Hourly Earnings (AHE) for the Total Private Nonfarm
Economy for Production and Nonsupervisory Workers to the ECI for Wages
and Salaries, Professional and Related Occupations, Private Industry.
Revise the price proxy for physician benefits from the ECI
for Benefits for the Total Private Industry to the ECI for Benefits,
Professional and Related Occupations, Private Industry.
Use the ECI for Wages and Salaries and the ECI for
Benefits of Hospital, Civilian workers (private industry) as the price
proxies for the new category of non-physician health-related workers.
Use ECIs to proxy the Professional Services occupational
subcategories that reflect the type of professional services purchased
by physicians' offices.
Revise the price proxy for the fixed capital category from
the CPI for Owners' Equivalent Rent of Residences to the PPI for
Lessors of Nonresidential Buildings (NAICS 53112).
d. Revising Expense Categories in the MEI
The MEI is used as part of the Sustainable Growth Rate (SGR)
methodology to update the PFS and represents the price component of
that update. The proposed expense categories in the MEI, along with
their respective weights, are primarily derived from data collected in
the 2006 AMA Physician Practice Information Survey (PPIS) for self-
employed physicians representing 42 medical specialties and selected
self-employed non-Medical Doctor (non-MD) specialties. Data for non-MD
specialties were collected in a supplemental survey of the PPIS survey
questionnaire. We included the data from the following non-medical
specialties in the MEI cost weight calculations (optometrists, oral
surgeons, podiatrists, and chiropractors) specialties in the MEI cost
weight calculations consistent with the definition of the term
``physician'' in section 1861(r) of the Act. In summary, the term
``physician'' when used in connection with the performance of functions
or actions an individual is legally authorized to perform means the
following: (1) A doctor of medicine or osteopathy; (2) a doctor of
dental surgery or of dental medicine; (3) a doctor of podiatric
medicine; (4) a doctor of optometry; or (5) a chiropractor. For a
complete definition, please see section 1861(r) of the Act. We are not
proposing to change the data source we used to establish the major MEI
cost weights, and therefore, we propose to continue to use of the 2006
AMA PPIS physician expense data at this time. Data for the dental
medicine specialty are not included in the weights since the PPIS
supplemental collection effort did not survey this specialty.
We are not proposing any changes in the methodology for estimating
the cost shares as finalized in the CY 2011 PFS final rule with comment
period (75 FR 73263-73267). For CY 2014, we are proposing to revise the
classification of certain expenses within the 2006-based MEI. The
following sections describe the details of the proposed revisions for
each of the categories and the rationale for the proposed changes. We
also provide the Panel recommendation that is the impetus for each of
the proposed revisions.
(1) Overall MEI Cost Weights
Table 14 lists the set of mutually exclusive and exhaustive cost
categories and weights that make up the proposed revised MEI as
compared to the current MEI cost categories.
The physician compensation cost weight under the proposed revised
MEI is 2.600 percentage points higher than the physician compensation
weight in the current MEI. This occurs because of the proposed
reclassification of expenses for non-physician clinical staff that can
bill independently from non-physician compensation to physician
compensation. This change lowers the PE cost weight by 2.600 percent as
well, all of which comes from a lower weight for non-physician
compensation. The remaining MEI cost weights are unchanged.
The proposed revised MEI includes four new detailed cost categories
and two new sub-aggregate cost categories. The proposed new detailed
cost categories are:
Health-related, non-physician wages and salaries.
Professional, scientific, and technical services.
Administrative support and waste management services.
All other services.
The proposed new sub-aggregate categories are:
Non-health, non-physician wages.
Miscellaneous office expenses.
The proposed revised MEI excludes two sub-aggregate categories that
were included in the current 2006-based MEI. The sub-aggregate
categories we propose to remove are:
Office expenses.
Drugs & supplies.

Table 14--Proposed Revised 2006 MEI Cost Categories and, Weights
Compared to the Current 2006 MEI Cost Categories and Weights
------------------------------------------------------------------------
Current MEI (2006 = 100), finalized in the Proposed revised MEI (2006 =
CY2011 PFS final rule 100), CY2014 PFS proposed
------------------------------------------- rule
-----------------------------
Current Revised
Cost category weights weights Revised cost
(percent) (percent) category
------------------------------------------------------------------------
Physician Compensation....... 48.266 50.866 Physician
Compensation.
Wages and Salaries........... 43.881 43.641 Wages and
Salaries.

[[Page 43313]]

Benefits..................... 4.386 7.225 Benefits.
Practice Expense............. 51.734 49.134 Practice
Expense.
Non-physician compensation... 19.153 16.553 Non-physician
compensation.
Non-physician wages.......... 13.752 11.885 Non-physician
wages.
7.249 Non-health, non-
physician
wages.
P&T.......................... 6.006 0.800 Professional
and Related.
Management................... 1.446 1.529 Management.
Clerical..................... 4.466 4.720 Clerical.
Services..................... 1.834 0.200 Services.
4.636 Health related,
non-physician
wages.
Non-physician benefits....... 5.401 4.668 Non-physician
benefits.
Other Practice Expense....... 26.308 32.581 Other Practice
Expense.
Office expenses.............. 20.035
Utilities.................... 1.266 1.266 Utilities.
2.478 Miscellaneous
Office
Expenses.
Chemicals.................... 0.723 0.723 Chemicals.
Paper........................ 0.656 0.656 Paper.
Rubber & Plastics............ 0.598 0.598 Rubber &
Plastics.
0.500 All other
products.
Telephone.................... 1.501 1.501 Telephone.
Postage...................... 0.898 0.898 Postage.
All other services........... 3.581 8.095 All Other
professional
services.
2.592 Professional,
scientific, &
technical
services.
3.052 Administrative
support &
waste
management.
2.451 All other
services.
All other products........... 0.500
Capital...................... 10.310 10.310 Capital.
Fixed Capital................ 8.957 8.957 Fixed Capital.
Moveable Capital............. 1.353 1.353 Moveable
Capital.
Professional Liability 4.295 4.295 Professional
Insurance. Liability
Insurance.
Medical Equipment............ 1.978 1.978 Medical
Equipment.
Drugs and Supplies........... 1.760
Prescription Drugs........... 0.000
Medical supplies............. 1.760 1.760 Medical
supplies.
Other Professional Expenses.. 4.513
All other.................... 4.513
------------------------------------------
Total MEI................ 100.000 100.000 Total MEI.
------------------------------------------------------------------------
* The term (2006 = 100) refers to the base year of the MEI

(2) Physician Compensation (Own time).
The component of the MEI that reflects the physician's own time is
represented by the net income portion of business receipts. The 2006
cost weight associated with the physician's own time (otherwise
referred to as the Physician's Compensation cost weight) is based on
2006 AMA PPIS data for mean physician net income (physician
compensation) for self-employed physicians and for the selected self-
employed specialties referenced previously in this rule. Expenses for
employed physician compensation are combined with expenses for self-
employed physician compensation to obtain an aggregate Physician
Compensation cost weight. Based on this methodology, the Physician
Compensation cost weight in the current MEI is 48.266 percent.
As discussed in the CY 2011 PFS final rule with comment period (75
FR 73265), when determining this weight, we classified the expenses for
non-physician clinical staff that can bill Medicare independently under
non-physician compensation, which is where these expenses have
historically been apportioned in the MEI. The AMA PPIS survey question
that collected the data for the clinical personnel who can
independently bill, such as nurse practitioners, physician assistants,
and other clinical personnel, captured these expenses under non-
physician compensation. Additionally, prior AMA surveys captured these
expenses as non-physician compensation costs.
The Panel reviewed this methodology and Recommendation 3.2 was
that:
``OACT evaluate the appropriate classification of the expenses
associated with non-physician clinical staff who can bill Medicare
independently. Among the factors OACT should consider are:
Any definition of `physicians' that exists under current
law in relation to the Medicare PFS and whether these definitions might
limit OACT's ability to make changes;
Whether time for non-physician staff who can bill
independently is included among the inputs to the PE RVU methodology
under the Medicare PFS (that is, is the treatment of this input under
the PE RVU methodology consistent with that under the MEI);
Whether there is any evidence these staff do not spend the
majority of their time providing `physicians' services' as defined by
Medicare; and
The extent to which those who can bill independently
actually do so.''

[[Page 43314]]

We are proposing to reclassify these expenses to physician
compensation for several reasons:
These types of practitioners furnish services that are
similar to those furnished by physicians.
If billing independently, these practitioners would be
paid at a percentage of the physicians' services or in certain cases at
the same rate as physicians.
The expenses related to the work components for the RVUs
would include work from clinical staff that can bill independently.
Therefore, it would improve consistency with the RVU payments to
include these expenses as physician compensation in the MEI.
The effect of moving the expenses related to clinical staff that
can bill independently is to increase the physician compensation cost
share by 2.600 percentage points and reduces non-physician compensation
costs by the same amount. The physician compensation cost share for the
proposed revised MEI is 50.866 percent compared to the physician
compensation cost share of 48.266 percent in the current MEI.
Within the physician compensation cost weight, the MEI includes a
separate weight for wages and salaries and a separate weight for
benefits. Under the current 2006-based MEI, the ratio for wages and
salaries, and benefits was calculated using data from the PPIS. Self-
employed physician wages and salaries accounted for 92.3 percent of
physician earnings while physician benefits accounted for the remaining
7.8 percent. For employed physician payroll, the distributions for
wages and salaries, and benefits for 2006 were 85.8 percent and 14.2
percent, respectively. This ratio was determined by calculating a
weighted average of available IRS Statistics of Income (SOI) data for
partnerships, corporations, and S-corporations specific to physicians
and outpatient care centers. Combining the information on self-employed
and employed physicians produced a physician wages & salaries cost
weight of 43.880 percent and a physician benefits cost weight of 4.386
percent, in the current MEI.
Recommendation 3.1 stated:

The Panel recommends that OACT revise the Physician Wages and
Salaries and Physician Benefit cost weights in the 2006-based MEI.
OACT should determine the cost weights for wages and benefits to
ensure they are consistent with the definitions in the Employment
Cost Index. Specifically, OACT should consider estimating the
proportion of the Physician Wages and Salaries cost weight
associated with physicians' retirement benefits, and reclassifying
that percentage into the Physician Benefits cost weight to be
consistent with the costs included in the ECI for Wages and Salaries
and the ECI for Benefits price proxies. Evaluation of the PPIS data
determined that retirement benefits were included in the Physician
Wages and Salaries cost weight while the associated price change is
currently reflected in the ECI for Benefits.

We are proposing to revise the wage and benefit split used for
physician compensation. Specifically, we are proposing to apply the
distribution from the SOI data to both self-employed and employed
physician compensation. In reviewing the detailed AMA PPIS survey
questions, it was clear that self-employed physician benefits were
mainly comprised of insurance costs while other benefits such as
physician retirement, paid leave, and payroll taxes were likely
included in physician wages and salaries.
By definition, the price proxy used for physician benefits, which
is an Employment Cost Index (ECI) concept, includes retirement savings.
Thus, using the AMA PPIS data produces a definitional inconsistency
between the cost weight and the price proxy. Therefore, we propose to
use the data on wages and salaries, and employee benefits from the SOI
for Offices of Physicians and Dentists for partnerships and
corporations for both self-employed and employed physicians. From the
SOI data, benefit expenses were estimated by summing the partnership
data for retirement plans and employee benefit programs with
corporation data for pension, profit-sharing plans and employee benefit
programs. For 2006, the split between wages and salaries, and benefits
was 85.8 percent and 14.2 percent, respectively. Retirement/pension
plans account for about 60 percent of total benefits. The SOI data do
not classify paid leave and supplemental pay as a benefit.
Combining the impact of classifying compensation for non-physicians
that can bill independently as physician compensation with the use of
the SOI data, the physician wages and salary cost share in the proposed
revised MEI is lower than the current MEI by 0.240 percentage points.
These two methodological changes result in an increase in the physician
benefit cost share in the proposed revised MEI of 2.839 percentage
points. As a result, the physician wages and salary cost share for the
proposed revised MEI is 43.641 percent and the physician benefit cost
share for the proposed revised MEI is 7.225 percent.
(3) Physician's Practice Expenses
To determine the PE cost weights, we use mean expense data from the
2006 PPIS survey. The derivation of the weights and categories for
practice expenses is the same as finalized in the CY 2011 PFS final
rule with comment period (75 FR 73264-73267), except where noted below.
(a) Non-physician Employee Compensation
The cost weight for Non-physician Employee Compensation was
developed using the 2006 AMA PPIS mean expenses for these costs. As
discussed previously, for CY 2014 we are proposing to exclude the
expenses related to non-physician clinical staff that can bill
independently from this cost category. Moving the expenses related to
the clinical staff that can bill independently out of non-physician
compensation costs decreases the share by 2.600 percentage points. The
non-physician compensation cost share for the proposed revised MEI is
16.553 percent compared to the current physician compensation cost
share of 19.153 percent.
We are proposing to use the same method as finalized in the CY 2011
PFS final rule to split the non-physician compensation between wages
and benefits. For reference, we use 2006 BLS Employer Costs for
Employee Compensation (ECEC) data for the Health Care and Social
Assistance (private industry). Data for 2006 in the ECEC for Health
Care and Social Assistance indicate that wages and benefits are 71.8
percent and 28.2 percent of compensation, respectively. The non-
physician wage and benefit cost shares for the proposed revised MEI are
11.885 percent and 4.668 percent, respectively; for the current MEI,
the non-physician wage and benefit cost shares are 13.752 percent and
5.401 percent, respectively.
The current 2006-based MEI further disaggregated the non-physician
wages into four occupational subcategories, the details of this method
can be found in 75 FR 73264-73265. The MEI TAP Recommendation 4.4
stated:

``The Panel recommends the disaggregation of the Non-Physician
Compensation costs to include an additional category for health-
related workers. This disaggregation would allow for health-related
workers to be separated from non-health-related workers. CMS should
rely directly on PPIS data to estimate the health-related non-
physician compensation cost weights. The non-health, non-physician
wages should be further disaggregated based on the Current
Population Survey and Occupational Employment Statistics data.''

We propose to implement this recommendation using expenses reported
on the AMA PPIS for non-

[[Page 43315]]

physician, non-health-related workers. The survey question asks for the
expenses for: ``Non-clinical personnel involved primarily in
administrative, secretarial or clerical activities (Including
transcriptionists, medical records personnel, receptionists, schedulers
and billing staff, coding staff, information technology staff, and
custodial personnel).'' The non-physician, non-health-related wage cost
share for the proposed revised MEI is 7.249 percent.
For wage costs of non-physician, health-related workers, the survey
question asks for the expenses for: ``Other clinical staff, including
RNs, LPNs, physicists, lab technicians, x-ray technicians, medical
assistants, and other clinical personnel who cannot independently
bill.'' The non-physician, health-related wage cost share for the
proposed revised MEI is 4.636 percent. Together the non-health and
health-related, non-physician wage costs sum to be equal to the total
non-physician wage share in the proposed revised MEI of 11.885 percent.
We are proposing to disaggregate the non-physician, non-health-
related wage cost weight of 7.249 percent into four occupational
subcategories. The methodology is similar to that finalized in the CY
2011 PFS final rule with comment period (75 FR 73264), in that we are
proposing to use 2006 Current Population Survey (CPS) data and 2006 BLS
Occupational Employment Statistics (OES) data to develop cost weights
for wages for non-physician, non-health-related occupational groups. We
determined total annual earnings for offices of physicians using
employment data from the CPS and mean annual earnings from the OES. To
arrive at a distribution for these separate occupational categories
(Professional & Related (P&R) workers, Managers, Clerical workers, and
Service workers), we determined annual earnings for each using the
Standard Occupational Classification (SOC) system. We then determined
the overall share of the total for each. The occupational distribution
in the proposed revised MEI as well as the distribution for the 2006-
based MEI is presented in Table 15.

Table 15--Percent Distribution of Nonphysician Payroll Expense by
Occupational Group: Proposed Revised 2006-Based MEI and Current 2006-
Based MEI
------------------------------------------------------------------------
Current MEI (2006 = 100), finalized in the Proposed MEI (2006 = 100),
CY11 PFS final rule CY14 PFS proposed rule
------------------------------------------------------------------------
Current Revised
Cost Category MEI06 MEI06 Revised cost
(percent) (percent) category
------------------------------------------------------------------------
Non-physician compensation... 19.153 16.553 Non-physician
compensation.
Non-physician wages.......... 13.752 11.885 Non-physician
wages.
........... 7.249 Non-health, non-
phys. wages.
P&T.......................... 6.006 0.800 Professional
and Related.
Management................... 1.446 1.529 Management.
Clerical..................... 4.466 4.720 Clerical.
Services..................... 1.834 0.200 Services.
........... 4.636 Health related,
non-phys.
Wages.
Non-physician benefits....... 5.401 4.668 Non-physician
benefits.
------------------------------------------------------------------------

The health-related workers were previously included mainly in the
Professional and Technical and Service Categories. These proposed
changes allow for health-related workers to be proxied by a health-
specific ECI rather than an ECI for more general occupations.
(b) Other Practice Expense
The remaining expenses in the MEI are categorized as Other Practice
Expenses. In the current 2006-based MEI we had classified other PEs in
one of the following subcategories: Office Expenses; Drugs and
Supplies; and All Other Professional Expenses. For CY 2014, we are
proposing to disaggregate these expenses in a way consistent with the
MEI TAP's recommendations, as detailed below.
We rely on the 2006 AMA PPIS data to determine the cost share for
Other Practice Expenses. These expenses are the total of office
expenses, medical supplies, medical equipment, Professional Liability
Insurance (PLI), and all other professional expenses.
For the proposed revised 2006-based MEI, we propose to disaggregate
Other Practice Expenses into 15 detailed subcategories as shown in
Table 16.

Table 16--Revised Cost Categories for Other Practice Expense
------------------------------------------------------------------------
Revised
Revised cost category MEI06
(percent)
------------------------------------------------------------------------
Other Practice Expense..................................... 32.581
Utilities.................................................. 1.266
Miscellaneous Office Expenses.............................. 2.478
Chemicals.................................................. 0.723
Paper...................................................... 0.656
Rubber & Plastics.......................................... 0.598
All other products......................................... 0.500
Telephone.................................................. 1.501
Postage.................................................... 0.898
All Other professional services............................ 8.095
Professional, Scientific, and Tech. Svcs................... 2.592
Administrative and support & waste......................... 3.052
All Other Services......................................... 2.451
Capital.................................................... 10.310
Fixed...................................................... 8.957
Moveable................................................... 1.353
Professional Liability Insurance........................... 4.295
Medical Equipment.......................................... 1.978
Medical supplies........................................... 1.760
------------------------------------------------------------------------

For most of these categories, we use the same method as finalized
in the CY 2011 PFS final rule with comment period to estimate the cost
shares. In particular, the cost shares for the following categories are
derived directly from expense data reported on the 2006 AMA PPIS: PLI;
Medical Equipment; and Medical Supplies. In each case, the cost shares
remain the same as in the current MEI. Additionally, we continue to use
the Bureau of Economic Analysis (BEA) 2002--Benchmark I/O data aged to
2006 to determine the cost weights for other expenses not collected
directly from the AMA PPIS. The BEA 2002-Benchmark I/O data can be
accessed at the following link: http://www.bea.gov/industry/io_benchmark.htm#2002data.
The derivation of the cost weight for each of the detailed
categories under Other Practice Expenses is provided below.
Utilities: The Utilities cost weight includes
expenses classified in the fuel, oil and gas, water and sewage, and
electricity industries. The proposed cost weight for utilities is 1.266
percent, the same cost share as in the current MEI.

[[Page 43316]]

Miscellaneous Office Expenses: We are proposing
to include an aggregate category of detailed office expenses that were
stand-alone categories in the current 2006-based MEI. During the CY
2011 PFS proposed rule comment period, several commenters expressed
confusion as to the relevance of these categories to their practice
costs. The MEI TAP discussed the degree of granularity needed in both
the calculation and reporting of the MEI. The MEI TAP concluded that it
might be prudent to collapse some of the non-labor PE categories with
other categories for presentation purposes. In particular,
Recommendation 3.4 was that:
``OACT report more aggregated costs under the Office Expenses cost
category. In particular, reported costs associated with Rubber and
Plastics, Chemicals, All Other Products, and Paper should be combined.
However, the Panel believes that OACT should maintain separately the
underlying details and calculations associated with these aggregated
costs when applying price proxies and calculating the overall MEI and
its subcomponents.'' Based on this recommendation, we are proposing to
add an aggregate category to the MEI that includes the expenses for
paper, chemicals, rubber and plastics, and all other products. The cost
shares for paper, chemicals, rubber and plastics, and all other
products remain the same for the proposed revised MEI as in the current
MEI.''
Telephone: The telephone cost weight includes
expenses classified in the telecommunications (accounting for the
majority of the telephone expenses) and cable industries. The cost
weight for Telephone services is 1.501 percent in the proposed revised
MEI, the same cost share as in the current MEI.
Postage: The Postage cost weight includes postal
service expenses. The cost weight for Postage is 0.898 percent in the
proposed revised MEI, the same cost share as in the current MEI.
All Other Services: We propose to combine the
All Other Services cost weight and All Other Professional Expenses into
a single cost category. The proposed weight for the All Other
Professional Services category is 8.095 percent, which is the sum of
the current MEI weight for All Other Services (3.581 percent) and All
Other Professional Expenses (4.513 percent), is more in line with the
GPCI Purchased Services index as finalized in the CY2012 PFS final rule
with comment period (76 FR 73085). The TAP Recommendation 3.3 was that

``OACT create a new cost category entitled Professional Services
that should consist of the All Other Services cost category (and its
respective weight) and the Other Professional Expenses cost category
(and its respective weight). The Panel further recommends that this
category be disaggregated into appropriate occupational categories
consistent with the relevant price proxies.''

We propose to combine the ``Other Professional Expenses'' and ``All
Other Services'' cost weights of the 2006-based MEI and further
disaggregate the 8.095 percent of expenses into more detail based on
the BEA I-O data, allowing for specific cost weights for services such
as contract billing services, accounting, and legal services. We
considered various levels of aggregation; however, in considering the
level of aggregation, the available corresponding price proxies must be
considered. Given the price proxies that are available from the ECI, we
propose to disaggregate these expenses into three categories:
NAICS 54 (Professional, Scientific, and Technical
Services): The Professional, Scientific, and Technical Services sector
comprises establishments that specialize in performing professional,
scientific, and technical activities for others. These activities
require a high degree of expertise and training. The establishments in
this sector specialize according to expertise and provide these
services to clients in a variety of industries, including but not
limited to: legal advice and representation; accounting, and payroll
services; computer services; management consulting services; and
advertising services and have a 2.592 percent weight.
NAICS 56 (Administrative and Support and Waste Management
and Remediation Services): The Administrative and Support and Waste
Management and Remediation Services sector comprises establishments
performing routine support activities for the day-to-day operations of
other organizations. The establishments in this sector specialize in
one or more of these support activities and provide these services to
clients in a variety of industries including but not limited to: office
administration; temporary help services; security services; cleaning
and janitorial services; and trash collection services. These services
have a 3.052 percent weight.
All Other Services, a residual category of these expenses:
The residual All Other Services cost category is mostly comprised of
expenses associated with service occupations, including but not limited
to: Lab and blood specimen transport; catering and food services;
collection company services; and dry cleaning services and have a 2.451
percent weight.
++ Fixed Capital: The Fixed Capital cost weight includes expenses
for building leases and depreciation. The cost weight for Fixed Capital
is 8.957 percent in the proposed revised MEI, the same cost share as in
the current MEI.
++ Moveable Capital: The Moveable Capital cost weight includes
expenses for non-medical equipment including but not limited to,
computer equipment and software, as well as the rental and leasing of
automotive and industrial machinery equipment. The cost weight for
Moveable Capital is 1.353 percent in the proposed revised MEI, the same
cost share as in the current MEI.
++ Professional Liability Insurance (PLI): The weight for PLI
expense was derived from the 2006 AMA survey and was calculated as the
mean PLI expense expressed as a percentage of total expenses. The cost
weight for PLI is 4.295 percent in the proposed revised MEI, the same
cost share as in the current MEI.
++ Medical Equipment Expenses: The proposed weight for Medical
Equipment was calculated using the 2006 AMA PPIS mean expense data. The
cost weight for Medical Equipment Expenses is 1.978 percent in the
proposed revised MEI, the same cost share as in the current MEI.
++ Medical Supplies Expenses: The proposed weight for Medical
Supplies was calculated using the 2006 AMA PPIS mean expense data. The
cost weight for Medical Supplies Expenses is 1.760 percent in the
proposed revised MEI, the same cost share as in the current MEI.
2. Selection of Price Proxies for Use in the MEI
After developing the cost category weights for the proposed revised
2006-based MEI, we reviewed all the price proxies based on the
recommendations from the MEI TAP. As was the case in the development of
the current 2006-based MEI, most of the proxy measures we considered
are based on BLS data and are grouped into one of the following four
categories:
Producer Price Indices (PPIs): PPIs measure price changes
for goods sold in markets other than retail markets. These fixed-weight
indexes are measures of price change at the intermediate or final stage
of production. They are the preferred proxies for physician purchases
as these prices appropriately reflect the product's first commercial
transaction.
Consumer Price Indices (CPIs): CPIs measure change in the
prices of final

[[Page 43317]]

goods and services bought by consumers. Like the PPIs, they are fixed
weight indexes. Since they may not represent the price changes faced by
producers, CPIs are used if there are no appropriate PPIs or if the
particular expenditure category is likely to contain purchases made at
the final point of sale.
Employment Cost Indices (ECIs) for Wages & Salaries: These
ECIs measure the rate of change in employee wage rates per hour worked.
These fixed-weight indexes are not affected by employment shifts among
industries or occupations and thus, measure only the pure rate of
change in wages.
Employment Cost Indices (ECIs) for Employee Benefits:
These ECIs measure the rate of change in employer costs of employee
benefits, such as the employer's share of Social Security taxes,
pension and other retirement plans, insurance benefits (life, health,
disability, and accident), and paid leave. Like ECIs for wages &
salaries, the ECIs for employee benefits are not affected by employment
shifts among industries or occupations.
When choosing wage and price proxies for each expense category, we
evaluate the strengths and weaknesses of each proxy variable using the
following four criteria.
Relevance: The price proxy should appropriately represent
price changes for specific goods or services within the expense
category. Relevance may encompass judgments about relative efficiency
of the market generating the price and wage increases.
Reliability: If the potential proxy demonstrates a high
sampling variability, or inexplicable erratic patterns over time, its
viability as an appropriate price proxy is greatly diminished. Notably,
low sampling variability can conflict with relevance--since the more
specifically a price variable is defined (in terms of service,
commodity, or geographic area), the higher the possibility of high
sampling variability. A well-established time series is also preferred.
Timeliness of actual published data: For greater
granularity and the need to be as timely as possible, we prefer monthly
and quarterly data to annual data.
Public availability: For transparency, we prefer to use
data sources that are publicly available.
Below we discuss the price and wage proxies for each cost category
of the proposed revised 2006-based MEI (as shown in Table 17). We will
continue to use the same price proxies as those used in the 2006-based
MEI except as noted below.
a. Physician Compensation (Physician's Own Time)
(1) Physician Wages and Salaries
Based on recommendations from the MEI TAP, we are proposing to use
the ECI for Wages and Salaries for Professional and Related Occupations
(Private Industry) (BLS series code CIU2020000120000I) to measure price
growth of this category in the proposed revised 2006-based MEI. The
current 2006-based MEI used Average Hourly Earnings (AHE) for
Production and Non-Supervisory Employees for the Private Nonfarm
Economy.
The MEI TAP had two recommendations concerning the price proxy for
physician Wages and Salaries. The first recommendation from the MEI TAP
was Recommendation 4.1, which was that: ``. . . OACT revise the price
proxy associated with Physician Wages and Salaries from an Average
Hourly Earnings concept to an Employment Cost Index concept.'' AHEs are
calculated by dividing gross payrolls for wages and salaries by total
hours. The AHE proxy was representative of actual changes in hourly
earnings for the nonfarm business economy, including shifts in
employment mix. The recommended alternative, the ECI concept, measures
the rate of change in employee wage rates per hour worked. ECIs measure
the pure rate of change in wages by industry and/or occupation and are
not affected by shifts in employment mix across industries and
occupations. The MEI TAP thought that the ECI concept better reflected
physician wage trends compared to the AHE concept.
The second recommendation related to the price proxy for physician
wages and salaries was Recommendation 4.2, which was that:

CMS revise the price proxy associated with changes in Physician
Wages and Salaries to use the Employment Cost Index for Wages and
Salaries, Professional and Related, Private Industry. The Panel
believes this change would maintain consistency with the guidance
provided in the 1972 Senate Finance Committee report titled `Social
Security Amendments of 1972,' which stated that the index should
reflect changes in practice expenses and `general earnings.' In the
event this change would be determined not to meet the legal
requirement that the index reflect ``general earnings,'' the Panel
recommends replacing the current proxy with the Employment Cost
Index for Wages and Salaries, All Workers, Private Industry. The
Panel believed this change would maintain consistency with the
guidance provided in the 1972 Senate Finance Committee report titled
``Social Security Amendments of 1972,'' which stated that the index
should reflect changes in practice expenses and ``general
earnings.'' \1\
---------------------------------------------------------------------------

\1\ U.S. Senate, Committee on Finance, Social Security
Amendments of 1972. ``Report of the Committee on Finance United
States Senate to Accompany H.R. 1,'' September 26, 1972, p. 191.

We agree that switching the proxy to the ECI for Wages and Salaries
for Professional and Related Occupations would be consistent with the
authority provided in the statute and reflect a wage trend more
consistent with other professionals that receive advanced training.
Additionally, we believe the ECI is a more appropriate concept than the
AHE because it can isolate wage trends without being impacted by the
change in the mix of employment.
(2) Physician Benefits
The MEI TAP states in Recommendation 4.3 that, ``. . . any change
in the price proxy for Physician Wages and Salaries be accompanied by
the selection and incorporation of a Physician Benefits price proxy
that is consistent with the Physician Wages and Salaries price proxy.''
We are proposing to use the ECI for Benefits for Professional and
Related Occupations (Private Industry) to measure price growth of this
category in the proposed revised 2006-based MEI. The ECI for Benefits
for Professional and Related Occupations is derived using BLS's Total
Compensation for Professional and Related Occupations (BLS series ID
CIU2010000120000I) and the relative importance of wages and salaries
within total compensation. We believe this series is technically
appropriate because it better reflects the benefit trends for
professionals requiring advanced training. The current 2006-based MEI
market basket used the ECI for Total Benefits for the Total Private
Industry.
b. Practice Expense
(1) Non-Physician Employee Compensation
(a) Non-Physician Wages and Salaries
(i) Non-Physician, Non-Health-Related Wages and Salaries
Professional and Related: We will continue using the ECI
for Wages and Salaries for Professional and Related Occupation (Private
Industry) (BLS series code CIU2020000120000I) to measure the price
growth of this cost category. This is the same proxy used in the
current 2006-based MEI.
Management: We will continue using the ECI for Wages and
Salaries for Management, Business, and Financial (Private Industry)
(BLS series code CIU2020000110000I) to measure the price growth of this
cost category. This

[[Page 43318]]

is the same proxy used in the current 2006-based MEI.
Clerical: We will continue using the ECI for Wages and
Salaries for Office and Administrative Support (Private Industry) (BLS
series code CIU2020000220000I) to measure the price growth of this cost
category. This is the same proxy used in the current 2006-based MEI.
Services: We will continue using the ECI for Wages and
Salaries for Service Occupations (Private Industry) (BLS series code
CIU2020000300000I) to measure the price growth of this cost category.
This is the same proxy used in the current 2006-based MEI.
(ii) Non-Physician, Health-Related Wages and Salaries
In Recommendation 4.4, the MEI TAP `` . . . recommend[ed] the
disaggregation of the Non-Physician Compensation costs to include an
additional category for health-related workers. This disaggregation
would allow for health-related workers to be separated from non-health-
related workers. CMS should rely directly on PPIS data to estimate the
health-related non-physician compensation cost weights. The non-health,
non-physician wages should be further disaggregated based on the
Current Population Survey and Occupational Employment Statistics data.
The new health-related cost category should be proxied by the ECI,
Wages and Salaries, Hospital (NAICS 622), which has an occupational mix
that is reasonably close to that in physicians' offices. The Non-
Physician Benefit category should be proxied by a composite benefit
index reflecting the same relative occupation weights as the non-
physician wages.'' We are proposing to use the ECI for Wages and
Salaries for Hospital Workers (Private Industry) (BLS series code
CIU2026220000000I) to measure the price growth of this cost category in
the proposed revised 2006-based MEI. The ECI for Hospital workers has
an occupational mix that approximates that in physicians' offices. This
cost category was not broken out separately in the current 2006-based
MEI.
(b) Non-Physician Benefits
We will continue using a composite ECI for non-physician employee
benefits in the proposed revised 2006-based MEI. However, we are
proposing to expand the number of occupations from four to five by
adding detail on Non-Physician Health-Related Benefits. The weights and
price proxies for the composite benefits index will be revised to
reflect the addition of the new category. Table 17 lists the five ECI
series and corresponding weights used to construct the proposed revised
composite benefit index for non-physician employees in the proposed
revised 2006-based MEI.

Table 17--CMS Composite Price Index for Non-Physician Employee Benefits
in the Proposed Revised 2006-Based MEI
------------------------------------------------------------------------
2006 Weight
ECI Series (%)
------------------------------------------------------------------------
Benefits for Professional and Related Occupation (Private 7
Industry).................................................
Benefits for Management, Business, and Financial (Private 12
Industry).................................................
Benefits for Office and Administrative Support (Private 40
Industry).................................................
Benefits for Service Occupations (Private Industry)........ 2
Benefits for Hospital Workers (Private Industry)........... 39
------------------------------------------------------------------------

(3) Other Practice Expense
(a) All Other Professional Services
As discussed previously, MEI TAP Recommendation 3.3 was that:
`` . . . OACT create a new cost category entitled Professional
Services that should consist of the All Other Services cost category
(and its respective weight) and the Other Professional Expenses cost
category (and its respective weight). The Panel further recommends that
this category be disaggregated into appropriate occupational categories
consistent with the relevant price proxies.'' We are proposing to
implement this recommendation in the proposed revised 2006-based MEI
using a cost category titled ``All Other Professional Services.''
Likewise, the MEI TAP stated in Recommendation 4.7 that `` . . . price
changes associated with the Professional Services category be proxied
by an appropriate blend of Employment Cost Indexes that reflect the
types of professional services purchased by physician offices.'' We
agree with this recommendation and are proposing to the use the
following price proxies for each of the new occupational categories:
Professional, Scientific, and Technical Services: We are
proposing to use the ECI for Total Compensation for Professional,
Scientific, and Technical Services (Private Industry) (BLS series code
CIU2015400000000I) to measure the price growth of this cost category.
This cost category was not broken out separately in the current 2006-
based MEI.
Administrative and Support Services: We are proposing to
use the ECI for Total Compensation for Administrative, Support, Waste
Management, and Remediation Services (Private Industry) (BLS series
code CIU2015600000000I) to measure the price growth of this cost
category. This cost category was not broken out separately in the
current 2006-based MEI.
All Other Services: We are proposing to use the ECI for
Compensation for Service Occupations (Private Industry) (BLS series
code CIU2010000300000I) to measure the price growth of this cost
category.
(b) Miscellaneous Office Expenses
Chemicals: We will continue using the PPI for Other Basic
Organic Chemical Manufacturing (BLS series code PCU32519-
32519) to measure the price growth of this cost category. This is the
same proxy used in the current 2006-based MEI.
Paper: We will continue using the PPI for Converted Paper
and Paperboard (BLS series code WPU0915) to measure the price
growth of this cost category. This is the same proxy used in the
current 2006-based MEI.
Rubber & Plastics: We will continue using the PPI for
Rubber and Plastic Products (BLS series code WPU07) to measure
the price growth of this cost category. This is the same proxy used in
the current 2006-based MEI.
All Other Products: We will continue using the CPI-U for
All Products less Food and Energy (BLS series code CUUR0000SA0L1E) to
measure the price growth of this cost category. This is the same proxy
used in the current 2006-based MEI.
Utilities: We will continue using the CPI for Fuel and
Utilities (BLS series code CUUR0000SAH2) to measure the price growth of
this cost category. This is the same proxy used in the current 2006-
based MEI.
Telephone: We will continue using the CPI for Telephone
Services (BLS series code CUUR0000SEED) to measure the price growth of
this cost category. This is the same proxy used in the current 2006-
based MEI.
Postage: We will continue using the CPI for Postage (BLS
series code CUUR0000SEEC01) to measure the price growth of this cost
category. This is the same proxy used in the current 2006-based MEI.
Fixed Capital: In Recommendation 4.5, ``The Panel
recommends using the Producer Price Index for Lessors of Nonresidential
Buildings (NAICS 53112) for the MEI Fixed Capital cost category as it
represents the types of

[[Page 43319]]

fixed capital expenses most likely faced by physicians. The Panel noted
the volatility in the index, which is greater than the Consumer Price
Index for Owners' Equivalent Rent of Residences. This relative
volatility merits ongoing monitoring and evaluation of alternatives.''
We are proposing to use the PPI for Lessors of Nonresidential Buildings
(BLS series code PCU531120531120) to measure the price growth of this
cost category in the proposed revised 2006-based MEI. The current 2006-
based MEI used the CPI for Owner's Equivalent Rent. We believe the PPI
for Lessors of Nonresidential Buildings is more appropriate as fixed
capital expenses in physician offices should be more congruent with
trends in business office space costs than residential costs.
Moveable Capital: In Recommendation 4.6, the MEI TAP
states that ``. . . CMS conduct research into and identify a more
appropriate price proxy for Moveable Capital expenses. In particular,
the Panel believes it is important that a proxy reflect price changes
in the types of non-medical equipment purchased in the production of
physicians' services, as well as the price changes associated with
Information and Communication Technology expenses (including both
hardware and software).'' We intend to continue to investigate possible
data sources that could be used to proxy the physician expenses related
to moveable capital in more detail. However, we will continue to use
the PPI for Machinery and Equipment (series code WPU11) to measure the
price growth of this cost category in the proposed revised 2006-based
MEI. This is the same proxy used in the current 2006-based MEI.
Professional Liability Insurance: Unlike the other price
proxies based on data from BLS and other public sources, the proxy for
PLI is based on data collected directly by CMS from a sample of
commercial insurance carriers. The MEI TAP discussed the methodology of
the CMS PLI index, as well as considered alternative data sources for
the PLI price proxy, including information available from BLS and
through state insurance commissioners. MEI TAP Finding 4.3 states:
``The Panel finds the CMS-constructed professional liability
insurance price index used to proxy changes in professional liability
insurance premiums in the MEI represents the best currently available
method for its intended purpose. The Panel also believes the pricing
patterns of commercial carriers, as measured by the CMS PLI index, are
influenced by the same driving forces as those observable in policies
underwritten by physician-owned insurance entities; thus, the Panel
believes the current index appropriately reflects the price changes in
premiums throughout the industry.'' Given this finding, we will
continue using the CMS Physician PLI index to measure the price growth
of this cost category in the proposed revised 2006-based MEI. This is
the same proxy used in the current 2006-based MEI.
Medical Equipment: We will continue using the PPI for
Medical Instruments and Equipment (BLS series code WPU1562) as the
price proxy for this category. This is the same proxy used in the
current 2006-based MEI.
Medical Materials and Supplies: We will continue using a
blended index comprised of 50/50 blend of the PPI for Surgical
Appliances (BLS series code WPU156301) and the CPI-U for Medical
Equipment and Supplies (BLS series code CUUR0000SEMG). This is the same
proxy used in the current 2006-based MEI.

Table 18--Proposed Revised 2006-Based MEI Cost Categories, Weights, and
Price Proxies
------------------------------------------------------------------------
2006 Weight
Cost category (percent) Price proxy
------------------------------------------------------------------------
Total MEI..................... 100.000
Physician Compensation........ 50.866
Wages and Salaries........ 43.641 ECI--Wages and salaries--
Professional and Related
(Private).
Benefits.................. 7.225 ECI--Benefits--Professional
and Related (Private).
Practice Expense.............. 49.134
Non-physician Compensation.... 16.553
Non-physician Wages........... 11.885
Non-health, non-physician 7.249
wages.
Professional and Related.. 0.800 ECI--Wages And Salaries--
Professional and Related
(Private).
Management................ 1.529 ECI--Wages And Salaries--
Mgmt., Business, and Finc.
(Private).
Clerical.................. 4.720 ECI--Wages And Salaries--
Office and Admin. Support
(Private).
Services.................. 0.200 ECI--Wages And Salaries--
Service Occupations
(Private).
Health related, non-phys. 4.636 ECI--Wages and Salaries--
Wages. Hospital (Private).
Non-physician Benefits........ 4.668 Composite Benefit Index.
Other Practice Expense........ 32.581
Miscellaneous Office Expenses. 2.478
Chemicals................. 0.723 PPI--Other Basic Organic
Chemical Manufacturing.
Paper..................... 0.656 PPI--Converted Paper and
Paperboard.
Rubber and Plastics....... 0.598 PPI--Rubber and Plastic
Products.
All other products........ 0.500 CPI--All Items Less Food
And Energy.
Telephone................. 1.501 CPI--Telephone.
Postage................... 0.898 CPI--Postage.
All Other Professional 8.095
Services.
Prof., Scientific, and Tech. 2.592 ECI--Compensation--Prof.,
Svcs. Scientific, and Technical
(Private).
Admin. and Support Services... 3.052 ECI--Compensation--Admin.,
Support, Waste Mgmt.
(Private).
All Other Services............ 2.451 ECI--Compensation--Service
Occupations (Private).
Capital:
Fixed Capital............. 8.957 PPI--Lessors of
Nonresidential Buildings.
Moveable Capital.......... 1.353 PPI--Machinery and
Equipment.
Professional Liability 4.295 CMS--Professional Liability
Insurance. Phys. Prem. Survey.
Medical Equipment............. 1.978 PPI--Medical Instruments
and Equipment.
Medical Supplies.............. 1.760 Composite--PPI Surgical
Appliances & CPI-U Medical
Supplies.
------------------------------------------------------------------------

[[Page 43320]]

3. Productivity Adjustment to the MEI
The MEI has been adjusted for changes in productivity since its
inception. In the CY 2003 PFS final rule with comment period (67 FR
80019), we implemented a change in the way the MEI was adjusted to
account for changes in productivity. The MEI used for the 2003
physician payment update incorporated changes in the 10-year moving
average of private nonfarm business (economy-wide) multifactor
productivity that were applied to the entire index. Previously, the
index incorporated changes in productivity by adjusting the labor
portions of the index by the 10-year moving average of economy-wide
private nonfarm business labor productivity.
The MEI TAP was asked to review this approach. In Finding 5.1,
``[t]he Panel reviewed the basis for the current economy-wide
multifactor productivity adjustment (Private Nonfarm Business
Multifactor Productivity) in the MEI and finds such an adjustment
continues to be appropriate. This adjustment prevents `double counting'
of the effects of productivity improvements, which would otherwise be
reflected in both (i) the increase in compensation and other input
price proxies underlying the MEI, and (ii) the growth in the number of
physician services performed per unit of input resources, which results
from advances in productivity by individual physician practices.''
Based on the MEI TAP's finding, we will continue to use the current
method for adjusting the full MEI for multifactor productivity in the
proposed revised 2006-based MEI. As described in the CY 2003 PFS final
rule with comment period, we believe this adjustment is appropriate
because it explicitly reflects the productivity gains associated with
all inputs (both labor and non-labor). We believe that using the 10-
year moving average percent change in economy-wide multifactor
productivity is appropriate for deriving a stable measure that helps
alleviate the influence that the peak (or a trough) of a business cycle
may have on the measure. The adjustment will be based on the latest
available historical economy-wide nonfarm business multifactor
productivity data as measured and published by BLS.
4. Results of Proposed Revisions on the MEI Update
Table 19 shows the average calendar year percent change from CY
2005 to CY 2014 for both the proposed revised 2006-based MEI and the
current 2006-based MEI. The average annual percent change in the
proposed revised 2006-based MEI is 0.1 percent lower than the current
2006-based MEI over the 2005-2013 period. On an annual basis over this
period, the differences vary by up to plus or minus 0.7 percentage
points. In the two most recent years (CY 2012 and CY 2013), the annual
percent change in the proposed revised 2006-based MEI was within 0.1
percentage point of the percent change in the current 2006-based MEI.
The majority of these differences over the historical period can be
attributed to the revised price proxy for physician wages and salaries
and benefits and the revised price proxy for fixed capital.

Table 19--Annual Percent Change in the Proposed Revised 2006-Based MEI,
Not Including Productivity Adjustment and the Current 2006-Based MEI,
Not Including Productivity Adjustment *
------------------------------------------------------------------------
Proposed
revised Current
Update year 2006-based 2006-based
MEI excl. MEI, excl.
MFP MFP
------------------------------------------------------------------------
CY 2005....................................... 3.8 3.1
CY 2006....................................... 4.0 3.3
CY 2007....................................... 3.2 3.2
CY 2008....................................... 3.2 3.4
CY 2009....................................... 2.9 3.1
CY 2010....................................... 2.4 2.8
CY 2011....................................... 0.9 1.6
CY 2012....................................... 1.7 1.8
CY 2013....................................... 1.7 1.8
Avg. Change for CYs 2005-2013................. 2.6 2.7
------------------------------------------------------------------------
* Update year based on historical data through the second quarter of the
prior calendar year. For example, the 2013 update is based on
historical data through the second quarter 2012, prior to MFP
adjustment.

As shown in Table 20, the projection of the proposed revised 2006-
based MEI for the CY 2014 PFS proposed rule is an increase of 0.7
percent, 0.1 percentage point lower than the projected increase using
the current 2006-based MEI. In the CY 2014 PFS final rule with comment
period, we will incorporate historical data through the second quarter
of 2013, and therefore, the current estimated increase of 0.7 percent
for 2014 may differ in the final rule.

Table 20--Projected Annual Percent Change in the CY 2014 Proposed
Revised 2006-Based MEI and the Current 2006-Based MEI *
------------------------------------------------------------------------
Proposed
revised Current
Update year 2006-based 2006-based
MEI MEI
------------------------------------------------------------------------
CY 2014....................................... 0.7 0.8
------------------------------------------------------------------------
* Based on the 2nd quarter 2013 forecast from IHS Global Insight, with
historical data through the 1st quarter 2013.

For the productivity adjustment, the 10-year moving average percent
change adjustment for CY 2014 is 0.9 percent, which is based on the
most historical data available from BLS at the time of the proposed
rule. If more recent historical data of MFP is available at the time of
the final rule, we will incorporate it into the final MEI update.

Table 21--Forecasted Annual Percent Change in the Proposed Revised MEI
for CY 2014
[All Categories]
------------------------------------------------------------------------
Revised CY14
Revised cost category Revised price cost weight update
proxy (percent) (percent)
------------------------------------------------------------------------
MEI.......................... 100.000 0.7
MFP.......................... 10-yr moving N/A 0.9
average of
Private
Nonfarm
Business
Multifactor
Productivity.
MEI without productivity 100.000 1.6
adjustment.

[[Page 43321]]

Physician Compensation....... 50.866 2.0
Wages and Salaries........... ECI--Wages and 43.641 1.9
salaries--Prof
essional and
Related
(private).
Benefits..................... ECI--Benefits-- 7.225 2.2
Professional
and Related
(private).
Practice Expense............. 49.134 1.3
Non-physician compensation... 16.553 1.7
Non-physician wages.......... 11.885 1.7
Non-health, non-physician 7.249 1.8
wages.
Professional & Related....... ECI--Wages And 0.800 1.9
Salaries--Prof
essional and
Related
(Private).
Management................... ECI--Wages And 1.529 1.7
Salaries--Mana
gers &
Administrators
(Private).
Clerical..................... ECI--Wages And 4.720 1.8
Salaries--Admi
n Support incl
Clerical
(Private).
Services..................... ECI--Wages And 0.200 1.5
Salaries--Serv
ice
Occupations
(Private).
Health related, non-physician ECI--Wages and 4.636 1.5
wages. Salaries--Hosp
ital
(civilian).
Non-physician benefits....... Composite 4.668 1.7
Benefit Index.
Other Practice Expense....... 32.581 1.1
Utilities.................... CPI Fuels and 1.266 0.7
Utilities.
Miscellaneous Office Expenses 2.478 0.3
Chemicals.................... Other Basic 0.723 -1.2
Organic
Chemical
Manufacturing
PPI325190.
Paper........................ PPI for 0.656 1.1
converted
paper.
Rubber & Plastics............ PPI for rubber 0.598 0.3
and plastics.
All other products........... CPI--All Items 0.500 1.9
Less Food And
Energy.
Telephone.................... CPI for 1.501 0.1
Telephone.
Postage...................... CPI for Postage 0.898 4.9
All Other Professional 8.095 1.7
Services.
Professional, Scientific, and ECI--Compensati 2.592 1.7
Tech. Svcs. on: Prof.
scientific,
tech.
Administrative and support & ECI--Compensati 3.052 1.8
waste. on
Administrative.
All Other Services........... ECI 2.451 1.6
Compensation:
Services
Occupations.
Capital...................... 10.310 0.5
Fixed........................ PPI for Lessors 8.957 0.5
of
nonresidential
buildings.
Moveable..................... PPI for 1.353 0.8
Machinery and
Equipment.
Professional Liability CMS--Prof. 4.295 0.9
Insurance. Liability.
Phys. Prem.
Survey.
Medical Equipment............ PPI--Med. Inst. 1.978 1.4
& Equip.
Medical supplies............. Composite--PPI 1.760 1.0
Surg. Appl. &
CPIU Med.
Supplies.
(CY2006).
------------------------------------------------------------------------
* Based on the 2nd quarter 2013 forecast from IHS Global Insight, with
historical data through the 1st quarter 2013.

E. Geographic Practice Cost Indices (GPCIs)

1. Background
Section 1848(e)(1)(A) of the Act requires us to develop separate
Geographic Practice Cost Indices (GPCIs) to measure resource cost
differences among localities compared to the national average for each
of the three fee schedule components (that is, work, PE, and
malpractice (MP)). The 89 total PFS localities are discussed in section
II.E.3. of this proposed rule. While requiring that the PE and MP GPCIs
reflect the full relative cost differences, section 1848(e)(1)(A)(iii)
of the Act requires that the work GPCIs reflect only one-quarter of the
relative cost differences compared to the national average. In
addition, section 1848(e)(1)(G) of the Act sets a permanent 1.5 work
GPCI floor for services furnished in Alaska beginning January 1, 2009,
and section 1848(e)(1)(I) of the Act sets a permanent 1.0 PE GPCI floor
for services furnished in frontier states (as defined in section
1848(e)(1)(I) of the Act) beginning January 1, 2011. Additionally,
section 1848(e)(1)(E) of the Act provided for a 1.0 floor for the work
GPCIs, which was set to expire at the end of 2012. Section 602 of the
ATRA amended the statute to extend the 1.0 floor for the work GPCIs
through CY 2013 (that is, for services furnished no later than December
31, 2013).
Section 1848(e)(1)(C) of the Act requires us to review and, if
necessary, adjust the GPCIs at least every 3 years. Section
1848(e)(1)(C) of the Act requires that ``if more than 1 year has
elapsed since the date of the last previous GPCI adjustment, the
adjustment to be applied in the first year of the next adjustment shall
be \1/2\ of the adjustment that otherwise would be made.'' Therefore,
since the previous GPCI update was implemented in CY 2011 and CY 2012,
we are proposing to phase in \1/2\ of the latest GPCI adjustment in CY
2014.
We have completed a review of the GPCIs and are proposing new
GPCIs, as well as a revision to the cost share weights that correspond
to all three GPCIs in this proposed rule. We also calculate a
geographic adjustment factor (GAF) for each PFS locality. The GAFs are
a weighted composite of each area's work, PE and malpractice expense
GPCIs using the national GPCI cost share weights. While we do not
actually use GAFs in computing the fee schedule payment for a specific
service, they are useful in comparing overall areas costs and payments.
The actual effect on payment for any actual service will

[[Page 43322]]

deviate from the GAF to the extent that the proportions of work, PE and
MP RVUs for the service differ from those of the GAF.
As noted above, section 602 of the ATRA extended the 1.0 work GPCI
floor only through December 31, 2013. Therefore, the proposed CY 2014
work GPCIs and summarized GAFs do not reflect the 1.0 work floor.
However, as required by sections 1848(e)(1)(G) and 1848(e)(1)(I) of the
Act, the 1.5 work GPCI floor for Alaska and the 1.0 PE GPCI floor for
frontier states are permanent, and therefore, applicable in CY 2014.
See Addenda D and E to this proposed rule for the proposed CY 2014
GPCIs and summarized GAFs available on the CMS Web site under the
supporting documents section of the CY 2014 PFS proposed rule located
at http://www.cms.gov/PhysicianFeeSched/.
2. GPCI Update
The proposed updated GPCI values were calculated by a contractor to
CMS. There are three GPCIs (work, PE, and MP), and all GPCIs are
calculated through comparison to a national average for each type.
Additionally, each of the three GPCIs relies on its own data source(s)
and methodology for calculating its value as described below.
Additional information on the CY 2014 GPCI update may be found in our
contractor's draft report, ``Draft Report on the CY 2014 Update of the
Geographic Practice Cost Index for the Medicare Physician Fee
Schedule,'' which is available on the CMS Web site. It is located under
the supporting documents section of the CY 2014 PFS proposed rule
located at http://www.cms.gov/PhysicianFeeSched/.
a. Work GPCIs
The physician work GPCIs are designed to reflect the relative costs
of physician labor by Medicare PFS locality. As required by statute,
the physician work GPCI reflects one quarter of the relative wage
differences for each locality compared to the national average.
To calculate the physician work GPCIs, we use wage data for seven
professional specialty occupation categories, adjusted to reflect one-
quarter of the relative cost differences for each locality compared to
the national average, as a proxy for physicians' wages. Physicians'
wages are not included in the occupation categories used in calculating
the work GPCI because Medicare payments are a key determinant of
physicians' earnings. Including physician wage data in calculating the
work GPCIs would potentially introduce some circularity to the
adjustment since Medicare payments typically contribute to or influence
physician wages. That is, including physicians' wages in the physician
work GPCIs would, in effect, make the indices, to some extent,
dependent upon Medicare payments.
The physician work GPCI updates in CYs 2001, 2003, 2005, and 2008
were based on professional earnings data from the 2000 Census. However,
for the CY 2011 GPCI update (75 FR 73252), the 2000 data were outdated
and wage and earnings data were not available from the more recent
Census because the ``long form'' was discontinued. Therefore, we used
the median hourly earnings from the 2006 through 2008 Bureau of Labor
Statistics (BLS) Occupational Employment Statistics (OES) wage data as
a replacement for the 2000 Census data. The BLS OES data meet several
criteria that we consider to be important for selecting a data source
for purposes of calculating the GPCIs. For example, the BLS OES wage
and employment data are derived from a large sample size of
approximately 200,000 establishments of varying sizes nationwide from
every metropolitan area and can be easily accessible to the public at
no cost. Additionally, the BLS OES is updated regularly, and includes a
comprehensive set of occupations and industries (for example, 800
occupations in 450 industries).
Because of its reliability, public availability, level of detail,
and national scope, we believe the BLS OES continues to be the most
appropriate source of wage and employment data for use in calculating
the work GPCIs (and as discussed in section II.E.2.b the employee wage
component and purchased services component of the PE GPCI). Therefore,
for the proposed CY 2014 GPCI update, we used updated BLS OES data
(2009 through 2011) as a replacement for the 2006 through 2008 data to
compute the work GPCIs.
We note that the Medicare Payment Advisory Commission (MedPAC) was
required by section 3004 of the MCTRJCA to submit a report to the
Congress by June 15, 2013 that assesses whether any adjustment under
section 1848 of the Act to distinguish the difference in work effort by
geographic area is appropriate and, if so, what that level should be
and where it should be applied. In the report, MedPAC was required to
also assess the impact of the work geographic adjustment under the Act,
including the extent to which the floor on such adjustment impacts
access to care. We did not have sufficient time to review this report,
which was issued on June 14, 2013 for this proposed rule. We look
forward to reviewing the MedPAC report and its recommendations with
respect to the work GPCI.
b. Practice Expense GPCIs
The PE GPCIs are designed to measure the relative cost difference
in the mix of goods and services comprising practice expenses (not
including malpractice expenses) among the PFS localities as compared to
the national average of these costs. Whereas the physician work GPCIs
(and as discussed later in this section, the MP GPCIs) are comprised of
a single index, the PE GPCIs are comprised of four component indices
(employee wages; purchased services; office rent; and equipment,
supplies and other miscellaneous expenses). The employee wage index
component measures geographic variation in the cost of the kinds of
skilled and unskilled labor that would be directly employed by a
physician practice. Although the employee wage index adjusts for
geographic variation in the cost of labor employed directly by
physician practices, it does not account for geographic variation in
the cost of services that typically would be purchased from other
entities, such as law firms, accounting firms, information technology
consultants, building service managers, or any other third-party
vendor. The purchased services index component of the PE GPCI (which is
a separate index from employee wages) measures geographic variation in
the cost of contracted services that physician practices would
typically buy. (For more information on the development of the
purchased service index, we refer readers to the CY 2012 PFS final rule
with comment period (76 FR 73084 through 73085).) The office rent index
component of the PE GPCI measures relative geographic variation in the
cost of typical physician office rents. For the medical equipment,
supplies, and miscellaneous expenses component, we believe there is a
national market for these items such that there is not significant
geographic variation in costs. Therefore, the ``equipment, supplies and
other miscellaneous expense'' cost index component of the PE GPCI is
given a value of 1.000 for each PFS locality.
For the previous update to the GPCIs (implemented in CY 2011 and CY
2012) we used 2006 through 2008 BLS OES data to calculate the employee
wage and purchased services indices for the PE GPCI. As discussed in
section II.E.2.a., because of its reliability, public availability,
level of detail, and national scope, we continue to believe the BLS

[[Page 43323]]

OES is the most appropriate data source for collecting wage and
employment data. Therefore, in calculating the proposed CY 2014 GPCI
update, we used updated BLS OES data (2009 through 2011) as a
replacement for the 2006 through 2008 data for purposes of calculating
the employee wage component and purchased service index of the PE GPCI.
Office Rent Index Discussion
Since the inception of the PFS, we have used residential rent data
(primarily the two-bedroom residential apartment rent data produced by
the Department of Housing and Urban Development (HUD) at the 50th
percentile) as the proxy to measure the relative cost difference in
physician office rents. As discussed in the CY 2012 PFS final rule with
comment period (76 FR 73084), we had concerns with the continued use of
the HUD rental data because the data were not updated frequently and
the Census ``long form,'' which was used to collect the necessary base
year rents for the HUD Fair Market Rent (FMR) data, was discontinued in
CY 2010 and would no longer be available for future updates. Therefore,
we examined the suitability of using 3-year (2006-2008) American
Community Survey (ACS) rental data as a proxy for physician office
rents to replace the HUD data. We determined that the ACS is one of the
largest nationally representative surveys of household rents in the
United States conducted annually by the U.S. Census Bureau, sampling
approximately 3 million addresses with a recent response rate above 97
percent, and that it reports rental information for residences at the
county level. Given that the ACS rental data provided a sufficient
degree of reliability, is updated annually, and was expected to be
available for future updates, we used the 2006 through 2008 ACS 3-year
residential rent data as a replacement for the HUD data to create the
office rent index for the CY 2012 PFS final rule with comment (76 FR
73084). For all the same reasons that we used the ACS data for the last
GPCI update, we propose to use the most recent 3-year ACS residential
rent data (2008 through 2010) to calculate the office rent component of
the PE GPCI. We note that when responding to the ACS survey,
individuals also report whether utilities are included in their rent.
Thus, the cost of utilities cannot be separated from ``gross rents''
since some individuals monthly rent also covers the cost of utilities.
As discussed in section II.E.2.d. we combined the cost weights for
fixed capital and utilities when assigning a proposed weight to the
office rent component of the PE GPCI.
For many years, we have received requests from physicians and their
representatives to use commercial rent data instead of residential rent
data as a proxy to measure the relative cost differences in physician
office rent. Additionally, in a report entitled ``Geographic Adjustment
in Medicare Payment, Phase I: Improving Accuracy,'' prepared for CMS
under contract and released on September 28, 2011, the Institute of
Medicine recommended that ``a new source of data should be developed to
determine the variation in the price of commercial office rent per
square foot.'' The Institute of Medicine report did not identify any
new data source and did not suggest how a new source of data might be
developed. Because we could not identify a reliable commercial rental
data source that is available on a national basis and includes data for
non-metropolitan areas, we continued to use residential rent data for
the CY 2012 GPCI update.
For the CY 2014 GPCI update, we continued our efforts to identify a
reliable source of commercial rent data that could be used in
calculating the rent index. We could not identify a nationally
representative commercial rent data source that is available in the
public sector. However, we identified a proprietary commercial rent
data source that has potential for use in calculating the office rent
indices in future years. To that end, we are attempting to negotiate an
agreement with the proprietor to use the data for purposes of
calculating the office rent component of the PE GPCI.
One of the challenges of using a proprietary data source is our
ability to make information available to the public. When using
government data, we are able to release all data for public
consideration. However, when using a proprietary data source, it is
likely that restrictions will be imposed on its use and our ability to
disclose data. In such a situation, those wishing to replicate our
calculations based on detailed data would also need to purchase the
underlying proprietary data. We also believe that, generally speaking,
a proprietary ``for profit'' data source is more susceptible to
periodic changes in the criteria used for data collection, including
possible changes in the data collected, the frequency at which the data
is updated, changes in ownership, and the potential for termination of
the survey vehicle entirely as changes are made to address economic
pressures or opportunities. As such, we cannot predict that a given
proprietary data source will be available in the format needed to
develop office rent indices in the future. Since we have not identified
a nationally representative commercial rent data source that is
available in the public sector, we believe it would be necessary to use
a proprietary data source for commercial office rent data. That is, in
the absence of using a proprietary data source, it is unlikely that we
would be able to use commercial rent data to calculate the office rent
index component of the PE GPCI. Therefore, we request comments on the
potential future use of a proprietary commercial rent data source as
well as whether there is a source for these data that is not
proprietary.
c. Malpractice Expense (MP) GPCIs
The MP GPCIs measure the relative cost differences among PFS
localities for the purchase of professional liability insurance (PLI).
The MP GPCIs are calculated based on insurer rate filings of premium
data for $1 million to $3 million mature claims-made policies (policies
for claims made rather than services furnished during the policy term).
For the CY 2011 GPCI update (sixth update) we used 2006 and 2007
malpractice premium data (75 FR 73256). The proposed CY 2014 MP GPCI
update reflects 2011 and 2012 premium data.
Additionally, for the past several GPCI updates, we were not able
to collect MP premium data from insurer rate filings for the Puerto
Rico payment locality. For the CY 2014 (seventh) GPCI update, we worked
directly with the Puerto Rico Insurance Commissioner and Institute of
Statistics to obtain data on MP insurance premiums that were used to
calculate an updated MP GPCI for Puerto Rico. Using updated MP premium
data would result in a 17 percent increase in MP GPCI for the Puerto
Rico payment locality under the proposed fully phased-in seventh GPCI
update, which would be effective CY 2015.
d. GPCI Cost Share Weights
To determine the cost share weights for the proposed CY 2014 GPCIs,
we used the weights we propose to use for the CY 2014 value for the
revised 2006-based Medicare Economic Index (MEI) as discussed in
section II.D. of this proposed rule. As discussed in detail in that
section, the MEI was rebased and revised in the CY 2011 PFS final rule
with comment period (75 FR 73262 through 73277) to reflect the
weighted-average annual price change for various inputs needed to
provide physicians' services. We have historically updated the GPCI
cost share weights to make them consistent with the most recent

[[Page 43324]]

update to the MEI, and propose to do so again for CY 2014. We would
note that consistent with this approach in the CY 2011 proposed rule,
the last time the MEI was revised, we proposed to update the GPCI cost
share weights to reflect these revisions to the MEI. However, in
response to public comments we did not finalize the proposal in the CY
2011 PFS final rule with comment period (75 FR 73258 and 73260), so
that we could explore public comments received suggesting the
reallocation of labor related costs from the medical equipment,
supplies and miscellaneous component to the employee compensation
component and comments received on the cost share weight for the rent
index of the PE GPCI as well as to continue our analysis of the cost
share weights attributed to the PE GPCIs as required by section
1848(e)(1)(H)(iv) of the Act.
In the CY 2012 PFS final rule (76 FR 73085 through 73086) we
addressed commenter concerns regarding the inclusion of the cost share
weight assigned to utilities within the office rent component of the PE
GPCI and to geographically adjust wage related industries contained
within the medical equipment, supplies and miscellaneous component of
the PE GPCI. As a result, to accurately capture the utility measurement
present in the ACS two bedroom gross rent data, the cost share weight
for utilities was combined with the fixed capital portion to form the
office rent index. Additionally, we developed a purchased service index
to geographically adjust the labor-related components of the ``All
Other Services'' and ``Other Professional Expenses'' categories of the
2006-based MEI market basket. Upon completing our analysis of the GPCI
cost share weights (as required by the Act) and addressing commenters'
concerns regarding the office rent and labor related industries
previously contained in the medical equipment, supplies and other
miscellaneous components of the PE GCPI, we updated the GPCI cost share
weights consistent with the weights established in the 2006-based MEI
in the CY 2012 PFS final rule (76 FR 73086).
The proposed revised 2006-based MEI cost share weights reflect our
actuaries' best estimate of the weights associated with each of the
various inputs needed to provide physicians' services. Use of the
current MEI cost share weights also provides consistency across the PFS
in the use of this data. Given that we have addressed previous
commenters concerns about the allocation of labor related costs (as
discussed earlier in this section) and that we have completed our
analysis of the GPCI cost share weights (as required by the Act) we
believe it is appropriate to propose to adopt the weights we are
proposing to use for the revised 2006-based MEI as the GPCI cost share
weights for CY 2014.
As a result, the cost share weight for the work GPCI (as a
percentage of the total) in this proposal is changed from 48.266
percent to 50.866 percent, and the cost share weight for the PE GPCI is
revised from 47.439 percent to 44.839 percent with a change in the
employee compensation component from 19.153 to 16.553 percentage
points. The cost share weights for the office rent component (10.223
percent), purchased services component (8.095 percent), and the medical
equipment, supplies, and other miscellaneous expenses component (9.968
percent) of the PE GPCI and the cost share weight for the MP GPCI
(4.295 percent) remains unchanged. A discussion of the specific MEI
cost centers and the respective weights used to calculate each GPCI
component (and subcomponent) is provided below.
(1) Work GPCIs
We propose to adopt the proposed revised weight of 50.866 for the
physician compensation cost category as the proposed work GPCI cost
share weight.
(2) Practice Expense GPCIs
For the cost share weight for the PE GPCIs, we used the revised
2006-based MEI proposed weight for the PE category of 49.134 percent
minus the PLI category weight of 4.295 percent (because the relative
costs differences in malpractice expenses are measured by its own
GPCI). Therefore, the proposed cost share weight for the PE GPCIs is
44.839 percent.
(a) Employee Compensation
For the employee compensation portion of the PE GPCIs, we used the
proposed non-physician employee compensation category weight of 16.553
percent reflected in the revised 2006-based MEI.
(b) Office Rent
We set the PE GPCI office rent portion at 10.223 percent which
includes the proposed revised 2006-based MEI cost weights for fixed
capital (reflecting the expenses for rent, depreciation on medical
buildings and mortgage interest) and utilities. As discussed previously
in this section, we propose to use 2008-2010 ACS rental data as the
proxy for physician office rent. As mentioned previously, these data
represent a gross rent amount and include data on utility expenditures.
Since it is not possible to separate the utilities component of rent
for all ACS survey respondents, we combined these two components to
calculate office rent values that were used to calculate the office
rent index component of the proposed PE GPCI. For purposes of
consistency, we combined those two cost categories when assigning a
proposed weight to the office rent component.
(c) Purchased Services
As discussed in section II.D. of this proposed rule, to be
consistent with the purchased services index, we are proposing to
combine the current MEI cost share weights for ``All Other Services''
and ``Other Professional Expenses'' into a component called ``All Other
Professional Services.'' The proposed weight for ``All Other
Professional Services'' is 8.095. As noted in the CY 2012 PFS final
rule with comment period (76 FR 73084), we only adjust for locality
cost differences of the labor-related share of the purchased services
index. We determined that only 5.011 percentage points of the total
8.095 proposed weight are labor-related and, thus, would be adjusted
for locality cost differences (5.011 adjusted purchased service + 3.084
non-adjusted purchased services = 8.095 total cost share weight).
Therefore, only 62 percent (5.011/8.095) of the purchased service index
is adjusted for geographic cost differences while the remaining 38
percent (3.084/8.095) of the purchased service index is not adjusted
for geographic variation.
(d) Equipment, Supplies, and Other Miscellaneous Expenses
To calculate the medical equipment, supplies, and other
miscellaneous expenses component, we removed PLI (4.295 percentage
points), non-physician employee compensation (16.553 percentage
points), fixed capital/utilities (10.223 percentage points), and
purchased services (8.095 percentage points) from the total proposed PE
category weight (44.839 percent). Therefore, the proposed cost share
weight for the medical equipment, supplies, and other miscellaneous
expenses component is 9.968 percent (44.839 - (4.295 + 16.553 + 10.223
+ 8.095) = 9.968). As explained above, because we believe there is a
national market for these items, costs that fall within this component
of the PE GPCI are not adjusted for geographic variation.
(3) Malpractice GPCIs
We propose to use the PLI weight of 4.295 percent for the MP GPCI
cost

[[Page 43325]]

share weight. The proposed GPCI cost share weights for CY 2014 are
displayed in Table 22.

Table 22--Proposed Cost Share Weights for CY 2014 GPCI Update
------------------------------------------------------------------------
Proposed CY
Current 2014 cost
Expense category cost share share
weight weight
(percent) (percent)
------------------------------------------------------------------------
Work.......................................... 48.266 50.866
Practice Expense.............................. 47.439 44.839
--Employee Compensation....................... 19.153 16.553
--Office Rent................................. 10.223 10.223
--Purchased Services.......................... 8.095 8.095
--Equipment, Supplies, Other.................. 9.968 9.968
Malpractice Insurance......................... 4.295 4.295
-------------------------
Total....................................... 100.000 100.000
------------------------------------------------------------------------

e. PE GPCI Floor for Frontier States
Section 10324(c) of the Affordable Care Act added a new
subparagraph (I) under section 1848(e)(1) of the Act to establish a 1.0
PE GPCI floor for physicians' services furnished in frontier States
effective January 1, 2011. In accordance with section 1848(e)(1)(I) of
the Act, beginning in CY 2011, we applied a 1.0 PE GPCI floor for
physicians' services furnished in States determined to be frontier
States. In general, a frontier state is one in which at least 50
percent of the counties are ``frontier counties,'' which are those that
have a population per square mile of less than 6. For more information
on the criteria used to define a frontier state, we refer readers to
the FY 2011 Inpatient Prospective Payment System final rule (75 FR
50160 through 50161). There are no changes in the States identified as
``Frontier States'' for the CY 2014 proposed rule. The qualifying
States are reflected in Table 23. In accordance with statute, we will
apply a 1.0 PE GPCI floor for these States in CY 2014.

Table 23--Frontier States Under Section 1848(E)(1)(I) of the Act
[As added by section 10324(c) of the Affordable Care Act]
----------------------------------------------------------------------------------------------------------------
Percent frontier
counties
State Total Frontier (relative to
counties counties counties in the
State) (percent)
----------------------------------------------------------------------------------------------------------------
Montana............................................................ 56 45 80
Wyoming............................................................ 23 17 74
North Dakota....................................................... 53 36 68
Nevada............................................................. 17 11 65
South Dakota....................................................... 66 34 52
----------------------------------------------------------------------------------------------------------------

f. Proposed GPCI Update
As explained above in the background section, the periodic review
and adjustment of GPCIs is mandated by section 1848(e)(1)(C) of the
Act. At each update, the proposed GPCIs are published in the PFS
proposed rule to provide an opportunity for public comment and further
revisions in response to comments prior to implementation. The proposed
CY 2014 updated GPCIs for the first and second year of the 2-year
transition, along with the GAFs, are displayed in Addenda D and E to
this proposed rule available on the CMS Web site under the supporting
documents section of the CY 2014 PFS proposed rule Web page at http://www.cms.gov/PhysicianFeeSched/.
3. Payment Locality Discussion
a. Background
The current PFS locality structure was developed and implemented in
1997. There are currently 89 total PFS localities; 34 localities are
statewide areas (that is, only one locality for the entire state).
There are 52 localities in the other 16 states, with 10 states having 2
localities, 2 states having 3 localities, 1 state having 4 localities,
and 3 states having 5 or more localities. The District of Columbia,
Maryland, and Virginia suburbs, Puerto Rico, and the Virgin Islands are
additional localities that make up the remainder of the total of 89
localities. The development of the current locality structure is
described in detail in the CY 1997 PFS proposed rule (61 FR 34615) and
the subsequent final rule with comment period (61 FR 59494).
Prior to 1992, Medicare payments for physicians' services were made
under the reasonable charge system. Payments were based on the charging
patterns of physicians. This resulted in large differences in payment
for physicians' services among types of services, geographic payment
areas, and physician specialties. Recognizing this, the Congress
replaced the reasonable charge system with the Medicare PFS in the
Omnibus Budget Reconciliation Act (OBRA) of 1989, and the PFS went into
effect January 1, 1992. Payments under the PFS are based on the
relative resources involved with furnishing services, and are adjusted
to account for geographic variations in resource costs as measured by
the GPCIs.
Payment localities originally were established under the reasonable
charge system by local Medicare carriers based on their knowledge of
local physician charging patterns and economic conditions. These
localities changed little between the inception of Medicare in 1967 and
the beginning of the PFS in 1992. Shortly after the PFS took effect,
CMS undertook a study in 1994 that culminated in a comprehensive
locality revision that was implemented in 1997 (61 FR 59494).
The revised locality structure reduced the number of localities
from 210 to the current 89, and the number of statewide localities
increased from 22 to 34. The revised localities were based on locality
resource cost differences as reflected by the GPCIs. For a full
discussion of the methodology, see the CY 1997 PFS final rule with
comment period (61 FR 59494). The current 89 fee schedule areas are
defined alternatively by state boundaries (for example, Wisconsin),
metropolitan areas (for example, Metropolitan St. Louis, MO), portions
of a metropolitan area (for example, Manhattan), or rest-of-state areas
that exclude metropolitan areas (for example, Rest of Missouri). This
locality

[[Page 43326]]

configuration is used to calculate the GPCIs that are in turn used to
calculate payments for physicians' services under the PFS.
As stated in the CY 2011 PFS final rule with comment period (75 FR
73261), we require that changes to the PFS locality structure be done
in a budget neutral manner within a state. For many years, before
making any locality changes, we have sought consensus from among the
professionals whose payments would be affected. In recent years, we
have also considered more comprehensive changes to locality
configuration. In 2008, we issued a draft comprehensive report
detailing four different locality configuration options (www.cms.gov/physicianfeesched/downloads/ReviewOfAltGPCIs.pdf). The alternative
locality configurations in the report are described below.
Option 1: CMS Core-Based Statistical Area (CBSA) Payment
Locality Configuration: CBSAs are a combination of Office of Management
and Budget (OMB's) Metropolitan Statistical Areas (MSAs) and
Micropolitan Statistical Areas. Under this option, MSAs would be
considered as urban CBSAs. Micropolitan Statistical Areas (as defined
by OMB) and rural areas would be considered as non-urban (rest of
state) CBSAs. This approach would be consistent with the areas used in
the Inpatient Prospective Payment System (IPPS) pre-reclassification
wage index, which is the hospital wage index for a geographic area
(CBSA or non-CBSA) calculated from submitted hospital cost report data
before statutory adjustments reconfigure, or ``reclassify'' a hospital
to an area other than its geographic location, to adjust payments for
differences in local resource costs in other Medicare payment systems.
Based on data used in the 2008 locality report, this option would
increase the number of PFS localities from 89 to 439.
Option 2: Separate High-Cost Counties from Existing
Localities (Separate Counties): Under this approach, higher cost
counties are removed from their existing locality structure, and they
would each be placed into their own locality. This option would
increase the number of PFS localities from 89 to 214, using a 5 percent
GAF differential to separate high-cost counties.
Option 3: Separate MSAs from Statewide Localities
(Separate MSAs): This option begins with statewide localities and
creates separate localities for higher cost MSAs (rather than removing
higher cost counties from their existing locality as described in
Option 2). This option would increase the number of PFS localities from
89 to 130, using a 5 percent GAF differential to separate high-cost
MSAs.
Option 4: Group Counties Within a State Into Locality
Tiers Based on Costs (Statewide Tiers): This option creates tiers of
counties (within each state) that may or may not be contiguous but
share similar practice costs. This option would increase the number of
PFS localities from 89 to 140, using a 5 percent GAF differential to
group similar counties into statewide tiers.
For a detailed discussion of the public comments on the
contractor's 2008 draft report detailing four different locality
configurations, we refer readers to the CY 2010 PFS proposed rule (74
FR 33534) and subsequent final rule with comment period (74 FR 61757).
There was no public consensus on the options, although a number of
commenters expressed support for Option 3 (separate MSAs from statewide
localities) because the commenters believed this alternative would
improve payment accuracy and could mitigate potential reductions to
rural areas compared to Option 1 (CMS CBSAs).
In response to some public comments regarding the third of the four
locality options, we had our contractor conduct an analysis of the
impacts that would result from the application of Option 3. Those
results were displayed in the final locality report released in 2011.
The final report, entitled ``Review of Alternative GPCI Payment
Locality Structures--Final Report,'' may be accessed directly from the
CMS Web site at www.cms.gov/PhysicianFeeSched/downloads/Alt_GPCI_Payment_Locality_Structures_Review.pdf.
Moreover, at our request, the Institute of Medicine conducted a
comprehensive empirical study of the Medicare GAFs established under
sections 1848(e) (PFS GPCI) and 1886(d)(3)(E) (IPPS hospital wage
index) of the Act. These adjustments are designed to ensure Medicare
payments reflect differences in input costs across geographic areas.
The first of the Institute of Medicine's two reports entitled,
``Geographic Adjustment in Medicare Payment, Phase I: Improving
Accuracy'' recommended that the same labor market definition should be
used for both the hospital wage index and the physician geographic
adjustment factor. Further, the Institute of Medicine recommended that
MSAs and statewide non-metropolitan statistical areas should serve as
the basis for defining these labor markets.
Under the Institute of Medicine's recommendations, MSAs would be
considered as urban CBSAs. Micropolitan Areas (as defined by the OMB)
and rural areas would be considered as non-urban (rest of State) CBSAs.
This approach would be consistent with the areas used in the IPPS pre-
reclassification wage index to make geographic payment adjustments in
other Medicare payment systems. For more information on the Institute
of Medicine's recommendations on the PFS locality structure, see the CY
2013 PFS final rule with comment period (77 FR 68949). We also provided
our technical analyses of the Institute of Medicine Phase I
recommendations in a report released on the PFS Web site at
www.cms.gov/PhysicianFeeSched.
Additionally, the Phase I report can be accessed on the Institute
of Medicine's Web site at http://www.iom.edu/Reports/2011/Geographic-Adjustment-in-Medicare-Payment-Phase-I-Improving-Accuracy.aspx.
b. Institute of Medicine Phase II Report Discussion
The Institute of Medicine's second report, entitled ``Geographic
Adjustment in Medicare Payment--Phase II: Implications for Access,
Quality, and Efficiency'' was released July 17, 2012 and can be
accessed on the Institute of Medicine's Web site at http://www.iom.edu/Reports/2011/Geographic-Adjustment-in-Medicare-Payment-Phase-I-Improving-Accuracy.aspx.
The Phase II report evaluated the effects of geographic adjustment
factors (hospital wage index and GPCIs) on the distribution of the
health care workforce, quality of care, population health, and the
ability to provide efficient, high value care. The Institute of
Medicine's Phase II report also included an analysis of the impacts of
implementing its recommendations for accuracy in geographic adjustments
which include a CBSA-based locality structure under the PFS. The
Institute of Medicine analysis found that adopting a CBSA-based
locality structure under the PFS creates large changes in county GAF
values; for example, approximately half of all US counties would
experience a payment reduction. The Institute of Medicine also found
that GPCIs calculated under a CBSA-based locality structure would
result in lower GAFs in rural areas (relative to the national average)
because the GPCI values for rural areas would no longer include
metropolitan practice costs within the current ``rest-of-state'' or
``statewide'' localities.
(1) Institute of Medicine Phase II Report Recommendations
The Institute of Medicine developed recommendations for improving
access to and quality of medical care. The

[[Page 43327]]

recommendations included in the Institute of Medicine's Phase II report
are summarized as follows:
Recommendation 1: The Medicare program should develop and
apply policies that promote access to primary care services in
geographic areas where Medicare beneficiaries experience persistent
access problems.
Recommendation 2: The Medicare program should pay for
services that improve access to primary and specialty care for
beneficiaries in medically underserved urban and rural areas,
particularly telehealth technologies.
Recommendation 3: To promote access to appropriate and
efficient primary care services, the Medicare program should support
policies that would allow all qualified practitioners to practice to
the full extent of their educational preparation.
Recommendation 4: The Medicare program should reexamine
its policies that provide location-based adjustments for specific
groups of hospitals, and modify or discontinue them based on their
effectiveness in ensuring adequate access to appropriate care.
Recommendation 5: Congress should fund an independent
ongoing entity, such as the National Health Care Workforce Commission,
to support data collection, research, evaluations, and strategy
development, and make actionable recommendations about workforce
distribution, supply, and scope of practice.
Recommendation 6: Federal support should facilitate
independent external evaluations of ongoing workforce programs intended
to provide access to adequate health services for underserved
populations and Medicare beneficiaries. These programs include the
National Health Services Corps, Title VII and VIII programs under the
Public Health Service Act, and related programs intended to achieve
these goals.
(2) Institute of Medicine Phase II Report Conclusions
The Institute of Medicine committee concluded that geographic
payment adjustments under the PFS are not a strong determinant of
access problems and not an appropriate mechanism for improving the
distribution of the healthcare workforce, quality of care, population
health, and the ability to provide efficient, high value care.
Specifically, the Institute of Medicine committee stated ``that there
are wide discrepancies in access to and quality of care across
geographic areas particularly for racial and ethnic minorities.
However, the variations do not appear to be strongly related to
differences in or potential changes to fee for service payment'' (Page.
6). The committee also concluded ``that Medicare beneficiaries in some
geographic pockets face persistent access and quality problems, and
many of these pockets are in medically underserved rural and inner-city
areas. However, geographic adjustment of Medicare payment is not an
appropriate approach for addressing problems in the supply and
distribution of the health care workforce. The geographic variations in
the distribution of physicians, nurses and physician assistants, and
local shortages that create access problems for beneficiaries should be
addressed through other means'' (Page. 7). Moreover, the committee
concluded that ``geographic [payment] adjustment is not an appropriate
tool for achieving policy goals such as improving quality of expanding
the pool of providers available to see Medicare beneficiaries'' (Page.
9).
(3) CMS Summary Response to Institute of Medicine Phase II Report
The Institute of Medicine's Phase II report recommendations are
broad in scope, do not propose specific recommendations for making
changes to the GPCIs or PFS locality structure, or are beyond the
statutory authority of CMS.
We agree with the Institute of Medicine's assessment that many
counties would experience a payment reduction and that large payment
shifts would occur as a result of implementing a CBSA-based locality
configuration under the PFS. Based on our contractor's analysis, there
would be significant redistributive impacts if we were to implement a
policy that would reconfigure the PFS localities based on the Institute
of Medicine's CBSA-based locality recommendation. Many rural areas
would see substantial decreases in their corresponding GAF and GPCI
values as higher cost counties are removed from current ``rest of
state'' payment areas. Conversely, many urban areas, especially those
areas that are currently designated as ``rest of state'' but are
located within higher cost MSAs, would experience increases in their
applicable GPCIs and GAFs. That is, given that urban and rural areas
would no longer be grouped together (for example, as in the current 34
statewide localities), many rural areas would see a reduction in
payment under a CBSA-based locality configuration.
As noted earlier in this section, we are assessing a variety of
approaches to changing the locality structure under the PFS and will
continue to study options for revising the locality structure. However,
to fully assess the implications of proposing a nationwide locality
reconfiguration under the PFS, we must also assess and analyze the
operational changes necessary to implement a revised locality
structure. Given that all options under consideration (including the
Institute of Medicine's CBSA-based approach) would expand the number of
current localities and result in payment reductions to primarily rural
areas, presumably any nationwide locality reconfiguration could
potentially be transitioned over a number of years (to phase-in the
impact of payment reductions gradually, from year to year, instead of
all at once). As such, transitioning from the current locality
structure to a nationwide reconfigured locality structure would present
operational and administrative challenges that need to be identified
and addressed. Therefore, we have begun to assess the broad operational
changes that would be involved in implementing a nationwide locality
reconfiguration under the PFS. Accordingly, we believe that it would be
premature to make any statements about potential changes we would
consider making to the PFS localities at this time. Any changes to PFS
fee schedule areas would be made through future notice and comment
rulemaking.
In the event that we develop a specific proposal for changing the
locality configuration during future rulemaking, we would provide
detailed analysis on the impact of the changes for physicians in each
county. We would also provide opportunities for public input.

F. Medicare Telehealth Services for the Physician Fee Schedule

1. Billing and Payment for Telehealth Services
a. History
Prior to January 1, 1999, Medicare coverage for services delivered
via a telecommunications system was limited to services that did not
require a face-to-face encounter under the traditional model of medical
care. Examples of these services included interpretation of an x-ray,
electroencephalogram tracing, and cardiac pacemaker analysis.
Section 4206 of the BBA provided for coverage of, and payment for,
consultation services delivered via a telecommunications system to
Medicare beneficiaries residing in rural health professional shortage
areas (HPSAs) as defined by the Public Health Service Act.
Additionally, the BBA required that a Medicare practitioner
(telepresenter) be with the patient at the time of a teleconsultation.
Further, the BBA

[[Page 43328]]

specified that payment for a teleconsultation had to be shared between
the consulting practitioner and the referring practitioner and could
not exceed the fee schedule payment that would have been made to the
consultant for the service furnished. The BBA prohibited payment for
any telephone line charges or facility fees associated with the
teleconsultation. We implemented this provision in the CY 1999 PFS
final rule with comment period (63 FR 58814).
Effective October 1, 2001, section 223 of the Medicare, Medicaid
and SCHIP Benefits Improvement Protection Act of 2000 (BIPA) (Pub. L.
106-554) added section 1834(m) to the Act, which significantly expanded
Medicare telehealth services. Section 1834(m)(4)(F)(i) of the Act
defines Medicare telehealth services to include consultations, office
visits, office psychiatry services, and any additional service
specified by the Secretary, when delivered via a telecommunications
system. We first implemented this provision in the CY 2002 PFS final
rule with comment period (66 FR 55246). Section 1834(m)(4)(F)(ii) of
the Act required the Secretary to establish a process that provides for
annual updates to the list of Medicare telehealth services. We
established this process in the CY 2003 PFS final rule with comment
period (67 FR 79988).
As specified in regulations at Sec. 410.78(b), we generally
require that a telehealth service be furnished via an interactive
telecommunications system. Under Sec. 410.78(a)(3), an interactive
telecommunications system is defined as, ``multimedia communications
equipment that includes, at a minimum, audio and video equipment
permitting two-way, real-time interactive communication between the
patient and distant site physician or practitioner. Telephones,
facsimile machines, and electronic mail systems do not meet the
definition of an interactive telecommunications system.'' An
interactive telecommunications system is generally required as a
condition of payment; however, section 1834(m)(1) of the Act allows the
use of asynchronous ``store-and-forward'' technology when the
originating site is a federal telemedicine demonstration program in
Alaska or Hawaii. As specified in regulations at Sec. 410.78(a)(1),
store-and-forward means the asynchronous transmission of medical
information from an originating site to be reviewed at a later time by
the practitioner at the distant site.
Medicare telehealth services may be furnished to an eligible
telehealth individual notwithstanding the fact that the practitioner
furnishing the telehealth service is not at the same location as the
beneficiary. An eligible telehealth individual means an individual
enrolled under Part B who receives a telehealth service furnished at an
originating site. Under the BIPA, originating sites were limited under
section 1834(m)(3)(C) of the Act to specified medical facilities
located in specific geographic areas. The initial list of telehealth
originating sites included the office of a practitioner, a critical
access hospital (CAH), a rural health clinic (RHC), a federally
qualified health center (FQHC) and a hospital (as defined in section
1861(e) of the Act). More recently, section 149 of the Medicare
Improvements for Patients and Providers Act of 2008 (Pub. L. 110-275)
(MIPPA) expanded the list of telehealth originating sites to include a
hospital-based renal dialysis center, a skilled nursing facility (SNF),
and a community mental health center (CMHC). To serve as a telehealth
originating site, a site must also be located in an area designated as
a rural HPSA, in a county that is not in a metropolitan statistical
area (MSA), or must be an entity that participates in a federal
telemedicine demonstration project that has been approved by (or
receives funding from) the Secretary as of December 31, 2000. Finally,
section 1834(m) of the Act does not require the eligible telehealth
individual to be with a telepresenter at the originating site.
b. Current Telehealth Billing and Payment Policies
As noted previously, Medicare telehealth services can only be
furnished to an eligible telehealth beneficiary in a qualifying
originating site. An originating site is defined as one of the
specified sites where an eligible telehealth individual is located at
the time the service is being furnished via a telecommunications
system. The originating sites authorized by the statute are as follows:
Offices of a physician or practitioner;
Hospitals;
CAHs;
RHCs;
FQHCs;
Hospital-Based or Critical Access Hospital-Based Renal
Dialysis Centers (including Satellites);
SNFs;
CMHCs.
Currently approved Medicare telehealth services include the
following:
Initial inpatient consultations;
Follow-up inpatient consultations;
Office or other outpatient visits;
Individual psychotherapy;
Pharmacologic management;
Psychiatric diagnostic interview examination;
End-stage renal disease (ESRD) related services;
Individual and group medical nutrition therapy (MNT);
Neurobehavioral status exam;
Individual and group health and behavior assessment and
intervention (HBAI);
Subsequent hospital care;
Subsequent nursing facility care;
Individual and group kidney disease education (KDE);
Individual and group diabetes self-management training
(DSMT);
Smoking cessation services;
Alcohol and/or substance abuse and brief intervention
services;
Screening and behavioral counseling interventions in
primary care to reduce alcohol misuse;
Screening for depression in adults;
Screening for sexually transmitted infections (STIs) and
high intensity behavioral counseling (HIBC) to prevent STIs;
Intensive behavioral therapy for cardiovascular disease;
and
Behavioral counseling for obesity.
In general, the practitioner at the distant site may be any of the
following, provided that the practitioner is licensed under state law
to furnish the service via a telecommunications system:
Physician;
Physician assistant (PA);
Nurse practitioner (NP);
Clinical nurse specialist (CNS);
Nurse-midwife;
Clinical psychologist;
Clinical social worker;
Registered dietitian or nutrition professional.
Practitioners furnishing Medicare telehealth services submit claims
for telehealth services to the Medicare contractors that process claims
for the service area where their distant site is located. Section
1834(m)(2)(A) of the Act requires that a practitioner who furnishes a
telehealth service to an eligible telehealth individual be paid an
amount equal to the amount that the practitioner would have been paid
if the service had been furnished without the use of a
telecommunications system. Distant site practitioners must submit the
appropriate HCPCS procedure code for a covered professional telehealth
service, appended with the -GT (via interactive audio and video
telecommunications system) or -GQ (via asynchronous telecommunications
system) modifier. By reporting the -GT or -GQ modifier with a covered

[[Page 43329]]

telehealth procedure code, the distant site practitioner certifies that
the beneficiary was present at a telehealth originating site when the
telehealth service was furnished. The usual Medicare deductible and
coinsurance policies apply to the telehealth services reported by
distant site practitioners.
Section 1834(m)(2)(B) of the Act provides for payment of a facility
fee to the originating site. To be paid the originating site facility
fee, the provider or supplier where the eligible telehealth individual
is located must submit a claim with HCPCS code Q3014 (telehealth
originating site facility fee), and the provider or supplier is paid
according to the applicable payment methodology for that facility or
location. The usual Medicare deductible and coinsurance policies apply
to HCPCS code Q3014. By submitting HCPCS code Q3014, the originating
site certifies that it is located in either a rural HPSA or non-MSA
county or is an entity that participates in a federal telemedicine
demonstration project that has been approved by (or receives funding
from) the Secretary as of December 31, 2000 as specified in section
1834(m)(4)(C)(i)(III) of the Act.
As previously described, certain professional services that are
commonly furnished remotely using telecommunications technology, but
that do not require the patient to be present in-person with the
practitioner when they are furnished, are covered and paid in the same
way as services delivered without the use of telecommunications
technology when the practitioner is in-person at the medical facility
furnishing care to the patient. Such services typically involve
circumstances where a practitioner is able to visualize some aspect of
the patient's condition without the patient being present and without
the interposition of a third person's judgment. Visualization by the
practitioner can be possible by means of x-rays, electrocardiogram or
electroencephalogram tracings, tissue samples, etc. For example, the
interpretation by a physician of an actual electrocardiogram or
electroencephalogram tracing that has been transmitted via telephone
(that is, electronically, rather than by means of a verbal description)
is a covered physician's service. These remote services are not
Medicare telehealth services as defined under section 1834(m) of the
Act. Rather, these remote services that utilize telecommunications
technology are considered physicians' services in the same way as
services that are furnished in-person without the use of
telecommunications technology; they are paid under the same conditions
as in-person physicians' services (with no requirements regarding
permissible originating sites), and should be reported in the same way
(that is, without the -GT or -GQ modifier appended).
c. Geographic Criteria for Originating Site Eligibility
Section 1834(m)(4)(C)(i)(I)-(III) of the Act specifies three
criteria for the location of eligible telehealth originating sites. One
of these is for entities participating in federal telemedicine
demonstration projects as of December 31, 2000, and the other two are
geographic. One of the geographic criteria is that the site is located
in a county that is not in an MSA and the other is that the site is
located in an area that is designated as a rural HPSA under section
332(a)(1)(A) of the Public Health Service Act (PHSA) (42 U.S.C.
254e(a)(1)(A)). Section 332(a)(1)(A) of the PHSA provides for the
designation of various types of HPSAs, but does not provide for
``rural'' HPSAs. In the absence of guidance in the PHSA, CMS has in the
past interpreted the term ``rural'' under section 1834(m)(4)(C)(i)(I)
to mean an area that is not located in an MSA. As such, the current
geographic criteria for telehealth originating sites limits eligible
sites to those that are not in an MSA.
To determine rural designations with more precision, HHS and CMS
have sometimes used methods that do not rely solely on MSA
designations. For example, the Office of Rural Health Policy (ORHP)
uses the Rural Urban Commuting Areas (RUCAs) to determine rural areas
within MSAs. RUCAs are a census tract-based classification scheme that
utilizes the standard Bureau of Census Urbanized Area and Urban Cluster
definitions in combination with work commuting information to
characterize all of the nation's census tracts regarding their rural
and urban status and relationships. They were developed under a
collaborative project between ORHP, the U.S. Department of
Agriculture's Economic Research Service (ERS), and the WWAMI Rural
Health Research Center (RHRC). A more comprehensive description is
available at the USDA ERS Web site at: www.ers.usda.gov/data-products/rural-urban-commuting-area-codes/documentation.aspx#.UcsKfZwzZKE. The
RUCA classification scheme contains 10 primary and 30 secondary codes.
The primary code numbers (1 through 10) refer to the primary, or single
largest, commuting share. Census tracts with RUCA codes of 4 through 10
refer to areas with a primary commuting share outside of a metropolitan
area. In addition to counties that are not in an MSA, ORHP considers
some census tracts in MSA counties to be rural. Specifically, census
tracts with RUCA codes 4 through 10 are considered to be rural, as well
as census tracts with RUCA codes 2 and 3 that are also at least 400
square miles and have a population density of less than 35 people per
square mile.
We are proposing to modify our regulations regarding originating
sites to define rural HPSAs as those located in rural census tracts as
determined by ORHP. We believe that defining ``rural'' to include
geographic areas located in rural census tracts within MSAs would allow
for the appropriate inclusion of additional HPSAs as areas for
telehealth originating sites. We also believe that adopting the more
precise definition of ``rural'' for this purpose would expand access to
health care services for Medicare beneficiaries located in rural areas.
We are also proposing to change our policy so that geographic
eligibility for an originating site would be established and maintained
on an annual basis, consistent with other telehealth payment policies.
Absent this proposed change, the status of a geographic area's
eligibility for telehealth originating site payment is effective at the
same time as the effective date for changes in designations that are
made outside of CMS. This proposed change would reduce the likelihood
that mid-year changes to geographic designations would result in sudden
disruptions to beneficiaries' access to services, unexpected changes in
eligibility for established telehealth originating sites and avoid the
operational difficulties associated with administering with mid-year
Medicare telehealth payment changes. We are proposing to establish
geographic eligibility for Medicare telehealth originating sites for
each calendar year based upon the status of the area as of December
31st of the prior calendar year. Accordingly, we are proposing to
revise our regulations at Sec. 410.78(b)(4) to conform with both of
these proposed policies.
2. Adding Services to the List of Medicare Telehealth Services
As noted previously, in the December 31, 2002 Federal Register (67
FR 79988), we established a process for adding services to or deleting
services from the list of Medicare telehealth services. This process
provides the public with an ongoing opportunity to submit requests for
adding services. We assign any request to make additions to the list of
telehealth services to one of

[[Page 43330]]

two categories. In the November 28, 2011 Federal Register (76 FR
73102), we finalized revisions to criteria that we use to review
requests in the second category. The two categories are:
Category 1: Services that are similar to professional
consultations, office visits, and office psychiatry services that are
currently on the list of telehealth services. In reviewing these
requests, we look for similarities between the requested and existing
telehealth services for the roles of, and interactions among, the
beneficiary, the physician (or other practitioner) at the distant site
and, if necessary, the telepresenter. We also look for similarities in
the telecommunications system used to deliver the proposed service, for
example, the use of interactive audio and video equipment.
Category 2: Services that are not similar to the current
list of telehealth services. Our review of these requests includes an
assessment of whether the service is accurately described by the
corresponding code when delivered via telehealth and whether the use of
a telecommunications system to deliver the service produces
demonstrated clinical benefit to the patient. In reviewing these
requests, we look for evidence indicating that the use of a
telecommunications system in delivering the candidate telehealth
service produces clinical benefit to the patient. Submitted evidence
should include both a description of relevant clinical studies that
demonstrate the service furnished by telehealth to a Medicare
beneficiary improves the diagnosis or treatment of an illness or injury
or improves the functioning of a malformed body part, including dates
and findings, and a list and copies of published peer reviewed articles
relevant to the service when furnished via telehealth. Our evidentiary
standard of clinical benefit does not include minor or incidental
benefits.
Some examples of clinical benefit include the following:
Ability to diagnose a medical condition in a patient
population without access to clinically appropriate in-person
diagnostic services.
Treatment option for a patient population without access
to clinically appropriate in-person treatment options.
Reduced rate of complications.
Decreased rate of subsequent diagnostic or therapeutic
interventions (for example, due to reduced rate of recurrence of the
disease process).
Decreased number of future hospitalizations or physician
visits.
More rapid beneficial resolution of the disease process
treatment.
Decreased pain, bleeding, or other quantifiable symptom.
Reduced recovery time.
Since establishing the process to add or remove services from the
list of approved telehealth services, we have added the following to
the list of Medicare telehealth services: Individual and group HBAI
services; psychiatric diagnostic interview examination; ESRD services
with 2 to 3 visits per month and 4 or more visits per month (although
we require at least 1 visit a month to be furnished in-person by a
physician, CNS, NP, or PA to examine the vascular access site);
individual and group MNT; neurobehavioral status exam; initial and
follow-up inpatient telehealth consultations for beneficiaries in
hospitals and skilled nursing facilities (SNFs); subsequent hospital
care (with the limitation of one telehealth visit every 3 days);
subsequent nursing facility care (with the limitation of one telehealth
visit every 30 days); individual and group KDE; and individual and
group DSMT (with a minimum of 1 hour of in-person instruction to ensure
effective injection training), smoking cessation services; alcohol and/
or substance abuse and brief intervention services; screening and
behavioral counseling interventions in primary care to reduce alcohol
misuse; screening for depression in adults; screening for sexually
transmitted infections (STIs) and high intensity behavioral counseling
(HIBC) to prevent STIs; intensive behavioral therapy for cardiovascular
disease; and behavioral counseling for obesity.
Requests to add services to the list of Medicare telehealth
services must be submitted and received no later than December 31 of
each calendar year to be considered for the next rulemaking cycle. For
example, requests submitted before the end of CY 2013 will be
considered for the CY 2015 proposed rule. Each request for adding a
service to the list of Medicare telehealth services must include any
supporting documentation the requester wishes us to consider as we
review the request. Because we use the annual PFS rulemaking process as
a vehicle for making changes to the list of Medicare telehealth
services, requestors should be advised that any information submitted
is subject to public disclosure for this purpose. For more information
on submitting a request for an addition to the list of Medicare
telehealth services, including where to mail these requests, we refer
readers to the CMS Web site at www.cms.gov/telehealth/.
3. Submitted Requests and Other Additions to the List of Telehealth
Services for CY 2014
We received a request in CY 2012 to add online assessment and E/M
services as Medicare telehealth services effective for CY 2014. The
following presents a discussion of this request, and our proposals for
additions to the CY 2014 telehealth list.
a. Submitted Requests
The American Telemedicine Association (ATA) submitted a request to
add CPT codes 98969 (Online assessment and management service provided
by a qualified nonphysician health care professional to an established
patient, guardian, or health care provider not originating from a
related assessment and management service provided within the previous
7 days, using the Internet or similar electronic communications
network) and 99444 (Online evaluation and management service provided
by a physician to an established patient, guardian, or health care
provider not originating from a related E/M service provided within the
previous 7 days, using the Internet or similar electronic
communications network) to the list of Medicare telehealth services.
As we explained in the CY 2008 PFS final rule with comment period
(72 FR 66371), we assigned a status indicator of ``N'' (Non-covered
service) to these services because: (1) These services are non-face-to-
face; and (2) the code descriptor includes language that recognizes the
provision of services to parties other than the beneficiary and for
whom Medicare does not provide coverage (for example, a guardian).
Under section 1834(m)(2)(A) of the Act, Medicare pays the physician or
practitioner furnishing a telehealth service an amount equal to the
amount that would have been paid if the service was furnished without
the use of a telecommunications system. Because CPT codes 98969 and
99444 are currently noncovered, there would be no Medicare payment if
these services were furnished without the use of a telecommunications
system. Since these codes are noncovered services for which no payment
may be made under Medicare, we are not proposing to add online
evaluation and management services to the list of Medicare Telehealth
Services for CY 2014.
b. Other Additions
Under our existing policy, we add services to the telehealth list
on a category 1 basis when we determine that they are similar to
services on the

[[Page 43331]]

existing telehealth list with respect to the roles of, and interactions
among, the beneficiary, physician (or other practitioner) at the
distant site and, if necessary, the telepresenter. As we stated in the
CY 2012 proposed rule (76 FR 42826), we believe that the category 1
criteria not only streamline our review process for publically
requested services that fall into this category, the criteria also
expedite our ability to identify codes for the telehealth list that
resemble those services already on this list.
For CY 2013, CMS finalized a payment policy for new CPT code 99495
(Transitional care management services with the following required
elements: Communication (direct contact, telephone, electronic) with
the patient and/or caregiver within 2 business days of discharge
medical decision making of at least moderate complexity during the
service period face-to-face visit, within 14 calendar days of
discharge) and CPT code 99496 (Transitional care management services
with the following required elements: Communication (direct contact,
telephone, electronic) with the patient and/or caregiver within 2
business days of discharge medical decision making of high complexity
during the service period face-to-face visit, within 7 calendar days of
discharge). These services are for a patient whose medical and/or
psychosocial problems require moderate or high complexity medical
decision making during transitions in care from an inpatient hospital
setting (including acute hospital, rehabilitation hospital, long-term
acute care hospital), partial hospitalization, observation status in a
hospital, or skilled nursing facility/nursing facility, to the
patient's community setting (home, domiciliary, rest home, or assisted
living). Transitional care management is comprised of one face-to-face
visit within the specified time frames following a discharge, in
combination with non-face-to-face services that may be performed by the
physician or other qualified health care professional and/or licensed
clinical staff under his or her direction.
We believe that that the interactions between the furnishing
practitioner and the beneficiary described by the required face-to-face
visit component of the TCM services are sufficiently similar to
services currently on the list of Medicare telehealth services for
these services to be added under category 1. Specifically, we believe
that the required face-to-face visit component of TCM services is
similar to the office/outpatient evaluation and management visits
described by CPT codes 99201-99205 and 99211-99215. We note that like
certain other non-face-to-face PFS services, the other components of
the TCM service are commonly furnished remotely using
telecommunications technology, and do not require the patient to be
present in-person with the practitioner when they are furnished. As
such, we do not need to consider whether the non-face-to-face aspects
of the TCM service are similar to other telehealth services. Were these
components of the TCM services separately billable, they would not need
to be on the telehealth list to be covered and paid in the same way as
services delivered without the use of telecommunications technology.
Therefore, we are proposing to add CPT codes 99495 and 99496 to the
list of telehealth services for CY 2014 on a category 1 basis.
Consistent with this proposal, we are also proposing to revise our
regulations at Sec. 410.78(b) and Sec. 414.65(a)(1) to include TCM
services as Medicare telehealth services.
4. Telehealth Frequency Limitations
The ATA asked that we remove the telehealth frequency limitation
for subsequent nursing facility services reported by CPT codes 99307
through 99310. Subsequent nursing facility services were added to the
list of Medicare telehealth services in the CY 2011 PFS final rule (75
FR 73317 through 73318), with a limitation of one telehealth subsequent
nursing facility care service every 30 days. In the CY 2011 PFS final
rule (75 FR 73615) we noted that, as specified in our regulation at
Sec. 410.78(e)(2), the federally mandated periodic SNF visits required
under Sec. 483.40(c) could not be furnished through telehealth.
The ATA requested that the frequency limitation be removed due to
``recent federal telecommunications policy changes'' and newly
available information from recent studies. Specifically, the ATA
pointed to the Federal Communications Commission (FCC) pilot funding of
a program to facilitate the creation of a nationwide broadband network
dedicated to health care, connecting public and private non-profit
health care providers in rural and urban locations, and a series of
studies that demonstrated the value to patients of telehealth
technology.
In considering this request, we began with the analysis contained
in the CY 2011 proposed rule (75 FR 73318), when we proposed to add SNF
subsequent care, to the list of Medicare telehealth services. We
discussed our complementary commitments to ensuring that SNF residents,
given their potential clinical acuity, continue to receive in-person
visits as appropriate to manage their complex care and to make sure
that Medicare pays only for medically reasonable and necessary care. To
meet these commitments, we believed it was appropriate to limit the
provision of subsequent nursing facility care services furnished
through telehealth to once every 30 days.
We then reviewed the publicly available information regarding both
the FCC pilot program and the ATA-referenced studies in light of the
previously stated commitments to assess whether these developments
warrant a change in 30-day frequency limitation policy. Based on our
review of the FCC demonstration project and the studies referenced in
the request, we found no information regarding the relative clinical
benefits of SNF subsequent care when furnished via telehealth more
frequently than once every 30 days. We did note that the FCC
information reflected an aim to improve access to medical specialists
in urban areas for rural health care providers, and that medical
specialists in urban areas can continue to use the inpatient telehealth
consultation HCPCS G-codes (specifically G0406, G0407, G0408, G0425,
G0426, or G0427) when reporting medically reasonable and necessary
consultations furnished to SNF residents via telehealth without any
frequency limitation.
We also reviewed the studies referenced by the ATA to assess
whether they provided evidence that more frequent telehealth visits
would appropriately serve this particular population given the
potential medical acuity and complexity of patient needs. We did not
find any such evidence in the studies. Three of the studies identified
by the ATA were not directly relevant to SNF subsequent care services.
One of these focused on using telehealth technology to treat patients
with pressure ulcers after spinal cord injuries. The second focused on
the usefulness of telehealth technology for patients receiving home
health care services. A third study addressed the use of interactive
communication technology to facilitate the coordination of care between
hospital and SNF personnel on the day of hospital discharge. The ATA
also mentioned a peer-reviewed presentation delivered at its annual
meeting related to SNF patient care, suggesting that the presentation
demonstrated that telehealth visits are better for SNF patients than
in-person visits to emergency departments or, in some cases, visits to
physician offices. Although we did not have access to the full
presentation it does not appear to

[[Page 43332]]

address subsequent nursing facility services, so we do not believe this
is directly relevant to the clinical benefit of SNF subsequent care
furnished via telehealth. More importantly, none of these studies
addresses the concerns we have expressed about the possibility that
nursing facility subsequent care visits furnished too frequently
through telehealth rather than in-person could compromise care for this
potentially acute and complex patient population.
We remain committed to ensuring that SNF inpatients receive
appropriate in-person visits and that Medicare pays only for medically
reasonable and necessary care. We are not persuaded by the information
submitted by the ATA that it would be beneficial or advisable to remove
the frequency limitation we established for SNF subsequent care when
furnished via telehealth. Because we want to ensure that nursing
facility patients with complex medical conditions have appropriately
frequent, medically reasonable and necessary encounters with their
admitting practitioner, we continue to believe that it is appropriate
for some subsequent nursing facility care services to be furnished
through telehealth. At the same time, because of the potential acuity
and complexity of SNF inpatients, we remain committed to ensuring that
these patients continue to receive in-person, hands-on visits as
appropriate to manage their care. Therefore, we are not proposing any
changes to the limitations regarding SNF subsequent care services
furnished via telehealth for CY 2014.

G. Therapy Caps

1. Outpatient Therapy Caps for CY 2014
Section 1833(g) of the Act applies annual, per beneficiary,
limitations on expenses considered incurred for outpatient therapy
services under Medicare Part B, commonly referred to as ``therapy
caps.'' There is one therapy cap for outpatient occupational therapy
(OT) services and another separate therapy cap for physical therapy
(PT) and speech-language pathology (SLP) services combined.
Until October 1, 2012, the therapy caps applied to all outpatient
therapy services except those furnished by a hospital or another entity
under an arrangement with a hospital described under section
1833(a)(8)(B) of the Act. For convenience, we will refer to the
exemption from the caps for services described under section
1833(a)(8)(B) of the Act as the ``outpatient hospital services
exemption.'' Section 3005(b) of the MCTRJCA added section 1833(g)(6) of
the Act to temporarily suspend the outpatient hospital services
exemption, thereby requiring that the therapy caps apply to services
described under section 1833(a)(8)(B) of the Act from October 1, 2012
to December 31, 2012 for services furnished during 2012. This broadened
application of the therapy caps was extended through December 31, 2013,
by section 603(a) of the ATRA. In addition, section 603(b) of the ATRA
amended section 1833(g)(6) of the Act to specify that during CY 2013,
for outpatient therapy services paid under section 1834(g) of the Act
(those furnished by a critical access hospital (CAH)), we must count
towards the therapy caps the amount that would be payable for the
services under Medicare Part B if the services were paid as outpatient
therapy services under section 1834(k)(1)(B) of the Act, which
describes payment for outpatient therapy services furnished by
hospitals and certain other entities, instead of as CAH outpatient
therapy services under section 1834(g) of the Act. Payment for
outpatient therapy services under section 1834(k)(1)(B) of the Act is
made at 80 percent of the lesser of the actual charge for the services
or the applicable fee schedule amount as defined in section 1834(k)(3)
of the Act. Section 1834(k)(3) of the Act defines applicable fee
schedule to mean the payment amount determined under a fee schedule
established under section 1848 of the Act, which refers to the PFS, or
an amount under a fee schedule for comparable services as the Secretary
specifies. The PFS is required as the applicable fee schedule to be
used as the payment basis under section 1834(k)(3) of the Act. Section
603(b) of the ATRA also specified that nothing in the amendments to
section 1833(g)(6) of the Act ``shall be construed as changing the
method of payment for outpatient therapy services under 1834(g) of the
Act.''
Since CY 2011, a therapy multiple procedure payment reduction
(MPPR) policy has applied to the second and subsequent ``always
therapy'' services billed on the same date of service for one patient
by the same practitioner or facility under the same NPI. Prior to April
1, 2013, the therapy MPPR reduced the practice expense portion of
office-based services by 20 percent and reduced the practice expense
portion of institutional-based services by 25 percent. As of April 1,
2013, section 633(a) of the ATRA amended sections 1848(b)(7) and
1834(k) of the Act to increase the therapy MPPR to 50 percent for all
outpatient therapy services furnished in office-based and institutional
settings. (For more information on the MPPR and its history, see
section II.B.4 of this proposed rule.)
Sections 1833(g)(1) and (3) of the Act specify that in counting
services towards the cap, ``no more than the amount specified in
paragraph (2) for the year shall be considered incurred expenses.'' As
noted above, section 603(b) of the ATRA amended section 1833(g)(6) of
the Act to require that outpatient therapy services furnished by CAHs
during CY 2013 are counted towards the therapy caps using the amount
that would be paid for those services under section 1834(k)(1)(B) of
the Act, which is how outpatient therapy services furnished by
hospitals and certain other entities are paid. Since payment for
outpatient therapy services under section 1834(k)(1)(B) of the Act is
made at the PFS rate and includes any applicable therapy MPPR, the
amounts for incurred expenses counted toward the caps for therapy
services furnished by a CAH also reflect any applicable therapy MPPR.
We believe that this is consistent with the statutory amendments
made by the ATRA. Including the therapy MPPR in calculating incurred
expenses for therapy services furnished by CAHs treats CAH services
consistently with services furnished in other applicable settings.
Therefore, therapy services furnished by CAHs during CY 2013 count
towards the therapy caps using the amount that would be payable under
section 1834(k)(1)(B) of the Act, which includes an applicable MPPR.
For a list of the ``always therapy'' codes subject to the therapy MPPR
policy, see Addendum H of this proposed rule.
The therapy cap amounts under section 1833(g) of the Act are
updated each year based on the Medicare Economic Index (MEI).
Specifically, the annual caps are calculated by updating the previous
year's cap by the MEI for the upcoming calendar year and rounding to
the nearest $10 as specified in section 1833(g)(2)(B) of the Act. The
therapy cap amounts for CY 2014 will be announced in the CY 2014 PFS
final rule with comment period.
An exceptions process for the therapy caps has been in effect since
January 1, 2006. Originally required by section 5107 of the Deficit
Reduction Act of 2005 (DRA), which amended section 1833(g)(5) of the
Act, the exceptions process for the therapy caps has been continuously
extended several times through subsequent legislation (MIEA-TRHCA,
MMSEA, MIPPA, the Affordable Care Act, MMEA, TPTCCA, and MCTRJCA). Last
amended by section 603(a) of the ATRA, the Agency's current authority
to provide an

[[Page 43333]]

exceptions process for therapy caps expires on December 31, 2013. After
expenses incurred for the beneficiary's services for the year have
exceeded the therapy cap, therapy suppliers and providers use the KX
modifier on claims for services to request an exception to the therapy
caps. By use of the KX modifier, the therapist is attesting that the
services above the therapy cap are reasonable and necessary and that
there is documentation of medical necessity for the services in the
beneficiary's medical record.
Under section 1833(g)(5)(C) of the Act, added by the MCTRJCA and
extended through 2013 by the ATRA, we are required to apply a manual
medical review process to therapy claims when a beneficiary's incurred
expenses exceed a threshold amount of $3,700. There are two separate
thresholds of $3,700, just as there are two therapy caps, and incurred
expenses are counted toward the thresholds in the same manner as the
caps. Under the statute, the required application of the manual medical
review process expires December 31, 2013. For information on the manual
medical review process, go to www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/Medical-Review/TherapyCap.html.
2. Proposed Application of Therapy Caps to Services Furnished by CAHs
Section 4541 of the BBA amended section 1833(g) of the Act to
create the therapy caps discussed above. This BBA provision applied the
therapy caps to outpatient therapy services described at section
1861(p) of the Act except for the outpatient therapy services described
in section 1833(a)(8)(B) of the Act. Section 1833(a)(8)(B) of the Act
refers to therapy services furnished by a hospital to an outpatient, to
services furnished to a hospital inpatient who has exhausted, or is not
entitled to, benefits under Part A; and to these same services when
furnished by an entity under arrangements with a hospital. Payment for
the services described under section 1833(a)(8)(B) of the Act is made
under section 1834(k)(1)(B) of the Act.
Section 4201 of the BBA amended section 1820 of the Act to require
a process for establishment of CAHs. Payment for CAH outpatient
services is described under section 1834(g) of the Act.
When we proposed language to implement the BBA provision
establishing therapy caps in the CY 1999 PFS proposed rule, we
indicated in the preamble that the therapy caps do not apply to therapy
services furnished directly or under arrangements by a hospital or CAH
to an outpatient or to an inpatient who is not in a covered Part A stay
(63 FR 30818, 30858). We included a similar statement in the preamble
to the final rule; however, we did not include the same reference to
CAHs in that sentence in the CY 1999 PFS final rule with comment period
(63 FR 58814, 58865). In the CY 1999 PFS final rule with comment
period, we also stated generally that the therapy caps apply only to
items and services furnished by nonhospital providers and therapists
(63 FR 58865). In the CY 1999 proposed rule, we proposed to include
provisions at Sec. 410.59(e)(3) and Sec. 410.60(e)(3) to describe,
respectively, the outpatient therapy services that are exempt from the
statutory therapy caps for outpatient OT services, and for outpatient
PT and SLP services combined. Specifically, in the CY 1999 PFS proposed
rule, we proposed to add the following regulatory language for OT and
for PT at Sec. Sec. 410.59(e)(3) and 410.60(e)(3): ``For purposes of
applying the limitation, outpatient [occupational therapy/physical
therapy] excludes services furnished by a hospital or CAH directly or
under arrangements'' (63 FR 30880). However, in the CY 1999 PFS final
rule with comment period, the phrase ``or CAH'' was omitted from the
final regulation text for OT in Sec. 410.59(e)(3), but was included in
the final regulation text for PT in Sec. 410.60(e)(3). We note that
for purposes of the therapy cap, outpatient PT services under our
regulation at Sec. 410.60 include outpatient SLP services described
under Sec. 410.62. As such, SLP services are included in the
references to PT under Sec. 410.60. Although the rulemaking history
and regulations appear inconclusive as to whether outpatient therapy
services furnished by CAHs were intended to be subject to the therapy
caps between January 1, 1999 and October 1, 2012, we believe that we
inadvertently omitted the phrase ``or CAH'' in the CY 1999 final
regulation for the occupational therapy cap. Moreover, we have
consistently excluded all outpatient therapy services furnished by CAHs
from the therapy caps over this time frame, whether the services were
PT, SLP, or OT.
Accordingly, from the outset of the therapy caps under section
1833(g) of the Act, therapy services furnished by CAHs have not been
subject to the therapy caps. Thus, CAHs have not been required to use
the exceptions process (including the KX modifier and other
requirements) when furnishing medically necessary therapy services
above the therapy caps; and therapy services furnished by CAHs above
the threshold amounts have not been subject to the manual medical
review process. Similarly, until section 603(b) of the ATRA amended the
statute to specify the amount that must be counted towards the therapy
caps and thresholds for outpatient therapy services furnished by CAHs,
we did not apply towards the therapy caps or thresholds any amounts for
therapy services furnished by CAHs. Therefore, we have interpreted the
statutory exclusion for outpatient therapy services furnished by
hospital outpatient departments also to apply to CAHs and implemented
the therapy caps accordingly.
As noted above, section 3005(b) of the MCTRJCA temporarily
suspended the outpatient hospital services exemption from October 1,
2012 through December 31, 2012 (which has subsequently been extended by
the ATRA through December 31, 2013). As a result, from October 1, 2012
to the present, CAH services have been treated differently than
services furnished in other outpatient hospital settings. In
implementing this change required by the MCTRJCA, we had reason to
assess whether, as a result of the amendment, the therapy caps should
be applied to outpatient therapy services furnished by CAHs. We
concluded that the MCTRJCA amendment did not make the therapy caps
applicable to services furnished by CAHs for which payment is made
under section 1834(g) of the Act because it affected only the
outpatient hospital services described under section 1833(a)(8)(B) of
the Act for which payment is made under section 1834(k)(1)(B) of the
Act. With the enactment in section 603(b) of the ATRA of specific
language requiring us to count amounts toward the therapy caps and
thresholds for services furnished by CAHs, we again had reason to
assess whether the therapy caps apply to services furnished by CAHs. We
concluded that the ATRA amendment did not explicitly make the therapy
caps applicable to services furnished by CAHs, but directed us to count
CAH services towards the caps. However, after reflecting on the
language of section 1833(g) of the Act, we have concluded that the
therapy caps should be applied to outpatient therapy services furnished
by CAHs.
To explain further, under sections 1833(g)(1) and (3) of the Act,
the therapy caps are made applicable to all services described under
section 1861(p) of the Act except those described under the outpatient
hospital services exemption. Section 1861(p) of the Act establishes the
benefit category for outpatient PT, SLP and OT services, (expressly for
PT

[[Page 43334]]

services and, through section 1861(ll)(2) of the Act, for outpatient
SLP services and, through section 1861(g) of the Act, for outpatient OT
services). Section 1861(p) of the Act defines outpatient therapy
services in the three disciplines as those furnished by a provider of
services, a clinic, rehabilitation agency, or a public health agency,
or by others under an arrangement with, and under the supervision of,
such provider, clinic, rehabilitation agency, or public health agency
to an individual as an outpatient; and those furnished by a therapist
not under arrangements with a provider of services, clinic,
rehabilitation agency, or a public health agency. As such, section
1861(p) of the Act defines outpatient therapy services very broadly to
include those furnished by providers and other institutional settings,
as well as those furnished in office settings. Under section 1861(u) of
the Act, a CAH is a ``provider of services.'' As such, unless the
outpatient therapy services furnished by a CAH fit within the
outpatient hospital services exemption under section 1833(a)(8)(B) of
the Act, the therapy caps would be applicable to PT, SLP, OT services
furnished by a CAH. As noted above, section 1833(a)(8)(B) of the Act
describes only outpatient therapy services for which payment is made
under section 1834(k) of the Act. Payment for CAH services is made
under section 1834(g) of the Act. Thus, the outpatient hospital
services exemption to the therapy caps under section 1833(a)(8)(B) of
the Act does not apply, and the therapy caps are applicable, to
outpatient therapy services furnished by a CAH.
However, we recognize that our current regulation specifically
excludes PT and SLP services furnished by CAHs from the therapy caps,
and our consistent practice since 1999 has been to exclude PT, SLP and
OT services furnished by CAHs from the therapy caps. As such, in order
to apply the therapy caps and related policies to services furnished by
CAHs for CY 2014 and subsequent years, we believe we would need to
revise our regulations.
We propose to apply the therapy cap limitations and related
policies to outpatient therapy services furnished by a CAH beginning on
January 1, 2014. Not only do we believe this is the proper statutory
interpretation, but we also believe it is the appropriate policy. Under
the existing regulations, with the suspension of the outpatient
hospital services exemption through 2013, the therapy caps apply to
outpatient therapy services paid under Medicare Part B and furnished in
all applicable settings except CAHs. We believe that outpatient therapy
services furnished by a CAH should be treated consistently with
outpatient therapy services furnished in all other settings. Therefore,
we propose to revise the therapy cap regulation at Sec. 410.60(e)(3)
to remove the exemption for services furnished by a CAH.
CAH outpatient therapy services are distinct from other outpatient
therapy services in that outpatient therapy services furnished in
office-based or other institutional settings are paid at the rates
contained in the PFS, whereas CAHs are paid for outpatient therapy
services under the methodology described under section 1834(g) of the
Act. Because the CAH reasonable cost-based payment amounts are
reconciled at cost reporting year-end, and are different from the fee
schedule-based payments for other outpatient therapy services, it might
have been difficult to identify the amounts that we should have accrued
towards the therapy caps for services furnished by CAHs. Therefore,
prior to 2013, not only did CMS not apply any caps to services provided
by a CAH, but also did not count CAH services towards the caps.
However, the ATRA amended the statute to require for outpatient therapy
services furnished by CAHs during 2013 that we count towards the caps
and the manual medical review thresholds the amount that would be
payable for the services under Medicare Part B as if the services were
paid as outpatient therapy services under section 1834(k)(1)(B) of the
Act instead of as CAH services under section 1834(g) of the Act. Thus,
the distinction in payment methodology no longer provides a technical
barrier to including an amount for therapy services furnished by CAHs
in the caps. We propose to continue this methodology of counting the
amount payable under section 1834(k)(1)(B) of the Act towards the
therapy cap and threshold for services furnished by CAHs in CY 2014 and
subsequent years.
We recognize that the outpatient hospital services exemption is
suspended under current law only through December 31, 2013. If this
provision is not extended, with our proposal to apply the therapy caps
to services furnished by CAHs, effective January 1, 2014, therapy
services furnished by CAHs would be treated differently than services
furnished in other outpatient hospital settings. We note that the
exceptions process described above, including use of the KX modifier to
attest to the medical necessity of therapy services above the caps and
other requirements, would apply for services furnished by a CAH in the
same way that it applies to outpatient therapy services furnished by
certain other facilities. Similarly, the manual medical review process
for claims that exceed the $3,700 thresholds would apply to therapy
services furnished by a CAH in the same way that they apply for
outpatient therapy services furnished by certain other facilities. We
recognize that the manual medical review process expires on December
31, 2013 and we would apply the manual medical review process to CAH
services only as required by statute. We are proposing to amend the
regulations establishing the conditions for PT, OT, and SLP services by
removing the exemption of CAH services from the therapy caps and
specifying that the therapy caps apply to such services.
Specifically, we propose to amend the regulations, which pertain to
the OT therapy cap and the combined PT and SLP therapy cap,
respectively, by including paragraph (e)(1)(iv) under Sec. 410.59 and
(e)(1)(iv) under Sec. 410.60 to specify that (occupational/physical)
therapy services furnished by a CAH directly or under arrangements
shall be counted towards the annual limitation on incurred expenses as
if such services were paid under section 1834(k)(1)(B) of the Act. We
also propose to add new paragraph (e)(2)(v) to Sec. 410.59 and
(e)(2)(vi) to Sec. 410.60. These new paragraphs would expressly
include outpatient (occupational/physical) therapy services furnished
by a CAH directly or under arrangements under the description of
services to which the annual limitation applies. Further, we propose to
amend the regulation at Sec. 410.60(e)(3), which currently excludes
services furnished by a CAH from the therapy cap for PT and SLP
services, to remove the phrase ``or CAH.''

H. Requirements for Billing ``Incident To'' Services

Section 1861(s)(2)(A) of the Act establishes the benefit category
for services and supplies furnished as ``incident to'' the professional
services of a physician. The statute specifies that ``incident to''
services and supplies are ``of kinds which are commonly furnished in
physicians' offices and are commonly either rendered without charge or
included in physicians' bills.''
In addition to the requirements of the statute, our regulation at
Sec. 410.26 sets forth specific requirements that must be met in order
for physicians and other practitioners to bill Medicare for incident to
physicians' services. Section 410.26(a)(7) limits ``incident to''
services to those included under section 1861(s)(2)(A) of the Act and
that are not covered under another benefit category. Section 410.26(b)
specifies (in part) that

[[Page 43335]]

in order for services and supplies to be paid as ``incident to''
services under Medicare Part B, the services or supplies must be:
Furnished in a noninstitutional setting to
noninstitutional patients.
An integral, though incidental, part of the service of a
physician (or other practitioner) in the course of diagnosis or
treatment of an injury or illness.
Furnished under direct supervision (as specified under
Sec. 410.26(a)(2) and defined in Sec. 410.32(b)(3)(ii)) of a
physician or other practitioner eligible to bill and directly receive
Medicare payment.
Furnished by the physician, practitioner with an
``incident to'' benefit, or auxiliary personnel.
In addition to Sec. 410.26, there are regulations specific to each
type of practitioner who is allowed to bill for ``incident to''
services. These are found at Sec. 410.71(a)(2) (clinical psychologist
services), Sec. 410.74(b) (physician assistants' services), Sec.
410.75(d) (nurse practitioners' services), Sec. 410.76(d) (clinical
nurse specialists' services), and Sec. 410.77(c) (certified nurse-
midwives' services). When referring to practitioners who can bill for
services furnished ``incident to'' their professional services, we are
referring to physicians and these practitioners.
``Incident to'' services are treated as if they were furnished by
the billing practitioner for purposes of Medicare billing and payment.
Consistent with this terminology, in this discussion when referring to
the practitioner furnishing the service, we mean the practitioner who
is billing for the service. When we refer to the ``auxiliary
personnel'' or the person who ``provides'' the service we are referring
to an individual who is personally performing the service or some
aspect of it. Since we treat ``incident to'' services as services
furnished by the billing practitioner for purposes of Medicare billing
and payment, payment is made to the billing practitioner under the PFS,
and all relevant Medicare rules apply including, but not limited to,
requirements regarding medical necessity, documentation, and billing.
Those practitioners who can bill Medicare for ``incident to'' services
are paid at their applicable Medicare payment rate as if they furnished
the service. For example, when ``incident to'' services are billed by a
physician, they are paid at 100 percent of the fee schedule amount, and
when the services are billed by a nurse practitioner or clinical nurse
specialist, they are paid at 85 percent of the fee schedule amount.
Payments are subject to the usual deductible and coinsurance.
As the services commonly furnished in physicians' offices and other
nonfacility settings have expanded to include more complicated
services, the types of services that can be furnished ``incident to''
physicians' services have also expanded. States have increasingly
adopted standards regarding the delivery of health care services in all
settings, including physicians' offices, in order to protect the health
and safety of their citizens. These state standards often include
qualifications for the individuals who are permitted to furnish
specific services or requirements about the circumstances under which
services may be actually furnished. For example, since 2009, New York
has required that offices in which surgery is furnished must be
accredited by a state-approved accredited agency or organization.
Similarly, Florida requires certain standards be met when surgery is
furnished in offices, including that the surgeon must ``examine the
patient immediately before the surgery to evaluate the risk of
anesthesia and of the surgical procedure to be performed'' and
``qualified anesthesia personnel shall be present in the room
throughout the conduct of all general anesthetics, regional anesthetics
and monitored anesthesia care.''
Over the past years, several situations have come to our attention
where Medicare was billed for ``incident to'' services that were
provided by auxiliary personnel who did not meet the state standards
for those services in the state in which the services were furnished.
The physician or practitioner billing for the services would have been
permitted under state law to personally furnish the services, but the
services were actually provided by auxiliary personnel who were not in
compliance with state law in providing the particular service (or
aspect of the service).
Practitioners authorized to bill Medicare for services that they
furnish to Medicare beneficiaries are required under Medicare to comply
with state law. For example, section 1861(r) of the Act specifies that
an individual can be considered a physician in the performance of any
function or action only when legally authorized to practice in the
particular field by the State in which he performs such function or
action. Section 410.20(b) of our regulations provides that payment is
made for services only if furnished by a doctor who is ``. . . legally
authorized to practice by the state in which he or she performs the
functions or actions, and who is acting within the scope of his or her
license.'' Similarly, section 1861(s)(2)(K)(ii) of the Act provides a
benefit category for services of a nurse practitioner (NP) or clinical
nurse specialist (CNS) that the NP or CNS is ``legally authorized to
perform by the State in which the services are performed, and Sec.
410.75(b) of our regulations provides that nurse practitioners'
services are covered only if the NP is ``authorized by the State in
which the services are furnished to practice as a nurse practitioner in
accordance with State law.'' There are similar provisions for clinical
psychologist services (Sec. 410.71(a)(2)), clinical social worker
services (Sec. 410.73(b)(1)), physician assistants' services (Sec.
410.74(a)(2)(ii)), clinical nurse specialists' services (Sec.
410.76(b)(1)), and certified nurse-midwives' services (Sec.
410.77(b)(1)).
However, the Medicare requirements for services and supplies
incident to a physician's professional services (Sec. 410.26 discussed
above), do not specifically make compliance with state law a condition
of payment for services (or aspects of services) and supplies furnished
and billed as ``incident to'' services. Nor do any of the regulations
regarding services furnished ``incident to'' the services of other
practitioners contain this requirement. Thus, Medicare has had limited
recourse when services furnished incident to a physician's or
practitioner's services are not furnished in compliance with state law.
In 2009, the Office of Inspector General issued a report entitled
``Prevalence and Qualifications of Nonphysicians Who Performed Medicare
Physician Services'' (OEI-09-06-00430) that considered in part the
qualifications of auxiliary personnel providing incident to physician
services. This report found that services were being billed to Medicare
that were provided by auxiliary personnel. After finding that services
were being provided and billed to Medicare by auxiliary personnel ``. .
. who did not possess the required licenses or certifications according
to State laws, regulations, and/or Medicare rules,'' the OIG
recommended that we revise the ``incident to'' rules to, among other
things, ``require that physicians who do not personally perform the
services they bill to Medicare ensure that no persons except . . .
nonphysicians who have the necessary training, certification, and/or
licensure, pursuant to State laws, State regulations, and Medicare
regulations personally perform the services under the direct
supervision of a licensed physician.'' We are also proposing amendments
to our regulations to address this recommendation.
To ensure that auxiliary personnel providing services to Medicare

[[Page 43336]]

beneficiaries incident to the services of other practitioners do so in
accordance with the requirements of the state in which the services are
furnished and to ensure that Medicare dollars can be recovered when
such services are not furnished in compliance with the state law, we
are proposing to add a requirement to the ``incident to'' regulations
at Sec. 410.26, Services and supplies incident to a physician's
professional services: Conditions. Specifically, we are proposing to
amend Sec. 410.26(b) by redesignating paragraphs (b)(7) and (b)(8) as
paragraphs (b)(8) and (b)(9), respectively, and by adding a new
paragraph (b)(7) to state that ``Services and supplies must be
furnished in accordance with applicable State law.'' We are also
proposing to amend the definition of auxiliary personnel at Sec.
410.26(a)(1) to require that the individual performing ``incident to''
services ``meets any applicable requirements to provide the services,
including licensure, imposed by the State in which the services are
being furnished.''
In addition, we are proposing to eliminate redundant and
potentially incongruent regulatory language by replacing the specific
``incident to'' requirements currently contained in the regulations
relating to each of the various types of practitioners with a reference
to the requirements of Sec. 410.26. Specifically, we are proposing to:
Revise Sec. 410.71(a)(2) regarding clinical psychologist
services to read ``Medicare Part B covers services and supplies
incident to the services of a clinical psychologist if the requirements
of Sec. 410.26 are met.''
Revise Sec. 410.74(b) regarding physician assistants'
services to read ``Medicare Part B covers services and supplies
incident to the services of a physician assistant if the requirements
of Sec. 410.26 are met.''
Revise Sec. 410.75(d) regarding nurse practitioners to
read ``Medicare Part B covers services and supplies incident to the
services of a nurse practitioner if the requirements of Sec. 410.26
are met.''
Revise Sec. 410.76(d) regarding clinical nurse
specialists' services to read with ``Medicare Part B covers services
and supplies incident to the services of a clinical nurse specialist if
the requirements of Sec. 410.26 are met.''
Revise the language in Sec. 410.77(c) regarding certified
nurse-midwives' services to read ``Medicare Part B covers services and
supplies incident to the services of a certified nurse-midwife if the
requirements of Sec. 410.26 are met.''
As discussed above, these practitioners are, and would continue to
be under this proposal, required to comply with Sec. 410.26 for
services furnished incident to their professional services. We believe
it is redundant and potentially confusing to have separate regulations
that generally restate the requirements for ``incident to'' services of
Sec. 410.26 using slightly different terminology. Our goal in
proposing the revisions to refer to Sec. 410.26 in the regulation for
each practitioner's ``incident to'' services is to reduce the
regulatory burden and make it less difficult for practitioners to
determine what is required. Reconciling these regulatory requirements
for physicians and all other practitioners who have the authority to
bill Medicare for ``incident to'' services is also consistent with our
general policy to treat nonphysician practitioners similarly to
physicians unless there is a compelling reason for disparate treatment.
We believe that this proposal would make the requirements clearer for
practitioners furnishing ``incident to'' services without eliminating
existing regulatory requirements or imposing new ones. We welcome
comments on any requirements that we may have inadvertently overlooked
in our proposed revisions, or any benefit that accrues from continuing
to carry these separate regulatory requirements.
The regulations applicable to Rural Health Clinics (RHCs) and
Federally Qualified Health Centers (FQHCs) have similar ``incident to''
rules, and we are proposing to make conforming changes to these
regulations. Specifically, we are also proposing to revise Sec.
405.2413(a), which addresses services and supplies incident to
physicians' services for RHCs and FQHCs, by redesignating paragraphs
(a)(4) and (a)(5) as paragraphs (a)(5) and (a)(6), respectively and by
adding a new paragraph (a)(4) that states services and supplies must be
furnished in accordance with applicable state law. Additionally, we are
proposing to amend Sec. 405.2415(a), which addresses services incident
to nurse practitioner and physician assistant services by redesignating
paragraphs (a)(4) and (a)(5) as paragraphs (a)(5) and (a)(6),
respectively and by adding a new paragraph (a)(4) that specifies
services and supplies must be furnished in accordance with applicable
state law. We are proposing to amend Sec. 405.2452(a), which addresses
services and supplies incident to clinical psychologist and clinical
social worker services by redesignating paragraphs (a)(4) and (a)(5) as
paragraphs (a)(5) and (a)(6), respectively and by adding a new
paragraph (a)(4) that states services and supplies must be furnished in
accordance with applicable state law. Finally, we are also proposing
the removal of the word ``personal'' in Sec. Sec. 405.2413, 405.2415,
and 405.2452 to be consistent with the ``incident to'' provisions in
Sec. 410.26 Services and supplies incident to a physician's
professional services: Conditions.
The proposed amendments to our regulations are consistent with the
traditional approach of relying primarily on the states to regulate the
health and safety of their residents in the delivery of health care
services. Throughout the Medicare program, as evidenced by several
examples above, the qualifications required for the delivery of health
care services are generally determined with reference to state law. As
discussed above, our current regulations governing practitioners who
can bill Medicare directly include a basic requirement to comply with
state law when furnishing Medicare covered services. However, the
Medicare regulations for ``incident to'' services and supplies do not
specifically make compliance with state law a condition of payment for
services and supplies furnished and billed as an incident to a
practitioner's services. The proposed amendments to our regulations
would rectify this situation and make compliance with state law a
requirement for all ``incident to'' services. In addition to health and
safety benefits we believe would accrue to the Medicare patient
population, this approach would assure that federal dollars are not
expended for services that do not meet the standards of the states in
which they are being furnished, and provides the ability for the
federal government to recover funds paid where services and supplies
are not furnished in accordance with state law.
We note that this proposal would not impose any new requirements on
those practitioners billing the Medicare program since auxiliary
personnel furnishing services in a state would already be required to
comply with the laws of that state. This regulatory change would simply
adopt the existing requirements as a condition of payment under
Medicare. Codifying this requirement would provide the federal
government a clear basis to deny a claim for Medicare payment when
services are not furnished in accordance with applicable state law and
the ability to recover funds, as well as assure that Medicare makes
payment for services furnished to beneficiaries only when the services
meet the requirements imposed by the states to regulate health care
delivery in order to ensure the health and safety of their citizens.

[[Page 43337]]

I. Complex Chronic Care Management Services

As we discussed in the CY 2013 PFS final rule with comment period,
we are committed to primary care and we have increasingly recognized
care management as one of the critical components of primary care that
contributes to better health for individuals and reduced expenditure
growth (77 FR 68978). Accordingly, we have prioritized the development
and implementation of a series of initiatives designed to improve
payment for, and encourage long-term investment in, care management
services. These initiatives include the following programs and
demonstrations:
The Medicare Shared Savings Program (described in
``Medicare Program; Medicare Shared Savings Program: Accountable Care
Organizations; Final Rule'' which appeared in the November 2, 2011
Federal Register (76 FR 67802)).
The testing of the Pioneer ACO model, designed for
experienced health care organizations (described on the Center for
Medicare and Medicaid Innovation's (Innovation Center's) Web site at
innovations.cms.gov/initiatives/ACO/Pioneer/index.html).
The testing of the Advance Payment ACO model, designed to
support organizations participating in the Medicare Shared Savings
Program (described on the Innovation Center's Web site at
innovations.cms.gov/initiatives/ACO/Advance-Payment/index.html).
The Primary Care Incentive Payment (PCIP) Program
(described on the CMS Web site at www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched/Downloads/PCIP-2011-Payments.pdf).
The patient-centered medical home model in the Multi-payer
Advanced Primary Care Practice (MAPCP) Demonstration designed to test
whether the quality and coordination of health care services are
improved by making advanced primary care practices more broadly
available (described on the CMS Web site at www.cms.gov/Medicare/Demonstration-Projects/DemoProjectsEvalRpts/downloads/mapcpdemo_Factsheet.pdf).
The Federally Qualified Health Center (FQHC) Advanced
Primary Care Practice demonstration (described on the CMS Web site at
www.cms.gov/Medicare/Demonstration-Projects/DemoProjectsEvalRpts/downloads/mapcpdemo_Factsheet.pdf and the Innovation Center's Web site
at innovations.cms.gov/initiatives/FQHCs/index.html).
The Comprehensive Primary Care (CPC) initiative (described
on the Innovation Center's Web site at innovations.cms.gov/initiatives/Comprehensive-Primary-Care-Initiative/index.html). The CPC initiative
is a multi-payer initiative fostering collaboration between public and
private health care payers to strengthen primary care in certain
markets across the country.
In coordination with these initiatives, we also continue to explore
potential refinements to the PFS that would appropriately value care
management within Medicare's statutory structure for fee-for-service
physician payment and quality reporting. For example, in the CY 2013
PFS final rule with comment period, we adopted a policy to pay
separately for care management involving the transition of a
beneficiary from care furnished by a treating physician during a
hospital stay to care furnished by the beneficiary's primary physician
in the community (77 FR 68978 through 68993). We view potential
refinements to the PFS such as these as part of a broader strategy that
relies on input and information gathered from the initiatives described
above, research and demonstrations from other public and private
stakeholders, the work of all parties involved in the potentially
misvalued code initiative, and from the public at large.
1. Patient Eligibility for Separately Payable Non-Face-to-Face Complex
Chronic Care Management Services
Under current PFS policy, the payment for non-face-to-face care
management services is bundled into the payment for face-to-face E/M
visits because care management is a component of those E/M services.
The pre- and post-encounter non-face-to-face care management work is
included in calculating the total work for the typical E/M services,
and the total work for the typical service is used to develop RVUs for
the E/M services. In the CY 2012 PFS proposed rule, we highlighted some
of the E/M services that include substantial care management work.
Specifically, we noted that the vignettes that describe a typical
service for mid-level office/outpatient services (CPT codes 99203 and
99213) include furnishing care management, communication, and other
necessary care management related to the office visit in the post-
service work (76 FR 42917).
However, the physician community continues to tell us that the care
management included in many of the E/M services, such as office visits,
does not adequately describe the typical non-face-to-face care
management work involved for certain categories of beneficiaries.
Because the current E/M office/outpatient visit CPT codes were designed
to support all office visits and reflect an overall orientation toward
episodic treatment, we agree that these E/M codes may not reflect all
the services and resources required to furnish comprehensive,
coordinated care management for certain categories of beneficiaries.
For example, we currently pay physicians separately for the non face-
to-face care plan oversight services furnished to beneficiaries under
the care of home health agencies or hospices and we currently pay
separately for care management services furnished to beneficiaries
transitioning from care furnished by a treating physician during a
hospital stay to care furnished by the beneficiary's primary physician
in the community.
Similar to these situations, we believe that the resources required
to furnish complex chronic care management services to beneficiaries
with multiple (that is, two or more) chronic conditions are not
adequately reflected in the existing E/M codes. Furnishing care
management to beneficiaries with multiple chronic conditions requires
complex and multidisciplinary care modalities that involve: Regular
physician development and/or revision of care plans; subsequent reports
of patient status; review of laboratory and other studies;
communication with other health professionals not employed in the same
practice who are involved in the patient's care; integration of new
information into the care plan; and/or adjustment of medical therapy.
Therefore, for CY 2015, we are proposing to establish a separate
payment under the PFS for complex chronic care management services
furnished to patients with multiple complex chronic conditions that are
expected to last at least 12 months or until the death of the patient,
and that place the patient at significant risk of death, acute
exacerbation/decompensation, or functional decline.
We have performed an analysis of Medicare claims for patients with
selected multiple chronic conditions (see http://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/Chronic-Conditions/Downloads/2012Chartbook.pdf). This analysis indicated that
patients with these selected multiple chronic conditions are at
increased risk for hospitalizations, use of post-acute care services,
and emergency department visits. We believe these findings would hold
in general for patients with multiple

[[Page 43338]]

complex chronic conditions that are expected to last at least 12 months
or until the death of the patient, and that place the patient at
significant risk of death, acute exacerbation/decompensation, or
functional decline. We believe that successful efforts to improve
chronic care management for these patients could improve the quality of
care while simultaneously decreasing costs (for example, through
reductions in hospitalizations, use of post-acute care services, and
emergency department visits.)
As described below in more detail in section II.I.3, we intend to
develop standards for furnishing complex chronic care management
services to ensure that the physicians who bill for these services have
the capability to provide them. One of the primary reasons for our
proposed 2015 implementation date is to provide sufficient time to
develop and obtain public input on the standards necessary to
demonstrate the capability to provide these services.
2. Scope of Complex Chronic Care Management Services
We consider the scope of complex chronic care management services
to include:
The provision of 24-hour-a-day, 7-day-a-week access to
address a patient's acute complex chronic care needs. To accomplish
these tasks, we would expect that the patient would be provided with a
means to make timely contact with health care providers in the practice
to address urgent complex chronic care needs regardless of the time of
day or day of the week. Members of the complex chronic care team who
are involved in the after-hours care of a patient must have access to
the patient's full electronic medical record even when the office is
closed so they can continue to participate in care decisions with the
patient.
Continuity of care with a designated practitioner or
member of the care team with whom the patient is able to get successive
routine appointments.
Care management for chronic conditions including
systematic assessment of patient's medical, functional, and
psychosocial needs; system-based approaches to ensure timely receipt of
all recommended preventive care services; medication reconciliation
with review of adherence and potential interactions; and oversight of
patient self-management of medications. In consultation with the
patient and other key practitioners treating the patient, the
practitioner furnishing complex chronic care management services should
create a patient-centered plan of care document to assure that care is
provided in a way that is congruent with patient choices and values. A
plan of care is based on a physical, mental, cognitive, psychosocial,
functional and environmental (re)assessment and an inventory of
resources and supports. It is a comprehensive plan of care for all
health issues. It typically includes, but is not limited to, the
following elements: Problem list, expected outcome and prognosis,
measurable treatment goals, symptom management, planned interventions,
medication management, community/social services ordered, how the
services of agencies and specialists unconnected to the practice will
be directed/coordinated, identify the individuals responsible for each
intervention, requirements for periodic review and, when applicable,
revision, of the care plan. The provider should seek to reflect a full
list of problems, medications and medication allergies in the
electronic health record to inform the care plan, care coordination and
ongoing clinical care.
Management of care transitions within health care
including referrals to other clinicians, visits following a patient
visit to an emergency department, and visits following discharges from
hospitals and skilled nursing facilities. The practice must be able to
facilitate communication of relevant patient information through
electronic exchange of a summary care record with other health care
providers regarding these transitions. The practice must also have
qualified personnel who are available to deliver transitional care
services to a patient in a timely way so as to reduce the need for
repeat visits to emergency departments and re-admissions to hospitals
and skilled nursing facilities.
Coordination with home and community based clinical
service providers required to support a patient's psychosocial needs
and functional deficits. Communication to and from home and community
based providers regarding these clinical patient needs must be
documented in practice's medical record system.
Enhanced opportunities for a patient to communicate with
the provider regarding their care through not only the telephone but
also through the use of secure messaging, internet or other
asynchronous non face-to-face consultation methods.
3. Standards for Furnishing Complex Chronic Care Coordination Services
Not all physicians and qualified nonphysician practitioners who
wish to furnish complex chronic care management services currently have
the capability to fully provide the scope of services described in
section II.I.2. without making additional investments in technology,
staff training, and the development and maintenance of systems and
processes to furnish the services. We intend to establish standards
that would be necessary to provide high quality, safe complex chronic
care management services. For example, potential standards could
include the following:
The practice must be using a certified Electronic Health
Record (EHR) for beneficiary care that meets the most recent HHS
regulatory standard for meaningful use. The EHR must be integrated into
the practice to support access to care, care coordination, care
management and communication.
The practice must employ one or more advanced practice
registered nurses or physicians assistants whose written job
descriptions indicate that their job roles include and are
appropriately scaled to meet the needs for beneficiaries receiving
services in the practice who require complex chronic care management
services provided by the practice.
The practice must be able to demonstrate the use of
written protocols by staff participating in the furnishing of services
that describe: (1) The methods and expected ``norms'' for furnishing
each component of complex chronic care management services provided by
the practice; (2) the strategies for systematically furnishing health
risk assessments to identify all beneficiaries eligible and who may be
willing to participate in the complex chronic care management services;
(3) the procedures for informing eligible beneficiaries about complex
chronic care management services and obtaining their consent; (4) the
steps for monitoring the medical, functional and social needs of all
beneficiaries receiving complex chronic care management services; (5)
system based approaches to ensure timely delivery of all recommended
preventive care services to beneficiaries; (6) guidelines for
communicating common and anticipated clinical and non-clinical issues
to beneficiaries; (7) care plans for beneficiaries post-discharge from
an emergency department or other institutional health care setting, to
assist beneficiaries with follow up visits with clinical and other
suppliers or providers, and in managing any changes in their
medications; (8) a systematic approach to communicate and
electronically exchange clinical information with and coordinate care
among all service providers involved in

[[Page 43339]]

the ongoing care of a beneficiary receiving complex chronic care
management services; (9) a systematic approach for linking the practice
and a beneficiary receiving complex chronic care management services
with long-term services and supports including home and community-based
services; (10) a systematic approach to the care management of
vulnerable beneficiary populations such as racial and ethnic minorities
and people with disabilities; and (11) patient education to assist the
beneficiary to self-manage a chronic condition that is considered at
least one of his/her complex chronic conditions. These protocols must
be reviewed and updated as is appropriate based on the best available
clinical information at least annually.
All practitioners including advanced practice registered
nurses or physicians assistants, involved in the delivery of complex
chronic care management services must have access at the time of
service to the beneficiary's EHR that includes all of the elements
necessary to meet the most recent HHS regulatory standard for
meaningful use. This includes any and all clinical staff providing
after hours care to ensure that the complex chronic care management
services are available with this level of EHR support in the practice
or remotely through a Virtual Private Network (VPN), a secure Web site,
or a health information exchange (HIE) 24 hours per day and 7 days a
week.
Some have suggested that, to furnish these services, practices
could be recognized as a medical home by one of the national
organizations including: the National Committee for Quality Assurance
(NCQA), the Accreditation Association for Ambulatory Health Care, The
Joint Commission, URAC, etc.; which are formally recognizing primary
care practices as a patient-centered medical home. We understand there
are differences among the approaches taken by national organizations
that formally recognize medical homes and therefore, we seek comment on
these and other potential care coordination standards, and the
potential for CMS recognizing a formal patient-centered medical home
designation as one means for a practice to demonstrate it has met any
final care coordination standards for furnishing complex chronic care
management services. Any regulatory changes would be addressed through
separate notice-and-comment rulemaking.
4. Billing for Separately Payable Complex Chronic Care Management
Services and Obtaining Informed Consent From the Beneficiary
To recognize the additional resources required to provide complex
chronic care management services to patients with multiple chronic
conditions, we are proposing to create two new separately payable
alphanumeric G-codes.

Complex chronic care management services furnished to patients
with multiple (two or more) complex chronic conditions expected to
last at least 12 months, or until the death of the patient, that
place the patient at significant risk of death, acute exacerbation/
decompensation, or functional decline;
GXXX1, initial services; one or more hours; initial 90 days
GXXX2, subsequent services; one or more hours; subsequent 90
days

Typically, we would expect the one or more hours of services to be
provided by clinical staff directed by a physician or other qualified
health care professional. Initial services include obtaining the
initial informed consent from the beneficiary as described below and
the initial implementation of the complex chronic care management
services described in section II.I.2. of this proposed rule.
Not all patients who are eligible for separately payable complex
chronic care management services may necessarily want these services to
be provided. Therefore, before the practitioner can furnish or bill for
these services, the eligible beneficiary must be informed about the
availability of the services from the practitioner and provide his or
her consent to have the services provided, including the electronic
communication of the patient's information with other treating
providers as part of care coordination. This would include a discussion
with the patient about what complex chronic care management services
are, how these services are accessed, how their information will be
shared among other providers in the care team, and that cost-sharing
applies to these services even when they are not delivered face-to-face
in the practice. To bill for the initial services (GXXX1), the
practitioner would be required to document in the patient's medical
record that all of the complex chronic care management services were
explained and offered to the patient, noting the patient's decision to
accept these services. Also, a written or electronic copy of the care
plan would be provided to the beneficiary and this would also be
recorded in the beneficiary's electronic medical record.
A practitioner would need to reaffirm with the beneficiary at least
every 12 months whether he or she wishes to continue to receive complex
chronic care management services during the following 12-month period.
The informed consent for complex chronic care management services
could be revoked by the beneficiary at any time. However, if the
revocation occurs during a current 90-day complex chronic care
management period, the revocation would not be effective until the end
of that period. The beneficiary could notify the practitioner either
verbally or in writing. At the time the informed consent is obtained,
the practitioner would be required to inform the beneficiary of the
right to stop the complex chronic care management services at any time
and the effect of a revocation of consent on complex chronic care
management services. Revocation by the beneficiary of the informed
consent must also be noted by recording the date of the revocation in
the beneficiary's medical record and by providing the beneficiary with
written confirmation that the practitioner would not be providing
complex chronic care management services beyond the current 90 day
period.
A beneficiary who has revoked informed consent for complex chronic
care management services from one practitioner may choose instead to
receive these services from a different practitioner, which can begin
at the conclusion of the current 90-day period. The new practitioner
would need to fulfill all the requirements for billing GXXX1 and then
GXXX2.
Prior to submitting a claim for complex chronic care management
services, the practitioner must notify the beneficiary that a claim for
these services will be submitted to Medicare. The notification must
indicate: that the beneficiary has been receiving these services over
the previous 90-day period (noting the beginning and end dates for the
90-day period), the reason(s) why the services were provided and a
description of the services provided. The notice may be delivered by a
means of communication mutually agreed to by the practitioner and
beneficiary such as mail, email, or facsimile, or in person (for
example, at the time of an office visit.) The notice must be received
by the beneficiary before the practitioner submits the claim for the
services. A separate notice must be received by the beneficiary for
each 90-day period for which the services will be billed. A copy of the
notice should be included in the medical record.
In addition to the requirement that at least an hour of complex
chronic care

[[Page 43340]]

management services be furnished to the patient, we propose that
billing for subsequent complex chronic care management services (GXXX2)
would be limited to those 90-day periods in which the medical needs of
the patient require substantial revision of the care plan discussed in
section II.I.2. Substantial revision to a care plan typically is
required when the patient's clinical condition changes sufficiently to
require: Significantly more intensive monitoring by clinical staff,
significant changes in the treatment regimen, and significant time to
educate the patient/caregiver about the patient's condition/change in
treatment plan and prognosis.
Because the payment for non-face-to-face care management services
is generally bundled into the payment for face-to-face E/M visits, the
resources required to provide care management services for patients
without multiple chronic conditions or for less than the one or more
hours of clinical staff time continues to be reflected in the payment
for face-to-face E/M visits. For similar reasons, the resources
required to provide care management services to patients residing in
facility settings where care management activity by facility staff
would be included in the associated facility payment also continues to
be reflected in the payment for face-to-face E/M visits.
We propose that complex chronic care management services include
transitional care management services (CPT 99495, 99496), home health
care supervision (HCPCS G0181), and hospice care supervision (HCPCS
G0182). If furnished, in order to avoid duplicate payment, we propose
that these services may not be billed separately during the 90 days for
which either GXXX1 or GXXX2 are billed. For similar reasons, we propose
that GXXX1 or GXXX2 cannot be billed separately if ESRD services (CPT
90951-90970) are billed during the same 90 days.
Practitioners billing a complex chronic care management code accept
responsibility for managing and coordinating the beneficiary's care
over this period. Therefore, we propose to pay only one claim for the
complex chronic care management services (either GXXX1 or GXXX2) billed
per beneficiary at the conclusion of each 90-day period. All of the
complex chronic care management services delineated in section II.H.2
above that are relevant to the patient must be furnished in order to
bill GXXX1 or GXXX2 for a 90-day period.
If a face-to-face visit is provided during the 90-day period by the
practitioner who is furnishing complex chronic care management
services, the practitioner should report the appropriate evaluation and
management code in addition to GXXX1 or GXXX2.
We note that to bill for these services, we propose that at least
60 minutes of complex chronic care management services must be
provided. Time of less than 60 minutes over the 90 day period could not
be rounded up to 60 minutes in order to bill for these services. We
also propose that for purposes of meeting the 60-minute requirement,
the practitioner could count the time of only one clinical staff member
for a particular segment of time, and could not count overlapping
intervals such as when two or more clinical staff members are meeting
about the patient.
In future rulemaking, we intend to propose RVUs for complex chronic
care management services. To inform our proposal, we seek input on the
physician work and practice expenses associated with these services.
5. Complex Chronic Care Management Services and the Annual Wellness
Visit (AWV) (HCPCS codes G0438, G0439)
We are proposing that a beneficiary must have received an AWV in
the past twelve months in order for a practitioner to be able to bill
separately for complex chronic care management services. We believe
that the linking of these services to the AWV makes sense for several
reasons. First, the AWV is designed to enable a practitioner to
systematically capture information that is essential for the
development of a care plan. This includes the establishment of a list
of current practitioners and suppliers that are regularly involved in
providing medical care to the beneficiary, the assessment of the
beneficiary's functional status related to chronic health conditions,
the assessment of whether the beneficiary suffers from any cognitive
limitations or mental health conditions that could impair self-
management of chronic health conditions, and an assessment of the
beneficiary's preventive health care needs including those that
contribute to or result from a beneficiary's chronic conditions.
Second, the beneficiary's selection of a practitioner to furnish the
AWV is a useful additional indicator to assist us in knowing which
single practitioner a beneficiary has chosen to furnish complex chronic
care management services. While a beneficiary would retain the right to
choose and change the practitioner to furnish complex chronic care
management services, we do not believe that it is in the interest of a
beneficiary to have more than one practitioner at a time coordinating
the beneficiary's care and we do not intend to pay multiple
practitioners for furnishing these services over the same time period.
Third, the AWV is updated annually which is consistent with the minimal
interval for reviewing and modifying the care plan required for the
complex chronic care management services.
We would expect that the practitioner the beneficiary chooses for
the AWV would be the practitioner furnishing the complex chronic care
management services. For the less frequent situations when a
beneficiary chooses a different practitioner to furnish the complex
chronic care management services from the practitioner who in the
previous year furnished the AWV, the practitioner furnishing the
complex chronic are management services would need to obtain a copy of
the assessment and care plan developed between the beneficiary and the
practitioner who furnished the AWV prior to billing for complex chronic
care management services.
Because a beneficiary is precluded from receiving an AWV within 12
months after the effective date of his or her first Medicare Part B
coverage period, for that time period we propose the Initial Preventive
Physical Examination (G0402) can substitute for the AWV to allow a
beneficiary to receive complex chronic care management services.
6. Complex Chronic Care Management Services Furnished Incident to a
Physician's Service Under General Physician Supervision
We outline the requirements for billing for services furnished in
the office, but not personally and directly performed by the physician
or qualified nonphysician practitioner (referred to as a
``practitioner'' in the following discussion), under our ``incident
to'' requirements in regulations and in section 60, Chapter 12, of
Medicare Benefit Policy Manual (100-02). One key requirement of
``incident to'' services is that a practitioner (as the term is used in
section II.H of this proposed rule directly supervise the provision of
services by auxiliary personnel by being in the office suite and able
to furnish assistance and direction throughout the provision of the
service. Section 60.4 of the Manual specifically discusses the one
exception that allows for general supervision of ``incident to''
services furnished to homebound patients in medically underserved
areas. Under that provision, we identify more specific requirements for
the personnel that can furnish ``incident to'' services under general
supervision. For example, we require that the personnel must be

[[Page 43341]]

employed by, employed by the same entity, or an independent contractor
of, the practitioner billing the ``incident to'' services.
One of the required capabilities for a physician to furnish complex
chronic care management services is 24-hour-a-day, 7-day-a-week
beneficiary access to the practice to address the patient's complex
chronic care needs. We would expect that the patient would be provided
with a means to make timely contact with health care providers in the
practice to address those needs regardless of the time of day or day of
the week. If the patient has a complex chronic care need outside of the
practice's normal business hours, the patient's initial contact with
the practice for that need could be with clinical staff employed by the
practice, (for example, a nurse or other appropriate auxiliary
personnel) and not necessarily with a physician or practitioner. Those
services would be furnished incident to the services of the billing
practitioner.
We have also proposed to require that at least one hour of complex
chronic care services be furnished to a patient during the 90-day
period in order for the practitioner to be able to bill separately for
the chronic care services. The time, if not personally performed by the
physician, must be directed by the physician. We are proposing that the
time spent by a clinical staff person furnishing aspects of complex
chronic care services outside of the practice's normal business hours
during which there is no direct physician supervision would count
towards the one hour requirement even though the services do not meet
the direct supervision requirement for ``incident to'' services.
We believe that the additional requirements we impose for personnel
under the exception for general supervision for homebound patients in
medically underserved areas should apply in these circumstances where
we are allowing a practitioner to bill Medicare for complex chronic
care management services furnished under their general supervision and
incident to their professional services. In both of these unusual
cases, these requirements help to ensure that appropriate services are
being furnished by appropriate personnel in the absence of the direct
supervision. Specifically, we propose that if a practice meets all the
conditions required to bill separately for complex chronic care
management services, the time spent by a clinical staff employee
furnishing aspects of these services to address a patient's complex
chronic care need outside of the practice's normal business hours is
counted towards the one hour requirement when at a minimum the
following conditions are met:
The clinical staff person is directly employed by the
physician and the employed clinical staff person meets any relevant
state requirements.
The services of the clinical staff person are an integral
part of the physician's complex chronic care management services to the
patient (the patient must be one the physician is treating and for
which informed consent is in effect), and are performed under the
general supervision of the physician. General supervision means that
the physician need not be physically present when the services are
performed; however, the services must be performed under the
physician's overall supervision and control. Contact is maintained
between the clinical staff person and the physician (for example, the
employed clinical staff person contacts the physician directly if
warranted and the physician retains professional responsibility for the
service.)
The services of the employed clinical staff person meet
all other ``incident to'' requirements with the exception of direct
supervision.
7. Complex Chronic Care Management Services and the Primary Care
Incentive Payment Program (PCIP)
Under section 1833(x) of the Act, the PCIP provides a 10 percent
incentive payment for primary care services within a specific range of
E/M services when furnished by a primary care practitioner. Specific
physician specialties and qualified nonphysician practitioners can
qualify as primary care practitioners if 60 percent of their PFS
allowed charges are primary care services. As we explained in the CY
2011 PFS final rule (75 FR 73435 through 73436), we do not believe the
statute authorizes us to add codes (additional services) to the
definition of primary care services. However, to avoid inadvertently
disqualifying community primary care physicians who follow their
patients into the hospital setting, we finalized a policy to remove
allowed charges for certain E/M services furnished to hospital
inpatients and outpatients from the total allowed charges in the PCIP
primary care percentage calculation. In the CY 2013 final rule (77 FR
68993), we adopted a policy that the TCM code should be treated in the
same manner as those services for the purposes of PCIP because post-
discharge TCM services are a complement in the community setting to the
hospital-based discharge day management services already excluded from
the PCIP denominator. Similar to the codes already excluded from the
PCIP denominator, we expressed concern that inclusion of the TCM code
in the denominator of the primary care percentage calculation could
produce unwarranted bias against ``true primary care practitioners''
who are involved in furnishing post-discharge care to their patients.
Complex chronic care management services are also similar to the
services that we have already excluded from the from the PCIP
denominator. For example, complex chronic care management includes
management of care transitions within health care settings including
referrals to other clinicians, visits following a patient visit to an
emergency department, and visits following discharges from hospitals
and skilled nursing facilities. Therefore, while physicians and
qualified nonphysician practitioners who furnish complex chronic care
management services would not receive an additional incentive payment
under the PCIP for the service itself (because it is not considered a
``primary care service'' for purposes of the PCIP), we propose that the
allowed charges for complex chronic care management services would not
be included in the denominator when calculating a physician's or
practitioner's percent of allowed charges that were primary care
services for purposes of the PCIP.
8. Summary
In summary, we are proposing for CY 2015 to establish a separate
payment under the PFS for complex chronic care management services
furnished to patients with multiple complex chronic conditions that are
expected to last at least 12 months or until the death of the patient,
and that place the patient at significant risk of death, acute
exacerbation/decompensation, or functional decline, as discussed in
section II.I.1. We are proposing the scope of these complex chronic
care management services discussed in section II.I.2; the billing
requirements for these services as discussed in section II.I.4; the AWV
requirement as discussed in section II.I.5; the general supervision
requirements as discussed in section II.I.6, and the PCIP denominator
exclusion as discussed in section II.I.7.
We are seeking input from the public on, the standards required to
provide these services as discussed in section II.I.3, and the work and
PE that would be associated with these services.
We are making this proposal to establish codes and separate payment
for complex chronic care management services in the context of the
broader

[[Page 43342]]

multi-year strategy to appropriately recognize and value primary care
and care management services. Should this proposal become final policy,
it may be a short-term payment strategy that would be modified and/or
revised to be consistent with broader primary care, and care management
and coordination services if the agency decides to pursue payment for a
broader set of management and coordination services in future
rulemaking. We also note that as we consider a final policy, we would
assess the potential impact of the policy on our current programs and
demonstrations designed to improve payment for, and encourage long-term
investment in, care management services. Likewise, to assure that there
are not duplicate payments for delivery of care management services, we
would consider whether such payments are appropriate for providers
participating in other programs and demonstrations.

J. Chiropractors Billing for Evaluation and Management Services

Section 1861(r)(5) of the Act includes chiropractors in its
definition of ``physician'' with language limiting chiropractors to
``treatment by means of manual manipulation of the spine (to correct a
subluxation).'' Specifically, the Act says:

The term ``physician,'' when used in connection with the
performance of any function or actions means . . . a chiropractor
who is licensed as such by the State (or in a State which does not
license chiropractors as such, is legally authorized to perform the
services of a chiropractor in the jurisdiction in which he performs
such services) and who meets uniform minimum standards promulgated
by the Secretary, but only for the purpose of sections 1861(s)(1)
and 1861(s)(2)(A) and only with respect to treatment by means of
manual manipulation of the spine (to correct a subluxation) which he
is legally authorized to perform the State or jurisdiction in which
such treatment is provided.

The statute, thus, limits chiropractic coverage to treatment of
subluxation of the spine. Our interpretation of this language allows
payment to chiropractors for chiropractic manual manipulation to
correct a subluxation of the spine. Specifically, we provide for
payment of the following codes listed in the chiropractic section of
the CPT Manual.

98940--Chiropractic manipulation treatment (CMT), spinal, 1-2 regions
98941--CMT spinal, 3-4 regions
98942--CMT spinal, 5 regions

(CPT includes an additional CPT code 98943--CMT extraspinal 1 or
more regions for which Medicare does not cover as it is not a spinal
manipulation.)
Section 240.1.2 of the IOM 100-02 includes requirements that must
be met to demonstrate that these services are necessary, using either
x-ray or physical examination. In addition, it includes documentation
requirements for initial and subsequent visits. These include a history
and physical exam.
According to the CPT manual, the codes for CMT describe services
including a ``pre-manipulative patient assessment,'' which is
consistent with the history and physical exam requirement discussed
above. In determining the relative value assigned to the CMT services
we include this pre-manipulative patient assessment.
These chiropractic codes have a global surgery indicator of 0,
meaning that we do not pay separately for services provided on the same
day and related to the same service. The CPT manual notes that separate
E/M services can be reported with a -25 modifier ``if the patient's
condition requires a significant, separately identified E/M service
above and beyond the usual preservice and postservice work associated
with the procedures.'' It goes on to note that a separate diagnosis is
not required.
We currently do not allow payment for E/M services to chiropractors
as we have not identified an E/M service that would be related to
treatment of subluxation of the spine, which is the statutory
requirement, beyond the preservice and postservice work associated with
the CMT. We have believed that the assessments included in the CMT
codes accurately capture the E/M that would typically be furnished by
chiropractors in furnishing CMT services.
Questions have arisen as to whether it would be appropriate to
allow chiropractors to furnish and bill Medicare for E/M services,
especially in light of the CPT language regarding the reporting of a
separate E/M service on the same day using a -25 modifier. We would
note that CPT codes are the HIPPA compliant code set. Their use is not
limited to Medicare, and other insurers may not limit chiropractic
coverage to manual manipulation to correct subluxation of the spine. We
are seeking comment to assess whether there are situations in which E/M
services that are not included in the CMT codes, but would meet the
statutory requirements for chiropractor services, would be appropriate.
We are not proposing to pay chiropractors for E/M services in CY 2014.
If after receiving and analyzing public comment we determine that it
would be appropriate to modify our policy with respect to chiropractors
and E/M services, we would do so in future rulemaking.
Specifically, we are seeking comments on the following questions:
Are there situations where a chiropractor would furnish E/
M services that are with respect to treatment by means of manual
manipulation of the spine (to correct a subluxation) that are not
included within the definition of the CMT codes? Specifically, we are
seeking information on the situations, the services that would be
provided, and the E/M codes that would be billed.
Would such a policy expand access to chiropractic services
for Medicare beneficiaries? Are there other benefits that would accrue?
If payment were to be allowed for E/M services, which
codes would be appropriate to report chiropractic E/M services? For
services provided in an office, would it be appropriate to allow
billing of all five office E/M codes for new or existing patient as
appropriate? Should one or a set of codes be created specifically for
chiropractic E/M services similar to those for therapy evaluations or
ophthalmic evaluations? With what frequency should chiropractors be
allowed to bill E/M services?
What would justify E/M services beyond those included in
CMT codes? Should they be allowed on every treatment day or only at the
onset of treatment?
Are these E/M services ones that are already being
furnished by another physician or other practitioner? If these are not
services currently covered by Medicare, what volume could be expected?

III. Other Provisions of the Proposed Regulations

A. Medicare Coverage of Items and Services in FDA Investigational
Device Exemption Clinical Studies--Revision of Medicare Coverage

1. Statutory Authority and Background
This proposed rule would revise certain Medicare regulations
currently codified in Sec. 405.201 through 405.214, and Sec.
411.15(o) relating to coverage of the costs of routine items and
services in Category A Investigational device exemption (IDE) studies
and trials, and coverage of the costs of Category B, investigational
devices and the costs of routine items and services in Category B
investigational device exemption (IDE) studies and trials. It is based
on section 1862(m) of the Act, which, among other things, authorizes
the Secretary to establish criteria to ensure that studies and trials
of Category A devices conform to appropriate scientific and ethical

[[Page 43343]]

standards. We are proposing to establish those criteria that ensure
that studies and trials of Category A devices conform to appropriate
scientific and ethical standards. We are also proposing, based on our
rulemaking authority in section 1871 of the Act, to extend the same
criteria proposed for Category A IDE studies and trials to Category B
IDE studies and trials. Our proposed rules are necessary to carry out
the administration of the insurance program under Title XVIII of the
Act). Finally, to ensure that coverage of items and services in IDE
studies and trials is uniform across Medicare administrative regions,
we are proposing that IDE coverage decisions will be made by CMS
centrally.
On September 8, 1995, the FDA and CMS (then known as HCFA) entered
into an interagency agreement in which the FDA agreed to categorize
investigational device exemptions (IDEs) for purposes of Medicare
coverage. The process identified in this interagency agreement is
reflected in a September 19, 1995 final rule (60 FR 48417). The
September 19, 1995 rule described two FDA device categories: (1)
Category A devices were described as experimental/investigational
devices; and (2) Category B devices were described as nonexperimental/
investigational devices.
a. Coverage of IDE--Costs of Routine Items, Services, and Devices
The September 19, 1995 rule created a path to Medicare coverage
under certain circumstances for Category B investigational devices and
the costs of routine items and services in IDE studies and trials. The
IDE coverage policy gave Medicare beneficiaries the opportunity to have
earlier access to new medical devices, but these determinations were
made by local Medicare contractors sometimes on a claim-by-claim basis.
Although the current IDE policy was a path to earlier access to certain
devices and the costs of routine items and services, we were also
hearing that the IDE coverage approval process was burdensome and
created national variability that made it difficult for study sponsors
to conduct national IDE studies.
As we evaluated the IDE review and approval process we heard and
sought out feedback from stakeholders (for example, manufacturers,
study sponsors, and hospitals). Most of the stakeholders told us that
obtaining coverage of the device and the costs of routine items and
services was inefficient; that each Medicare contractor has different
processes to review IDE devices and studies. It also became apparent
that the lack of centralization led to inconsistent IDE coverage across
the Medicare contractors. These factors contributed to some reluctance
to enroll Medicare beneficiaries in IDE studies.
We also requested feedback from the Medicare local contractors. We
found that the Medicare contractors reviewed pertinent available
evidence and the FDA-approved IDE study protocol as factors in their
decision-making process. Reviewing all of the information related to
the IDE device and the FDA-approved study was a way to ensure that the
device, as used, is reasonable and necessary for the Medicare
beneficiary and furnished in a setting appropriate to the patient's
medical needs. While each contractor's process was appropriate, they
were in practice slightly different from contractor to contractor; and
in most cases duplicative. Furthermore, we found that local Medicare
contractors were applying varying levels of scrutiny in reviewing IDE
devices and the costs of routine items and services within IDE studies.
Most contractors reviewed IDE study protocols extensively, while other
contractors may have reviewed them less extensively.
2. Proposals
We are proposing a transparent, centralized review process that
would be more efficient by reducing the burden for stakeholders
interested in conducting nationwide trials. Once the IDE coverage
process is centralized, there would be a single entity making the IDE
coverage decision. This enhances administrative efficiency by
eliminating the need for duplicative reviews by Medicare local
contractors and the submission of duplicated coverage requests to
different contractors by stakeholders. We believe that a centralized
review process would not significantly reduce the number of IDE devices
currently covered; but we are specifically requesting public to comment
on this issue. Changing the review and decision of IDE coverage to a
centralized review process in no way changes any beneficiary appeal
rights.
a. Category A IDE Devices
In 2003, section 731(b) of the Prescription Drug, Improvement, and
Modernization Act (MMA) provided that the Secretary could not exclude
coverage for certain routine care costs in IDE studies and trials of
Category A devices, provided to beneficiaries under section
1862(a)(1)(A) of the Act. A Category A IDE device is a device for which
the initial questions of safety and effectiveness have not been
resolved and the FDA is unsure whether the device type can be safe and
effective. In addition, the Secretary was given the authority to ensure
that any Category A IDE device study conform to appropriate scientific
and ethical standards (section 1862(m)(1) of the Act). While the
Congress gave the Secretary the authority to determine the scope of
routine care costs, the Congress did not authorize or establish
coverage for the Category A device itself. Therefore, we are not
proposing any changes to coverage of the Category A IDE device.
Category A devices would continue to be noncovered under section
1862(a)(1)(A) of the Act.
The Congress has expressly authorized the Secretary to establish
criteria to ensure that any Category A IDE device study conform to
appropriate scientific and ethical standards. (For more information,
see section 1862(m)(2)(B) of the Act.) In the November 15, 2004
conforming final rule (69 FR 66420), we finalized a regulatory
provision at Sec. 405.207(b)(2) requiring Category A IDE devices be
furnished in conjunction with an FDA-approved clinical study and that
the study standards would be defined through the national coverage
determination (NCD) process. Rather than establish standards through
the NCD process, we would specify the study standards in this proposed
rule. We believe the Congress gave the Secretary the authority to
create appropriate scientific and ethical standards because of their
importance in protecting for Medicare beneficiaries.
The use of standards is essential to protecting Medicare study
participants in category A trials. Studies that have high scientific
and ethical standards lead to generalizable and reliable knowledge for
Medicare providers, practitioners and beneficiaries.
We believe that minimum standards are needed for IDE studies and
trials for which Medicare coverage of devices or routine items and
services is provided to ensure that Medicare beneficiaries who
volunteer to participate in studies are protected and that the study
design is appropriate to answer questions of importance to Medicare and
its beneficiaries. Although an item or service may be considered
``reasonable and necessary'' when used by a clinician for the benefit
of an individual patient, it may not necessarily be reasonable and
necessary when used in the context of an IDE study or trial. The use of
such an item or service in an IDE study or trial may expose the study
participants to increased risks that must be balanced by other factors,
including the likelihood that the study would add important information
to the body of

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medical knowledge. There are numerous studies that may be considered
``scientifically valid,'' but are of little benefit to patients or to
the Medicare program.
It is essential that CMS-approved IDE studies or trials serve the
best interests of Medicare beneficiaries. We believe, in concert with
other federal agencies, that appropriate study design is critical to
ensure that not only are participants in research studies exposed to
the least risk possible, but also to ensure that the results from the
study would be useful in improving healthcare delivery. Scientifically
and ethically flawed studies will not produce valid results, exposing
Medicare beneficiaries to unnecessary risk; and wasting time and
resources for all involved.
We are proposing 13 standards that Category A IDE studies must meet
in order for the costs of routine care items and services to be
coverable. The first four and the seventh proposed standards embody
ethical values. The fifth and sixth proposed standards were developed
in response to reports of egregious misconduct in the past in endeavors
to conduct clinical research by placing individuals at the risk of harm
for the good of others. Both the independent review of protocols and
informed consent by study participants are warranted to provide
accountability to the public that the conduct of the study is not
compromised by potential conflicts of interest on the part of
investigators, and the study subject's autonomy is respected.
The IDE study and trial standards that we are proposing are as
follows:
The principal purpose of the study is to test whether the
item or service meaningfully improves health outcomes of patients who
are represented by the Medicare-enrolled subjects.
The rationale for the study is well supported by available
scientific and medical information, or it is intended to clarify or
establish the health outcomes of interventions already in common
clinical use.
The study results are not anticipated to unjustifiably
duplicate existing knowledge.
The study design is methodologically appropriate and the
anticipated number of enrolled subjects is appropriate to answer the
research question(s) being asked in the study.
The study is sponsored by an organization or individual
capable of completing it successfully.
The study is in compliance with all applicable federal
regulations concerning the protection of human subjects found at 45 CFR
part 46.
All aspects of the study are conducted according to
appropriate standards of scientific integrity set by the International
Committee of Medical Journal Editors.
The study has a written protocol that clearly demonstrates
adherence to the standards listed here as Medicare requirements.
Where appropriate, the clinical research study is not
designed to exclusively test toxicity or disease pathophysiology in
healthy individuals. Trials of all medical technologies measuring
therapeutic outcomes as one of the objectives may be exempt from this
standard only if the disease or condition being studied is life
threatening as defined in 21 CFR 312.81(a) and the patient has no other
viable treatment options.
The study is registered on the ClinicalTrials.gov Web site
and/or the Registry of Patient Registries (RoPR) by the principal
sponsor/investigator prior to the enrollment of the first study
subject.
The study protocol specifies the method and timing of
public release of results on all pre-specified outcomes, including
release of negative outcomes. The release should be hastened if the
study is terminated early. The results must be made public within 24
months of the end of data collection. If a report is planned to be
published in a peer reviewed journal, then that initial release may be
an abstract that meets the requirements of the International Committee
of Medical Journal Editors (http://www.icmje.org). However, a full
report of the outcomes must be made public no later than 3 years after
the end of data collection.
The study protocol explicitly discusses subpopulations
affected by the item or service under investigation, particularly
traditionally underrepresented groups in clinical studies, how the
inclusion and exclusion criteria effect enrollment of these
populations, and a plan for the retention and reporting of said
populations in the study. If the inclusion and exclusion criteria are
expected to have a negative effect on the recruitment or retention of
underrepresented populations, the protocol must discuss why these
criteria are necessary.
The study protocol explicitly discusses how the results
are or are not expected to be generalizable to subsections of the
Medicare population to infer whether Medicare patients may benefit from
the intervention. Separate discussions in the protocol may be necessary
for populations eligible for Medicare due to age, disability or
Medicaid eligibility.
In proposed Sec. 405.212(a)(1) through (7), we would set forth
scientific standards for IDE studies or trials in which providers,
practitioners, suppliers or beneficiaries are requesting payment for
items or services provided to Medicare beneficiaries participating in
the IDE study or trial.
While most studies are undertaken only after a detailed protocol
has been developed, some are not. The protocol is the primary source of
knowledge on the proposed design and management of the study. Without
this document, reviewers and funding entities are unable to ascertain
the quality and validity of the study. The exercise of committing to
paper all the aspects of the study is crucial to ensuring that all
potential concerns have been addressed. It is impossible to evaluate
the adequacy of trial design without a written protocol. We do not
propose to define the content of that protocol. Numerous federal
agencies and other scientific entities have done that. However, in
proposed Sec. 405.212(a)(8) we would specify that all IDE studies or
trials must have a written protocol addressing the Medicare standards.
In proposed Sec. 405.212(a)(9), we would specify the ``therapeutic
intent'' requirement. We are proposing a standard that limits IDE
studies to those that do not exclusively test toxicity or disease
pathophysiology in healthy individuals but also have a therapeutic
outcome. However, the study may exclusively test toxicity or disease
pathophysiology, if the disease or condition being studied must be
life-threatening as defined in 21 CFR 312.81(a) and the patient has no
other viable treatment options or is severely debilitating as defined
in 21 CFR 312.81(b). In proposed Sec. 405.212(a)(10), we would specify
the standard that requires that IDE studies and trials that Medicare
supports be registered on ClinicalTrials.gov site. The National
Institutes of Health/National Library of Medicine (NIH/NLM) established
a clinical trials registry (ClinicalTrials.gov) to meet the requirement
of the 1997 Food and Drug Administration Modernization Act. After a
thorough review of the NIH/NLM ClinicalTrials.gov Web site, we believe
that all studies covered under this policy should be registered in this
registry prior to enrollment of the first subject.
Registration into ClinicalTrials.gov assures that beneficiaries
would have pertinent information about and IDE study or trial Medicare
supports--an essential component of transparency to

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facilitate patient-provider informed decision-making. The World Health
Organization and International Committee of Medical Journal Editors
(WHO/ICMJE) data elements are the required data elements in this
registry. Information about this registry may be obtained at http://www.clinicaltrials.gov/. We believe that registration serves the
public's desire to obtain information about the studies that their
Medicare premiums and tax dollars support.
In proposed Sec. 405.212(a)(11), we would address the issue of
dissemination of the IDE study or trial findings. We believe that it is
imperative that the results of IDE studies and trials for which
Medicare has made payment of any clinical costs be made available to
the public regardless of the outcomes. If trial results are not
published, they do not add to the clinical evidence base and cannot be
used for medical decision-making. For this standard, we are suggesting
that the study protocol provides a discussion of the publication/
dissemination plan of the study findings.
In proposed Sec. 405.212(a)(12), we would focus on the issue of
under-representation of specific demographic groups in U.S. clinical
research studies. We want to support studies that allow Medicare
beneficiaries to voluntarily participate in; and that add to the
knowledge base about the use of the IDE device in the Medicare
population, to ultimately improve the quality of care that Medicare
beneficiaries receive. Well-designed studies have protocols that define
the populations with the highest risk of having the disease or
condition being studied. If data are not available that clearly
demonstrate differences of clinical importance in subgroups defined by
gender, race/ethnicity, age, or other relevant subpopulations, then the
protocol must discuss the necessary steps to enroll appropriate numbers
of these populations to ensure a valid analysis of the intervention
effects. It is not our intention to require a specific enrollment of
all subpopulations. However, it is, our intention that all covered
study protocols address populations affected by the technology under
investigation with special emphasis on minority and other groups that
have experienced disparities in health care due to a lack of quality
research data. If convincing evidence indicates that no differences
exist between identified subgroups, that information should be noted in
the protocol.
In proposed Sec. 405.212(a)(13), we would specify the standard
that requires that an IDE study or trial protocol explicitly discuss
how the results are or are not expected to be generalizable to
subsections of the Medicare population and to infer whether Medicare
patients may benefit from the intervention. More often than not the
published evidence does not include the Medicare population. We believe
that unless there are clear data documenting that no important
differences exist between the Medicare beneficiaries and the population
studied, the study must discuss the enrollment of appropriate numbers
representative of the Medicare population to ensure that the analysis
of the results of the intervention may be applicable to Medicare
beneficiaries.
In Sec. 405.211, we are proposing that if the following two
characteristics are also included met in addition to the criteria
listed in Sec. 405.212(a)(1) through (a)(13), we would automatically
cover the costs of routine items and services in the Category A study
or trial, and the costs of the investigation device and the routine
items and services in a Category B study or trial as follows:
The study is a pivotal study.
The study has is a superiority study design.
In Sec. 405.212, we propose a process by which Category A IDE
studies will qualify for Medicare coverage of routine items and
services provided in the studies. We propose that any interested party
who seeks coverage in an IDE study may send us a request letter that
describes the scope and nature of the IDE study, discussing each of the
15 standards in this policy.
b. Category B IDE Devices
Under our regulations, a nonexperimental/investigational (Category
B) device was described as a device for which the underlying questions
of safety and effectiveness has been resolved. In the absence of a NCD,
Medicare coverage for Category B devices has been decided by Medicare
contractors, subject to review under the claims review process at Sec.
405.211(b). If the Category B device was covered, Medicare also covered
the costs of items and services specific to the use of the device and
furnished in conjunction with an FDA-approved clinical study.
Beyond Category A IDE studies, we believe that all investigational
device studies wherein Medicare coverage is sought should conform to
rigorous scientific and ethical standards. We believe that regardless
of whether the device is categorized as an A or B the IDE study should
meet the same scientific and ethical standards. Thus, we are proposing
to require that Category B IDE trials must meet the same scientific and
ethical standards.
c. Review and Approval (Sec. 405.212)
We are proposing a centralized IDE coverage review process for
Category A and Category B IDEs. We believe the criteria Sec.
405.212(a)(1) through (a)(13) are integral to coverage in any study
that is Medicare-approved because it ensures that the IDE device is
being furnished in a study with high levels of scientific and ethical
integrity.
In addition, we propose to cover Category B IDE devices and the
costs of routine care items and services furnished in an IDE study that
meets the criteria proposed Sec. 405.212(a) and the following
additional criteria:
The study is a pivotal study.
The study has is a superiority study design.
As we review the IDE studies, we would look for reasonable
assurance that enrolled Medicare beneficiary subjects will receive the
best possible care and are protected when they are subjects in these
IDE studies. The pivotal study and superiority study design criteria
furnish assurances that the study results will be informative for
beneficiary choices and medical decision-making in the non-trial
settings where most care is actually furnished. We believe that their
decisions are facilitated by trial designs that allow them to compare
their options and determine which one is superior for the beneficiary.
Non-inferiority trial designs (in contrast to superiority designs) only
support more limited and thus less useful conclusions, that is, that
the investigated device is no worse than the comparator treatment by
some pre-specified margin.
Supporting materials may be submitted. The request would include
the following information:
The FDA approval letter.
IDE study protocol.
IRB approval letter(s).
The ClinicalTrials.gov identifier
We propose that requests should be submitted via email to
[email protected] or via hard copy to the following
address:
Centers for Medicare & Medicaid Services, Center for Clinical
Standards & Quality, Director, Coverage and Analysis Group, ATTN:
Clinical Study Certification, Mailstop: S1-02-01, 7500 Security Blvd.,
Baltimore, MD 21244.
d. Notification
We propose that we would notify beneficiaries, providers, and
practitioners of the IDE studies of all IDE devices eligible for
coverage by

[[Page 43346]]

posting the IDE study title and ClinicalTrials.gov registry number on
our Web site and publishing a list in the Federal Register.
e. Additional/Conforming Changes
In addition to the proposed changes in Sec. 405.211 and Sec.
405.212, we note the following changes:
In Sec. 405.201(b), Definitions, we would be revised the
section by removing, revising and adding definitions. Some of the
definitions that we are proposing to remove comprise factors that will
allow stakeholders to understand the clinical study criteria for items
and services furnished in an IDE study including the Category A and B
device itself. Therefore, we proposing the following changes
++ Removal of the following definitions:
++ Class I, II, and III devices which refers to the different
designations of FDA devices. These designations are not relevant to CMS
coverage of an IDE device and routine items and services in an IDE
study.
++ Post-market approval refers to a marketing application for a
Class III device. Like class this is not relevant to whether CMS may
cover an IDE device or routine items or services in an IDE study.
++ Adding the following definitions:

--Clinicaltrials.gov which refers to the National Institutes of
Health's National Library of Medicine's online registry and results
database of publicly and privately supported clinical studies of human
participants conducted around the world. After a thorough review of the
NIH/NLM ClinicalTrials.gov Web site, we believe that all studies
covered under this policy should be registered in this registry. This
is common practice in the research community. Studies and trials are
now transparent--the study sites, investigator names, source of
support, description of the study methods, and study results are open
to the public, including Medicare beneficiaries. We believe that
registration serves the public's desire to obtain information about the
studies they may want to participate. This is a benefit to
beneficiaries and their providers participating in IDE studies.
--Pivotal studies or trials, which refer to clinical investigations
designed to collect definitive evidence of the safety and effectiveness
of a device for a specified intended use, typically in a statistically
justified number of subjects. It may or may not be preceded by an early
and/or a traditional feasibility study or trial.
--Routine care items and services, which refer to items and services
that are otherwise generally available to Medicare beneficiaries (that
is, there exists a benefit category, it is not statutorily excluded,
and there is not a national noncoverage decision) that are furnished in
either the experimental or the control arms of a clinical trial and
that would be otherwise furnished even if the beneficiary were not
enrolled in a clinical trial. We note that noncoverage of a routine
care item or services under an IDE trial in no way restricts a
beneficiary's access to guaranteed Medicare benefits outside of an IDE
trial.
--Superiority studies refer to studies or trials that are intended to
demonstrate at some pre-specified level of confidence that the effect
of an investigational treatment is superior to that of an active
control by more than a pre-specified margin.
We are proposing the additions of the previously discussed
definitions because we would use these factors in our decision to cover
an investigational device and the costs of routine items and services
in an IDE study.

We are proposing to modify the following definitions:
++ The term Category A which was developed in cooperation with the
FDA for the purposes of distinguishing those FDA classes under which
investigational and non-investigational devices fall. A Category A IDE
device is considered an experimental device; and therefore, deemed
noncovered by Medicare standards.
++ Category A device would be defined as a device for which
``absolute risk'' of the device type has not been established (that is,
the question of safety and effectiveness have not been resolved) and
the FDA is unsure whether the device type can be safe and effective.
++ The term Category B which was developed in cooperation with the
FDA for the purposes of distinguishing those FDA classes under which
investigational and non-investigational devices fall. FDA assigns each
device with an FDA-approved IDE to one of two categories. We propose to
revise the definition of Category B (Nonexperimental/investigational)
device to mean a device for which the incremental risk is the primary
risk in question (that is, initial questions of safety and
effectiveness of that device type have been resolved), or it is known
that the device type can be safe and effective because, for example,
other manufacturers have obtained FDA approval for that device type.
++ Contractors mean Medicare Administrative Contractors and other
entities that contract with CMS to review and adjudicate claims for
Medicare items and services. Currently, this is the definition refers
to CMS's local Medicare Contractors. We propose to update the current
definition in order for the definition to be accurate and consistent
Agency-wide.
++ IDE stands for investigational device exemption. An FDA-approved
IDE application permits a device, which would otherwise be subject to
marketing approval or clearance, to be shipped lawfully for the purpose
of conducting a clinical study in accordance with 21 U.S.C. 360j(g) and
21 CFR parts 812 and 813.
In Sec. 405.203, FDA categorization of investigational devices, we
are not proposing any changes. We have found that the interagency
agreement between the FDA and CMS that supports the FDA categorization
of devices to one of two categories for investigational purpose is
widely accepted among device manufacturers. Therefore, to avoid future
confusion by changing the categorization, we believe that maintaining
this process continues to support the development of new health
technologies and tools that practitioners and beneficiaries have
access. It should be noted that neither the determination nor any re-
evaluation made by FDA, nor the review determination made by CMS under
Sec. 405.211, would be considered coverage determinations that
implicate the Part 426 NCD/LCD appeals process.
In Sec. 405.207--
In paragraph (a), we are not proposing any changes to our
current noncoverage of Category A IDE devices. As stated previously, we
continue to find that because initial questions of safety and
effectiveness have not been resolved and the FDA is unsure of whether
the device type can be safe and effective, experimental/investigational
(Category A) devices are not reasonable and necessary under section
1862(a)(1)(A) of the Act; and
Paragraph (b) currently states that all Category A IDE
studies and trials must meet the criteria established through the NCD
process. Because we are proposing scientific and ethical standards, we
no longer need to establish the IDE study criteria through the NCD
process; and therefore, we are proposing to delete the NCD process
requirement. We are also proposing to remove the following statement
from Sec. 405.207(b)(2) that states ``If the trial is initiated before
January 1, 2010, the device must be determined as intended for use in
the diagnosis, monitoring or treatment of an immediately life-

[[Page 43347]]

threatening disease or condition'' because it is no longer applicable.
We are not proposing changes to Sec. 405.207(b)(1) or (b)(3).
In Sec. Sec. 405.205, 405.207, 405.209, and 405.211, we propose to
retain the current explanation of coverage and payment for non-
experimental/investigational devices.
For Sec. 405.213, Re-evaluation of a device categorization, we are
not proposing any changes to this section because we believe that
maintaining this process continues to support the development of new
health technologies and tools that practitioners and beneficiaries have
access.
We are proposing to retain the protections in Sec. 405.215,
Confidential Commercial and Trade Secret Information, without
modification. We note that section 502(c) of the Act broadly prohibits
the disclosure of trade secret and confidential commercial or financial
information--information exempt from public disclosure by the Freedom
of Information Act (FOIA) 5 U.S.C. 552(b)(4) outside the Department.
This prohibition is found in the devices and regulatory inspections
provisions of the Act, and is not limited to device-related
information. This disclosure prohibition also applies to information
reported or otherwise obtained by the Department during inspection
activities and other activities. This prohibition is interpreted to
allow information sharing within the U.S. Department of Health and
Human Services only.
In Sec. 411.15(o)(2), Experimental or investigational device
exclusions, we propose to revise the requirement to specify that the
exclusions under this section include experimental or investigational
devices, except for certain devices furnished in accordance with the
CMS IDE study and trial standards established in Sec. 405.21l. We are
proposing this change to be consistent with the IDE study
characteristics.

B. Ultrasound Screening for Abdominal Aortic Aneurysms

1. Background and Statutory Authority
Section 1861(s)(2)(AA) of the Act authorizes Medicare coverage
under Part B of ultrasound screening for abdominal aortic aneurysms
(``AAA screening''), as defined in section 1861(bbb) of the Act. Our
implementing regulations for AAA screening are at Sec. 410.19. AAA
screening is covered for a beneficiary that meets certain criteria
including that he or she must receive a referral during the initial
preventive physical examination (IPPE) and has not previously had an
AAA screening covered under the Medicare program. The IPPE, as
described in section 1861(ww) of the Act (and regulations at Sec.
410.16), includes a time restriction and must be furnished not more
than one year after the effective date of the beneficiary's first Part
B coverage period (see section 1862(a)(1)(K) of the Act). This time
limitation for the IPPE effectively reduces a Medicare beneficiary's
ability to obtain a referral for AAA screening.
Section 1834(n) of the Act, added by section 4105 of the Affordable
Care Act, grants the Secretary the discretion and authority to modify
coverage of certain preventive services identified in section
1861(ddd)(3) of the Act, which in turn cross-references section
1861(ww)(2) of the Act (including AAA screening at section
1861(ww)(2)(L). The Secretary may modify coverage to the extent that
such modification is consistent with the recommendations of the United
States Preventive Services Task Force (USPSTF) per section
1834(n)(1)(A) of the Act. In 2005, the USPSTF recommended ``one-time
screening for [AAA] by ultrasonography in men ages 65 through 75 who
have ever smoked. (Grade: B Recommendation)'' (Screening for Abdominal
Aortic Aneurysm: Recommendation Statement. http://www.uspreventiveservicestaskforce.org/uspstf05/aaascr/aaars.htm). The
USPSTF recommendation does not include a time limit with respect to the
referral for this test.
2. Provisions of the Proposed Regulations
We are proposing to exercise our discretion and authority under
section 1834(n) of the Act to modify coverage of AAA screening
consistent with the recommendations of the USPSTF to eliminate the one-
year time limit with respect to the referral for this service. This
proposed modification would allow coverage of AAA screening for
eligible beneficiaries without requiring them to receive a referral as
part of the IPPE. Specifically for purposes of coverage of AAA
screening, we propose to modify the definition of ``eligible
beneficiary'' in Sec. 410.19(a) by removing paragraph (a)(1), of this
definition, and redesignating paragraphs (a)(2) and (a)(3) of this
definition as paragraphs (a)(1) and (a)(2), respectively.
The IPPE is a one-time benefit available to beneficiaries under
Part B that receive the IPPE not more than one year after the effective
date of the beneficiary's first Medicare Part B coverage period. Many
beneficiaries were either not eligible to receive an IPPE (which did
not become effective until January 1, 2005) or may not have taken
advantage of the IPPE when they were eligible, limiting access to AAA
screening. We believe that our proposed modification is consistent with
current USPSTF recommendations for one-time screening and allows for
expanded access to this important preventive service. We invite public
comment on this proposal.

C. Colorectal Cancer Screening: Modification to Coverage of Screening
Fecal Occult Blood Tests

1. Background and Statutory Authority
Sections 1861(s)(2)(R) and 1861(pp)(1) of the Act authorize
Medicare coverage of colorectal cancer screening. The statute
authorizes coverage of screening fecal occult blood tests (FOBT),
screening flexible sigmoidoscopies, screening colonoscopies, and other
tests determined to be appropriate, subject to certain frequency and
payment limits. Section 410.37(b) (condition for coverage of screening
FOBT) specifies that Medicare Part B pays for screening FOBT if ordered
in writing by the beneficiary's attending physician. For purposes of
Sec. 410.37, ``attending physician'' is defined as ``a doctor of
medicine or osteopathy (as defined in section 1861(r)(1) of the Act)
who is fully knowledgeable about the beneficiary's medical condition,
and who would be responsible using the results of any examination
performed in the overall management of the beneficiary's specific
medical problem.''
The coverage provisions for FOBT screening were established in 1997
and effective on January 1, 1998 (62 FR 59048, October 31, 1997). In
the preamble to that final rule, we stated that the requirement for a
written order from the attending physician was intended to make certain
that beneficiaries receive appropriate preventive counseling about the
implications and possible results of having these examinations
performed (62 FR 59081).
Since then, Medicare coverage of preventive services has expanded
to include, among other things, coverage of an annual wellness visit
(as defined in Sec. 410.15). The annual wellness visit includes
provisions for furnishing personalized health advice and appropriate
referrals. In addition to physicians, the annual wellness visit can be
furnished by certain nonphysician practitioners, including physician
assistants, nurse practitioners, and clinical nurse specialists.
Additionally, Sec. 410.32 provides coverage and payment rules for
diagnostic x-ray tests, diagnostic laboratory tests, and other
diagnostic

[[Page 43348]]

tests. Section 410.32(a)(2) states: ``Nonphysician practitioners (that
is, clinical nurse specialists, clinical psychologists, clinical social
workers, nurse-midwives, nurse practitioners, and physician assistants)
who furnish services that would be physician services if furnished by a
physician, and who are operating within the scope of their authority
under State law and within the scope of their Medicare statutory
benefit, may be treated the same as physicians treating beneficiaries
for the purpose of this paragraph.''
2. Proposed Revisions
We are proposing to revise Sec. 410.37(b), ``Condition for
coverage of screening fecal-occult blood tests,'' to allow an attending
physician, physician assistant, nurse practitioner, or clinical nurse
specialist to furnish written orders for screening FOBT. These proposed
modifications would allow for expanded coverage and access to screening
FOBT, particularly in rural areas. We invite public comment on this
proposal. In addition, we are seeking public comment regarding whether
a practitioner permitted to order a screening FOBT must be the
beneficiary's attending practitioner as described earlier.

D. Ambulance Fee Schedule

1. Amendment to Section 1834(l)(13) of the Act
Section 146(a) of the Medicare Improvements for Patients and
Providers Act of 2008 (Pub. L. 110-275, enacted on July 15, 2008)
(MIPPA) amended section 1834(l)(13)(A) of the Act to specify that,
effective for ground ambulance services furnished on or after July 1,
2008 and before January 1, 2010, the ambulance fee schedule amounts for
ground ambulance services shall be increased as follows:
For covered ground ambulance transports that originate in
a rural area or in a rural census tract of a metropolitan statistical
area, the fee schedule amounts shall be increased by 3 percent.
For covered ground ambulance transports that do not
originate in a rural area or in a rural census tract of a metropolitan
statistical area, the fee schedule amounts shall be increased by 2
percent.
Sections 3105(a) and 10311(a) of the Affordable Care Act further
amended section 1834(l)(13)(A) of the Act to extend the payment add-ons
described above for an additional year, such that these add-ons also
applied to covered ground ambulance transports furnished on or after
January 1, 2010, and before January 1, 2011. In the CY 2011 PFS final
rule with comment period (75 FR 73385, 73386, 73625), we revised Sec.
414.610(c)(1)(ii) to conform the regulations to this statutory
requirement.
Section 106(a) of the Medicare and Medicaid Extenders Act of 2010
(Pub. L.111-309, enacted December 15, 2010) (MMEA) again amended
section 1834(l)(13)(A) of the Act to extend the payment add-ons
described above for an additional year, such that these add-ons also
applied to covered ground ambulance transports furnished on or after
January 1, 2011, and before January 1, 2012. In the CY 2012 End-Stage
Renal Disease Prospective Payment System (ESRD PPS) final rule (76 FR
70228, 70284 through 70285, and 70315), we revised Sec.
414.610(c)(1)(ii) to conform the regulations to this statutory
requirement.
Section 306(a) of the Temporary Payroll Tax Cut Continuation Act of
2011 (TPTCA) (Pub. L. 112-78, enacted on December 23, 2011) amended
section 1834(l)(13)(A) of the Act to extend the payment add-ons
described above through February 29, 2012; and section 3007(a) of the
Middle Class Tax Relief and Job Creation Act of 2012 (Pub. L. 112-96,
enacted on February 22, 2012) (MCTRJCA) further amended section
1834(l)(13)(A) of the Act to extend these payment add-ons through
December 31, 2012. Thus, these payment add-ons also applied to covered
ground ambulance transports furnished on or after January 1, 2012 and
before January 1, 2013. In the CY 2013 PFS final rule (77 FR 69139,
69368), we revised Sec. 414.610(c)(1)(ii) to conform the regulations
to this statutory requirement.
Subsequently, section 604(a) of the ATRA amended section
1834(l)(13)(A) of the Act to extend the payment add-ons described above
through December 31, 2013. Thus, these payment add-ons also apply to
covered ground ambulance transports furnished on or after January 1,
2013 and before January 1, 2014. Thus, we propose to revise Sec.
414.610(c)(1)(ii) to conform the regulations to this statutory
requirement.
This statutory requirement is self-implementing. A plain reading of
the statute requires only a ministerial application of the mandated
rate increase, and does not require any substantive exercise of
discretion on the part of the Secretary.
2. Amendment to Section 146(b)(1) of MIPPA
Section 146(b)(1) of the MIPPA amended the designation of certain
rural areas for payment of air ambulance services. This section
originally specified that any area that was designated as a rural area
for purposes of making payments under the ambulance fee schedule for
air ambulance services furnished on December 31, 2006, must continue to
be treated as a rural area for purposes of making payments under the
ambulance fee schedule for air ambulance services furnished during the
period July 1, 2008 through December 31, 2009.
Sections 3105(b) and 10311(b) of the Affordable Care Act amended
section 146(b)(1) of MIPPA to extend this provision for an additional
year, through December 31, 2010. In the CY 2011 PFS final rule (75 FR
73385, 73386, and 73625 through 73626), we revised Sec. 414.610(h) to
conform the regulations to this statutory requirement.
Section 106(b) of the MMEA amended section 146(b)(1) of MIPPA to
extend this provision again through December 31, 2011. In the CY 2012
ESRD PPS final rule (76 FR 70284, 70285, and 70315), we revised Sec.
414.610(h) to conform the regulations to this statutory requirement.
Subsequently, section 306(b) of the TPTCCA amended section
146(b)(1) of MIPPA to extend this provision through February 29, 2012;
and section 3007(b) of the MCTRJCA further amended section 146(b)(1) of
MIPPA to extend this provision through December 31, 2012. In the CY
2013 PFS final rule (77 FR 69139, 69140, and 69368), we revised Sec.
414.610(h) to conform the regulations to this statutory requirement.
Subsequently, section 604(b) of the ATRA amended section 146(b)(1)
of MIPPA to extend this provision through June 30, 2013. Thus, we
propose to revise Sec. 414.610(h) to conform the regulations to this
statutory requirement.
This statutory requirement is self-implementing. A plain reading of
the statute requires only a ministerial application of a rural
indicator, and does not require any substantive exercise of discretion
on the part of the Secretary. Accordingly, for areas that were
designated as rural on December 31, 2006, and were subsequently re-
designated as urban, we have re-established the ``rural'' indicator on
the ZIP Code file for air ambulance services through June 30, 2013.
3. Amendment to Section 1834(l)(12) of the Act
Section 414 of the Medicare Prescription Drug, Improvement and
Modernization Act of 2003 (Pub. L. 108-

[[Page 43349]]

173, enacted on December 8, 2003) (MMA) added section 1834(l)(12) to
the Act, which specified that in the case of ground ambulance services
furnished on or after July 1, 2004, and before January 1, 2010, for
which transportation originates in a qualified rural area (as described
in the statute), the Secretary shall provide for a percent increase in
the base rate of the fee schedule for such transports. The statute
requires this percent increase to be based on the Secretary's estimate
of the average cost per trip for such services (not taking into account
mileage) in the lowest quartile of all rural county populations as
compared to the average cost per trip for such services (not taking
into account mileage) in the highest quartile of rural county
populations. Using the methodology specified in the July 1, 2004
interim final rule (69 FR 40288), we determined that this percent
increase was equal to 22.6 percent. As required by the MMA, this
payment increase was applied to ground ambulance transports that
originated in a ``qualified rural area''; that is, to transports that
originated in a rural area included in those areas comprising the
lowest 25th percentile of all rural populations arrayed by population
density. For this purpose, rural areas included Goldsmith areas (a type
of rural census tract).
Sections 3105(c) and 10311(c) of the Affordable Care Act amended
section 1834(l)(12)(A) of the Act to extend this rural bonus for an
additional year through December 31, 2010. In the CY 2011 PFS final
rule with comment period (75 FR 73385, 73386 and 73625), we revised
Sec. 414.610(c)(5)(ii) to conform the regulations to this statutory
requirement.
Section 106(c) of the MMEA amended section 1834(l)(12)(A) of the
Act to extend the rural bonus described above for an additional year,
through December 31, 2011. Therefore, in the CY 2012 ESRD PPS final
rule (76 FR 70284, 70285 and 70315), we revised Sec. 414.610(c)(5)(ii)
to conform the regulations to this statutory requirement.
Section 306(c) of the TPTCCA amended section 1834(l)(12)(A) of the
Act to extend this rural bonus through February 29, 2012; and section
3007(c) of the MCTRJCA further amended section 1834(l)(12)(A) of the
Act to extend this rural bonus through December 31, 2012. In the CY
2013 PFS final rule with comment period (77 FR 69140, 69368), we
revised Sec. 414.610(c)(5)(ii) to conform the regulations to these
statutory requirements.
Subsequently, section 604(c) of the ATRA amended section
1834(l)(12)(A) of the Act to extend this rural bonus through December
31, 2013. Therefore, we are continuing to apply the 22.6 percent rural
bonus described above (in the same manner as in previous years), to
ground ambulance services with dates of service on or after January 1,
2013 and before January 1, 2014 where transportation originates in a
qualified rural area. Accordingly, we propose to revise Sec.
414.610(c)(5)(ii) to conform the regulations to this statutory
requirement.
This rural bonus is sometimes referred to as the ``Super Rural
Bonus'' and the qualified rural areas (also known as ``super rural''
areas) are identified during the claims adjudicative process via the
use of a data field included on the CMS-supplied ZIP Code File.
This statutory requirement is self-implementing. This provision
requires a one-year extension of the rural bonus (which was previously
established by the Secretary) through December 31, 2013, and does not
require any substantive exercise of discretion on the part of the
Secretary.
4. Addition of Section 1834(l)(15) of the Act
Section 637 of the ATRA, which added section 1834(l)(15) of the
Act, specifies that the fee schedule amount otherwise applicable under
the preceding provisions of section 1834(l) of the Act shall be reduced
by 10 percent for ambulance services furnished on or after October 1,
2013, consisting of non-emergency basic life support (BLS) services
involving transport of an individual with end-stage renal disease for
renal dialysis services (as described in section 1881(b)(14)(B) of the
Act) furnished other than on an emergency basis by a provider of
services or a renal dialysis facility. We are proposing to revise Sec.
414.610 by adding paragraph (c)(8) to conform the regulations to this
statutory requirement.
This statutory requirement is self-implementing. A plain reading of
the statute requires only a ministerial application of the mandated
rate decrease, and does not require any substantive exercise of
discretion on the part of the Secretary. Accordingly, for the ambulance
services described in section 637 of the ATRA furnished on or after
October 1, 2013, the fee schedule amount otherwise applicable (both
base rate and mileage) will be reduced by 10 percent. For further
information regarding application of this mandated rate decrease,
please see CR 8269.
5. Studies of Ambulance Costs
Section 604(d)(1) of the ATRA provides that the Secretary shall
conduct the following studies:
(A) A study that analyzes data on existing cost reports for
ambulance services furnished by hospitals and critical access
hospitals, including variation by characteristics of such providers of
services, with a Report to Congress on such study due no later than
October 1, 2013; and
(B) A study of the feasibility of obtaining cost data on a periodic
basis from all ambulance providers of services and suppliers for
potential use in examining the appropriateness of the Medicare add-on
payments for ground ambulance services furnished under the fee schedule
under section 1834(l) of the Act and in preparing for future reform of
such payment system, with a Report to Congress due on such study no
later than July 1, 2014.
Further, in conducting the study under paragraph (B) above, section
604(d)(2) of the ATRA directs the Secretary to:
Consult with industry on the design of such cost
collection efforts;
Explore the use of cost surveys and cost reports to
collect appropriate cost data and the periodicity of such cost data
collection;
Examine the feasibility of developing a standard cost
reporting tool for providers of services and suppliers of ground
ambulance services; and
Examine the ability to furnish such cost data by various
types of ambulance providers of services and suppliers, especially by
rural and super-rural providers of services and suppliers.
As noted above, in conducting the study under section 604(d)(1) of
the ATRA described in paragraph (B) above, the Secretary is required to
consult with industry on the design of such cost collection efforts
(see section 604(d)(2)(A) of the ATRA). We are using this proposed rule
as the instrument to collect information, comments, and ideas from the
industry on the design of such cost collection efforts as described
above, and on the feasibility of obtaining cost data on a periodic
basis from all ambulance providers of services and suppliers for
potential use in examining the appropriateness of the Medicare add-on
payments for ground ambulance services furnished under the fee schedule
under section 1834(l) of the Act and in preparing for future reform of
such payment system. We therefore invite public comment on these issues

[[Page 43350]]

as part of the study we are conducting under section 604(d)(1)(B) of
the ATRA.

E. Proposals Regarding the Clinical Laboratory Fee Schedule

1. Background on the Clinical Laboratory Fee Schedule
Under Medicare Part B, clinical diagnostic laboratory tests
furnished on or after July 1, 1984, in a physician's office, by an
independent laboratory, or by a hospital laboratory for its outpatients
and nonpatients currently are paid on the basis of the Clinical
Laboratory Fee Schedule (CLFS), with limited exceptions. For each
Healthcare Common Procedure Coding System (HCPCS) code, payment is the
lesser of:
The amount of charges billed for the test;
The fee schedule amount for the State or a local
geographic area; or
A national limitation amount (NLA) (section
1833(a)(1)(D)(i), (a)(2)(D)(i), (h)(1), and (h)(4)(B) of the Act). The
NLA for a clinical diagnostic laboratory test performed after December
31, 1997 is equal to 74 percent of the median of all fee schedules
established for that test for that laboratory setting or 100 percent of
such median in the case of a clinical diagnostic laboratory test
performed on or after January 1, 2001, that the Secretary determines is
a new test for which no limitation amount has previously been
established (section 1833(h)(4)(B)(viii) of the Act).
Currently, we update the CLFS amounts annually to reflect changes
in the Consumer Price Index for all Urban Consumers (U.S. city average)
(CPI-U) and apply a multi-factor productivity adjustment (see section
1833(h)(2)(A) of the Act). In the past, we also implemented other
adjustments or did not apply the change in the CPI-U to the CLFS in
accordance with statutory mandates. For example, under section
1833(h)(2)(A)(i) of the Act, we were required to subtract 0.5
percentage points from the CPI-U adjustment for 2009 and 2010. We do
not otherwise update or change the CLFS.
For any clinical diagnostic laboratory tests where a new or
substantially revised HCPCS code is assigned on or after January 1,
2005, we determine the basis for, and amount of, payment for these
clinical diagnostic laboratory tests (see section 1833(h)(8) of the Act
and 42 CFR 414.500 through 414.509). Once established, however, in most
cases, we only have the opportunity to reconsider the basis and/or
amount of payment for new tests for one additional year after the basis
or payment is initially set. Once the reconsideration process is
complete, payment is not further adjusted (except by a change in the
CPI-U, the productivity adjustment, and any other adjustments required
by statute), regardless of any shift in the actual costs incurred to
perform the test.
This lack of an established mechanism to adjust payment amounts is
unique among the Medicare payment schedules and systems. Generally, fee
schedules and prospective payment systems are evaluated each year to
reflect the changing mix of services provided under that system or
schedule and then the system or schedule is adjusted to maintain budget
neutrality. Since there is currently no process to make such
adjustments for the CLFS, payment amounts are essentially locked in
place and do not change when the cost of the test changes. As discussed
below, in this proposed rule, we are proposing to implement a process
to adjust payment amounts based on changes in technology.
2. Proposals Regarding Technological Changes Under Section
1833(h)(2)(A)(i) of the Act
a. Background on Technological Changes
There has been a significant amount of technological change in the
clinical laboratory area since the implementation of the CLFS, which
has resulted in the increased use of point-of-care testing, brand new
tests being developed, and the proliferation of laboratory-developed
tests. The Institute of Medicine (IOM) dedicated a chapter of its 2000
report ``Medicare Laboratory Payment Policy: Now and in the Future'' to
discussing trends in laboratory technology. The report noted rapid and
dramatic innovation in the laboratory sector since the 1980s and
remarkable growth in the range and complexity of available tests. The
IOM concluded that the introduction of new tests, advances in equipment
and testing techniques, and the proliferation of advanced information
technology have all made testing more efficient and automated.
Technology has enabled a significant site-of-service shift for many
laboratory tests from the laboratory environment to the point of health
care delivery. This point-of-care testing has increased since the
1980s, when this type of testing first became available, mainly due to
changes in technology which resulted in smaller, cheaper, and more
portable test kits that are simple to use. For example, drug abuse
testing has become readily available at the point of care. Point-of-
care testing can be performed in various institutional and community
settings but the main objective of such testing is to produce a result
quickly, at the place where the patient is receiving care, such as at a
physician's office or at a hospital bedside, to facilitate decisions
about appropriate treatment.
There are also brand new technologies that did not exist when the
CLFS was established, most notably genetic and genomic tests. This area
of medicine evolved from the work of the Human Genome Project and
subsequent research and development by both the federal government and
private firms. The cost of sequencing a genome has dropped dramatically
since the early inception of this technology in 2001 from more than $95
million per genome to approximately $5,700 in early 2013 (http://www.genome.gov/pages/der/sequencing_cost.xlsx). Early tests in this
area were less likely to be covered by Medicare because they were
either screening tests or tests for conditions found in the pediatric
population. As this area has expanded over the past several decades,
Medicare has taken on a more prominent role in payment for these
services (see 77 FR 68994 through 69002 for a thorough discussion of
how Medicare pays for these tests). We expect the number of codes and
tests in this area to continue to grow as the technology evolves and
more tests become available in the areas of pharmacogenomics,
personalized and predictive medicine, and companion diagnostics.
We also note the growth in laboratory-developed tests (LDTs) over
the years. These proprietary tests are developed by laboratories, which
then offer the service of providing the test. Some of the most advanced
laboratory tests currently being performed are LDTs which use
sophisticated proprietary technology. Many LDTs do not have their own
codes; instead, they are billed using unlisted codes for which
contractors establish a payment amount. Other LDTs were billed to
Medicare using ``stacking codes,'' where a laboratory submits a code
for each step of the testing process; however, these ``stacking codes''
were eliminated at the end of 2012 for molecular pathology tests and
replaced with 114 new test-specific codes. These payment processes
provide us with limited information about the technology used to
perform these tests. However, we know that the number of LDTs has been
growing over the years and multiple laboratories have developed ways to
perform the same test. Further, our recent experience with using a gap
filling methodology to price molecular pathology tests, which are often
LDTs, has shown that the costs of performing these tests have decreased
since contractors initially established

[[Page 43351]]

payment amounts for the tests, or compared to the code stack previously
billed. Our experience with gap filling molecular pathology tests has
also shown that there is wide variation in the cost of performing the
same test by different laboratories.
We believe that, given the technological changes that have occurred
in the laboratory industry over the past several decades and the growth
in the number of clinical laboratory tests (CMS has added approximately
800 new test codes to the CLFS since its inception), it would be
appropriate to establish a process to reconsider payment amounts on the
CLFS to take into account increased efficiency, changes in laboratory
personnel and supplies necessary to conduct a test, changes in sites of
service, and other changes driven by technological advances.
Section 1833(h)(2)(A)(i) of the Act requires the Secretary to set
the fee schedules for clinical laboratory tests ``for the 12-month
period beginning July 1, 1984, adjusted annually (to become effective
on January 1 of each year) by, subject to [the multi-factor
productivity adjustment], [the change in the CPI-U] and subject to such
other adjustments as the Secretary determines are justified by
technological changes'' (emphasis added). Under this authority, we are
proposing a process under which we will systematically reexamine the
payment amounts established under the CLFS to determine if changes in
technology for the delivery of that service warrant an adjustment to
the payment amount.
b. Proposed Definition of Technological Changes
We are proposing to define technological changes as changes to the
tools, machines, supplies, labor, instruments, skills, techniques, and
devices by which laboratory tests are produced and used. Changes in
technology could result in changes to, among other things, the
resources required to perform the test (such as the type, volume, or
number of supplies or reagents required), the laboratory personnel
required to perform the test, and/or the frequency of testing, volume
of testing, or site of service (for example, a shift in service site
from a specialty laboratory to a physician's office). We believe this
broad definition would capture all of the technological changes that
could impact the resource inputs for various tests on the CLFS. As
discussed below, the technological changes for a specific test would be
discussed in the proposed rule in which we are proposing to adjust the
payment amount for that test, and we would seek public comment on our
determination of the technological changes and the payment adjustment.
c. Proposed Process
We are proposing that, each year, we would review certain codes on
the CLFS, as described in the next section, to determine whether we
believe that payment for these codes should be adjusted due to
technological changes. For those codes where we determine that payment
adjustments should be made, beginning with the CY 2015 PFS proposed
rule, we would identify the test code, discuss how it has been impacted
by technological changes, and propose an associated adjustment to the
payment amount for the test code as appropriate to reflect the impact
of such technological changes.
We believe such adjustments could be made both to increase fee
schedule amounts (for example, in situations where new high cost
technologies are employed), and to provide for reductions in existing
amounts (for example in situations where technology reduces costs
through increased efficiencies). We expect that most payment amounts
will decrease due to the changes in technology that have occurred over
the years since the payment amounts were established and the general
downward trend of costs once technology has had an opportunity to
diffuse. A key goal in establishing this review process is to ensure
payment accuracy after technological changes; thus payment rates could
increase or decrease as a result of these reviews.
Under our proposed process, we would also list codes that we
reviewed but for which there was insufficient information to support or
establish an adjustment to the payment amount due to technological
changes. We would solicit comment on the technology used to perform any
tests we reviewed for possible payment changes, and any relevant cost
information. We expect that we would finalize any payment adjustments
in the PFS final rule, beginning with the CY 2015 PFS final rule. We
are proposing that the CPI-U and multi-factor productivity adjustments
would be applied after we establish the new payment amount through our
usual instruction process.
We believe that this proposed process would best allow for the
greatest amount of transparency in review and the most structured and
consistent opportunity for the public to provide input into the
process. We are soliciting comment on these proposals.
d. Proposed Identification and Prioritization of Codes to be Reviewed
We are proposing to review all codes currently on the CLFS. We are
proposing to start our review by examining the codes that have been on
the CLFS the longest and then work our way forward, over multiple
years, until we have reviewed all of the codes on the CLFS. We believe
that the payment amounts for codes that have been on the CLFS the
longest amount of time would be most affected by changes in technology
because, in general, technology is most expensive earliest in its life
cycle but decreases in cost as the technology matures and diffuses. If
during the course of reviewing these individual codes we find that
there are additional, newer codes that are clinically and/or
technologically similar, we are proposing to consider them for review
at the same time as we review the older codes because we expect we
would have the same or similar justifications for making payment
adjustments to those codes. We intend to review these codes as quickly
as possible but we believe there would be a significant administrative
burden associated with such a comprehensive review of the 1,250 codes
on the CLFS. We are estimating that it would take at least 5 years to
review all of the existing codes on the CLFS.
Once we have completed our review of the codes currently on the
CLFS and made any adjustments necessary due to technological changes,
we are proposing to review codes added to the CLFS after 2015 that have
been on the CLFS for at least 5 years. We would also review codes again
that have not been reviewed in the previous 5 years, as time and
resources allow. We believe that tests that are less than 5 years old
are likely still in their technological infancy and enough time would
not have passed to adequately assess any change in technology for those
services. Similarly, for previously reviewed codes, we believe that
technology likely would not have changed dramatically in less than 5
years. We are soliciting public comment on how to prioritize these
codes, which we expect to address in future rulemaking on this issue.
After the initial review of the codes currently on the CLFS, we are
also proposing to allow the public to nominate additional codes for
review, including those that had been previously reviewed for
technological change. We are proposing that the public may nominate
only codes that have been on the CLFS for at least 5 years and that
have not been reviewed in the previous 5 years. Further, we are

[[Page 43352]]

proposing that the nomination must include an explanation from the
nominator of the technological change in the service and the way that
change affects its delivery. We would then consider these nominations
and, in the Federal Register the following year, either propose a
payment change based on technological changes or explain why we think
such a change is not warranted at that time.
We are proposing to codify the proposed process at 42 CFR 414.511.
We are seeking public comment on these proposals. We also are
seeking comment on alternative approaches to achieving our goal of
paying appropriately for laboratory tests by accounting for changes in
technology. Finally, we are soliciting comment on general trends in
technology change in the laboratory industry and the health care sector
in general.
3. Proposed Changes in the CY 2014 OPPS/ASC Proposed Rule
In the CY 2014 OPPS/ASC proposed rule, CMS is proposing to package
payment for certain clinical diagnostic laboratory tests into the base
payment for the Ambulatory Payment Classification (APC). For details on
this proposal, please see the ``Proposed Changes to Packaged Items and
Services'' section of the CY 2014 OPPS/ASC proposed rule. Comments on
the OPPS proposal should be made to the CY 2014 OPPS/ASC proposed rule.
Comments on the proposals in this rule should be made to the CY 2014
PFS proposed rule.

F. Liability for Overpayments to or on Behalf of Individuals Including
Payments to Providers or Other Persons

1. Background and Statutory Authority
CMS waives recovery of overpayments in certain situations for
claims based fee-for-service provider, supplier or beneficiary
overpayments in accordance with section 1870 of the Act. Section
1870(b) and (c) of the Act provide a waiver of recovery of provider,
supplier or beneficiary overpayments under certain presumptions within
a specified timeframe. Section 1870(b) and (c) of the Act allow the
Secretary to reduce the specified time period to not less than one year
if the Secretary finds that such a reduction is consistent with the
objectives of the Medicare program. Section 638 of the American
Taxpayer Relief Act of 2012 (ATRA) (Pub. L. 112-240, enacted January 2,
2013) changed the timeframes associated with section 1870(b) and (c) of
the Act.
Section 1870(b) of the Act provides for the waiver of recovery of
an overpayment to a provider of services (hereinafter, ``provider'') or
other person whenever that provider or other person is ``without
fault'' in incurring the overpayment. For purposes of section 1870 of
the Act and this proposed rule, the term ``other person'' includes
practitioners, physicians, and other suppliers.
Section 1870(b) of the Act also establishes circumstances under
which a provider or other person is presumed for administrative
purposes to be ``without fault'' for an overpayment. If an overpayment
is determined after a specified period of time, a provider or other
person is presumed to be ``without fault.'' This presumption is
negated, however, if there is evidence to show that the provider or
other person was responsible for causing the overpayment.
Section 1870(c) of the Act provides for the waiver of recovery of
an overpayment to an individual whenever the individual is ``without
fault'' in incurring the overpayment, and recovery would either defeat
the purpose of the Social Security or Medicare programs or would be
``against equity and good conscience.''
Section 1870(c) of the Act also establishes circumstances under
which recovery of an overpayment for an individual is presumed to be
``against equity and good conscience.'' After a specified period of
time, recovery of certain overpayments from individuals who are
``without fault'' is presumed ``against equity and good conscience.''
The overpayments addressed by this provision are payments for items or
services for which payment may not be made because of the prohibitions
found in section 1862(a)(1) or (a)(9) of the Act. Sections 1862(a)(1)
and (a)(9) prohibit payment for, among other things, items and services
that are not reasonable and necessary or that are for custodial care.
Section 638 of the ATRA amended the timeframe specified in section
1870(b) of the Act ``without fault'' presumption from 3 to 5 years so
that the presumption of ``without fault'' only applies if the Medicare
claims based fee-for-service overpayment determination for a provider
or other person is made subsequent to the fifth year (instead of the
third year) following the year in which the notice was sent to such
individual that such amount had been paid. Likewise, section 638 of the
ATRA amended the timeframe in section 1870(c) of the Act so that the
presumption for ``against equity and good conscience'' for certain
types of denials for an individual who is ``without fault'' only
applies if the overpayment determination is made subsequent to the
fifth year (instead of the third year) following the year in which
notice of such payment was sent to such individual.
These ATRA changes do not affect or change CMS' claims reopening
regulation at Sec. 405.980. Specifically, we retain our authority to
reopen claims for any reason within one year, for good cause within 4
years, and at any time for fraud or similar fault.
2. Provisions of the Proposed Regulations
We propose to revise Sec. 405.350(c) and Sec. 405.355(b). These
proposed revisions would change the timing of the triggering event for
the ``without fault'' and ``against equity and good conscience''
presumptions. These revisions are being proposed to reflect the
revisions to section 1870 of the Act as specified in by section 638 of
ATRA.
Specifically, we propose to change the timeframe at Sec.
405.350(c) so that the rebuttable ``without fault'' presumption for the
provider or other person would apply if the Medicare claims based fee-
for-service overpayment determination is made subsequent to the fifth
year (instead of the third year) following the year in which the notice
was sent to such individual that such amount had been paid.
Likewise, we propose to amend the timeframe at Sec. 405.355(b) for
the presumption ``against equity and good conscience'' for certain
types of denials for an individual who is ``without fault'' so that the
presumption would apply if the overpayment determination is made
subsequent to the fifth year (instead of the third year) following the
year in which the notice of payment was sent to the individual.
Additionally, in our review of the current regulation implementing
section 1870(c) of the Act, we noted that Sec. 405.355(b) does not
clearly reflect the statutory language, which limits the ``against
equity and good conscience'' presumption to overpayments associated
with denials under section 1862(a)(1) or (a)(9) of the Act.
Accordingly, we propose to update and clarify Sec. 405.355(b) so that
it clearly reflects the statutory language by adding that the ``against
equity and good conscience'' presumption would be applicable for an
individual who is ``without fault'' only if the overpayment is related
to items and services that are not payable under section 1862(a)(1) or
(a)(9) of the Act. In addition, we propose to delete the parenthetical
at the end of Sec. 405.355(b) because the regulations referenced no
longer exists; those

[[Page 43353]]

sections of the regulations were reassigned. (See the October 11, 1989
Federal Register (54 FR 41733).) The modifications we propose to Sec.
405.355(b) makes the references in the parenthetical no longer
necessary.

G. Physician Compare Web site

1. Background and Statutory Authority
Section 10331 (a)(1) of the Affordable Care Act, requires that, by
no later than January 1, 2011, we develop a Physician Compare Internet
Web site with information on physicians enrolled in the Medicare
program under section 1866(j) of the Act, as well as information on
other eligible professionals who participate in the Physician Quality
Reporting System (PQRS) under section 1848 of the Act.
CMS launched the first phase of Physician Compare on December 30,
2010 (www.medicare.gov/physiciancompare). In the initial phase, we
posted the names of eligible professionals that satisfactorily
submitted quality data for the 2009 PQRS, as required by section
1848(m)(5)(G) of the Act.
Section 10331(a)(2) of the Affordable Care Act also requires that,
no later than January 1, 2013, and for reporting periods that begin no
earlier than January 1, 2012, we implement a plan for making publicly
available through Physician Compare information on physician
performance that provides comparable information on quality and patient
experience measures. We met this requirement in advance of January 1,
2013, as outlined below, and intend to continue to address elements of
the plan through rulemaking.
To the extent that scientifically sound measures are developed and
are available, we are required to include, to the extent practicable,
the following types of measures for public reporting:
Measures collected under the PQRS.
An assessment of patient health outcomes and functional
status of patients.
An assessment of the continuity and coordination of care
and care transitions, including episodes of care and risk-adjusted
resource use.
An assessment of efficiency.
An assessment of patient experience and patient,
caregiver, and family engagement.
An assessment of the safety, effectiveness, and timeliness
of care.
Other information as determined appropriate by the
Secretary.
As required under section 10331(b) of the Affordable Care Act, in
developing and implementing the plan, we must include, to the extent
practicable, the following:
Processes to ensure that data made public are
statistically valid, reliable, and accurate, including risk adjustment
mechanisms used by the Secretary.
Processes for physicians and eligible professionals whose
information is being publicly reported to have a reasonable
opportunity, as determined by the Secretary, to review their results
before posting to Physician Compare. This would consist of a 30-day
preview period for all measurement performance data that will allow
physicians and other eligible professionals to view their data as it
will appear on the Web site in advance of publication. Details of the
preview process will be communicated on the Physician Compare
Initiative page on CMS.gov in advance of the preview period.
Processes to ensure the data published on Physician
Compare provides a robust and accurate portrayal of a physician's
performance.
Data that reflects the care provided to all patients seen
by physicians, under both the Medicare program and, to the extent
applicable, other payers, to the extent such information would provide
a more accurate portrayal of physician performance.
Processes to ensure appropriate attribution of care when
multiple physicians and other providers are involved in the care of the
patient.
Processes to ensure timely statistical performance
feedback is provided to physicians concerning the data published on
Physician Compare.
Implementation of computer and data infrastructure and
systems used to support valid, reliable and accurate reporting
activities.
Section 10331(d) of the Affordable Care Act requires us to consider
input from multi-stakeholder groups in selecting quality measures for
Physician Compare, which we note we are working to accomplish through a
variety of means including rulemaking and various forms of stakeholder
outreach. In developing the plan for making information on physician
performance publicly available through Physician Compare, section
10331(e) of the Affordable Care Act requires the Secretary, as the
Secretary deems appropriate, to consider the plan to transition to
value-based purchasing for physicians and other practitioners that was
developed under section 131(d) of the Medicare Improvements for
Patients and Providers Act of 2008 (MIPPA) (Pub. L. 110-275, enacted on
July 15, 2008).
Under section 10331(f) of the Affordable Care Act, we are required
to submit a report to the Congress, by January 1, 2015, on Physician
Compare development, and include information on the efforts and plans
to collect and publish data on physician quality and efficiency and on
patient experience of care in support of value-based purchasing and
consumer choice. Initial work on this report is currently underway.
Section 10331(g) of the Affordable Care Act provides that any time
before that date, we may continue to expand the information made
available on Physician Compare.
We believe section 10331 of the Affordable Care Act supports our
overarching goals of providing consumers with quality of care
information to make informed decisions about their healthcare, while
encouraging clinicians to improve on the quality of care they provide
to their patients. In accordance with section 10331 of the Affordable
Care Act, we intend to utilize Physician Compare to publicly report
physician performance results.
2. Public Reporting of Physician Performance Data
Since the initial launch of the Web site, we have continued to
build on and improve Physician Compare. In 2013, we launched a full
redesign of Physician Compare offering significant improvements
including a complete overhaul of the underlying database and a new
Intelligent Search feature, addressing two of our stakeholders' primary
critiques of the site and considerably improving functionality and
usability. The primary source of administrative information on
Physician Compare is the Provider Enrollment, Chain, and Ownership
System (PECOS); as the sole source of verified Medicare professional
information, PECOS remains the primary information source. However,
with the redesign, we incorporated Medicare claims information to
verify the information in PECOS to ensure only the most current and
accurate information is included on the site.
With the redesign, users can now search for Medicare physicians and
other healthcare professionals by defining a location--a ZIP code, a
city/State combination, an exact address, or landmark--and by entering
a medical specialty, health care professional or group practice name, a
medical condition, body part, or organ system. The site produces a list
of suggested specialties, as defined by the 855i Medicare Enrollment
Form, users can choose related to their search term or a list of names,
as appropriate.

[[Page 43354]]

Currently, users can view information about approved Medicare
professionals such as name, primary and secondary specialties, practice
locations, group affiliations, hospital affiliations that link to the
hospital's profile on Hospital Compare as available, Medicare
Assignment status, education, languages spoken, and American Board of
Medical Specialties (ABMS) board certification information. In
addition, for group practices, users can also view group practice
names, specialties, practice locations, Medicare Assignment status, and
affiliated professionals.
As required by 1848(m)(5)(G) of the Act, we are required to post on
a CMS Web site the names of eligible professionals who satisfactorily
report under the PQRS, as well as those eligible professionals who are
successful electronic prescribers under the Medicare Electronic
Prescribing (eRx) Incentive Program, and Physician Compare contains a
link to the list of names. In addition to the list of names, there is a
section on each individual's profile page listing the quality programs
under which the specific individual satisfactorily reported or was a
successful electronic prescriber. The program name is listed and a
green check mark clearly indicates participation. These data will be
updated annually with the most recent data available.
With the Physician Compare redesign, we have also added a quality
programs section to each group practice profile page in order to
indicate which group practices are satisfactorily reporting in Group
Practice Reporting Option (GPRO) under the PQRS or the eRx Incentive
program. We have also included a notation and check mark for
individuals that participate in the Medicare EHR Incentive Program, as
authorized by section 1848(o)(3)(D) of the Act. These data will be
updated with the most recent data available.
As we indicated in the 2013 PFS final rule with comment period (77
FR 69166), we will include a check mark in the quality programs section
of the profile page to note those individuals who report the PQRS
Cardiovascular Prevention measures group in support of the Million
Hearts Initiative. Finally, a check mark will be added to indicate
those individuals who have earned a Maintenance of Certification
Additional Incentive starting with data reported for CY 2013. We will
update this information annually moving forward.
We are now instituting our plan for a phased approach to public
reporting of performance information on Physician Compare. The first
phase of our plan was finalized with the 2012 PFS final rule with
comment period (77 FR 69166), where we established that PQRS GPRO
measures collected through the GPRO Web interface during 2012 would be
publicly reported on Physician Compare. These measures will be publicly
reported on Physician Compare in CY 2014. We expanded our plan with the
2013 PFS final rule with comment period (77 FR 69166) where we
established that the specific GPRO web interface measures that would be
posted on Physician Compare include the Diabetes Mellitus (DM) and
Coronary Artery Disease (CAD) PQRS GPRO measures, and that we would
develop and report composite measures for these measure groups in
future years, if technically feasible. For data reported in 2013 under
the GPRO, DM and CAD PQRS GPRO measures and composites collected via
the GPRO web interface that meet the minimum sample size of 20
patients, and that prove to be statistically valid and reliable, will
be publicly reported on Physician Compare in late CY 2014, if
technically feasible. As we previously established, if the minimum
threshold is not met for a particular measure, or the measure is
otherwise deemed not to be suitable for public reporting, the group's
performance rate on that measure will not be publicly reported.
In the Shared Savings Program final rule (76 FR 67948), we noted
that because Accountable Care Organization (ACO) providers/suppliers
that are eligible professionals are considered to be group practices
for purposes of qualifying for a PQRS incentive under the Shared
Savings Program, we would publicly report performance on quality
measures as we report performance on quality measures for PQRS GPRO
group practices. Public reporting of performance on these measures will
be presented at the ACO level only.
In the CY 2013 PFS final rule with comment period (77 FR 69167), we
also finalized our decision to publicly report Clinician and Group
Consumer Assessment of Healthcare Providers and Systems (CG-CAHPS) data
for group practices of 100 or more eligible professionals reporting
data in 2013 under the GPRO, and for ACOs participating in the Shared
Savings Program. We anticipate posting these data on Physician Compare
as early as 2014.
3. Future Development of Physician Compare
We will continue to phase in an expansion of Physician Compare over
the next several years by incorporating quality measures from a variety
of sources, as technically feasible. We previously finalized a decision
to publicly report on Physician Compare the performance rates on a
limited set of Web interface quality measures that group practices
submit under the 2012 and 2013 PQRS GPRO Web interface (76 FR 73417 and
77 FR 69166).
For 2014, we propose to expand the quality measures posted on
Physician Compare by publicly reporting performance on all measures
collected through the GPRO Web interface for groups of all sizes
participating in 2014 under the PQRS GPRO and for ACOs participating in
the Medicare Shared Savings Program. These data would include measure
performance rates for measures reported that met the minimum sample
size of 20 patients, and that prove to be statistically valid and
reliable. We will provide a 30-day preview period prior to publication
of quality data on Physician Compare so that group practices and ACOs
can view their data as it will appear on Physician Compare before it is
publicly reported. CMS will detail the process for the 30-day preview
and provide a detailed timeline and instructions for preview in advance
of the start of the preview period.
For 2013 and 2014, we expanded the group reporting option for PQRS
GPRO to include a registry reporting option, which we propose to
further modify for data reported in 2014 under the PQRS GPRO registry
option. Consistent with the requirement under section 10331(a)(2)(A) of
the Affordable Care Act to make publicly available information on
quality measures submitted by physicians and other eligible
professionals under PQRS, we propose to publicly report on Physician
Compare performance on certain measures that groups report via
registries and EHRs in 2014 for the PQRS GPRO. Specifically, we propose
to report, no earlier than 2015, performance on the GPRO registry and
EHR measures identified below that can also be reported via the GPRO
Web interface in 2014. By proposing to include on Physician Compare
performance on these measures reported by participants under the GPRO
through registries and EHRs, as well as the GPRO Web interface, we
continue to provide beneficiaries with a consistent set of measures
over time. For registry reporting, publicly reported measures would
include:
Diabetes: Hemoglobin A1c Poor Control.
Heart Failure (HF): Beta-Blocker Therapy for Left
Ventricular Systolic Dysfunction (LVSD).
Medication Reconciliation.

[[Page 43355]]

Preventive Care and Screening: Influenza Immunization.
Pneumococcal Vaccination Status for Older Adults.
Preventive Care and Screening: Breast Cancer Screening.
Colorectal Cancer Screening.
Coronary Artery Disease (CAD): Angiotensin-converting
Enzyme (ACE) Inhibitor or Angiotensin Receptor Blocker (ARB) Therapy--
Diabetes or Left Ventricular Systolic Dysfunction (LVEF < 40%).
Adult Weight Screening and Follow-Up.
Preventive Care and Screening: Screening for Clinical
Depression.
Coronary Artery Disease (CAD): Lipid Control.
Ischemic Vascular Disease (IVD): Use of Aspirin or Another
Antithrombotic.
Preventive Care and Screening: Tobacco Use: Screening and
Cessation Intervention.
Hypertension (HTN): Controlling High Blood Pressure.
Ischemic Vascular Disease (IVD): Complete Lipid Panel and
LDL Control.
Preventive Care and Screening: Screening for High Blood
Pressure and Follow-Up Documented.
For EHR reporting, publicly reported measures would include:
Diabetes: Hemoglobin A1c Poor Control.
Heart Failure (HF): Beta-Blocker Therapy for Left
Ventricular Systolic Dysfunction (LVSD).
Preventive Care and Screening: Influenza Immunization.
Pneumococcal Vaccination Status for Older Adults.
Preventive Care and Screening: Breast Cancer Screening.
Colorectal Cancer Screening.
Adult Weight Screening and Follow-Up.
Coronary Artery Disease (CAD): Lipid Control.
Ischemic Vascular Disease (IVD): Use of Aspirin or Another
Antithrombotic.
Preventive Care and Screening: Tobacco Use: Screening and
Cessation Intervention.
Hypertension (HTN): Controlling High Blood Pressure.
Ischemic Vascular Disease (IVD): Complete Lipid Panel and
LDL Control.
Preventive Care and Screening: Screening for High Blood
Pressure and Follow-Up Documented.
Consistent with the requirement under section 10331(a)(2) of the
Affordable Care Act to make comparable information on patient
experience of care measures publicly available, we previously finalized
a plan to post performance on patient experience survey-based measures
from the Clinician and Group Consumer Assessment of Healthcare
Providers and Systems (CG-CAHPS) (77 FR 44804) including the following
patient experience of care measures for group practices participating
in the PQRS GPRO (77 FR 44964):
CAHPS: Getting Timely Care, Appointments, and Information.
CAHPS: How Well Your Doctors Communicate.
CAHPS: Patients' Rating of Doctor.
CAHPS: Access to Specialists.
CAHPS: Health Promotion and Education
These measures capture patients' experiences with clinicians and
their staff, and patients' perception of care. We finalized a decision
to publicly report performance on these measures on Physician Compare
in 2014 for data collected for PY 2013 for group practices with 100 or
more eligible professionals participating in the PQRS GPRO in 2013 and
reporting data through the GPRO Web interface. At least for data
reported for 2013, we noted that we would administer and collect
patient experience survey data on a sample of the group practices'
beneficiaries.
For ACOs participating in the Shared Savings Program, consistent
with the PQRS policy of publicly reporting patient experience measures
on Physician Compare starting with data collected for CY 2013, we will
publicly report patient experience data in addition to the measure data
reported through the GPRO Web interface (76 FR 67948). Specifically,
the patient experience measures that would be reported for ACOs include
the CG-CAHPS measures in the Patient/Caregiver Experience domain
finalized in the Shared Savings Program final rule (76 FR 67889):
CAHPS: Getting Timely Care, Appointments, and Information.
CAHPS: How Well Your Doctors Communicate.
CAHPS: Patients' Rating of Doctor.
CAHPS: Access to Specialists.
CAHPS: Health Promotion and Education.
CAHPS: Shared Decision Making
CAHPS: Health Status/Functional Status
For data reported for 2014, we propose to continue public reporting
of these CG-CAHPS data for PQRS GPRO group practices of 100 or more
eligible professionals participating in the GPRO via the Web interface
and for Shared Savings Program ACOs reporting through the GPRO Web
interface or other CMS-approved tool or interface. Consistent with what
we finalized for CY 2013 under the PQRS GPRO, we will administer and
fund the collection of data for these groups. As we will administer and
collect the data for these surveys, we do not anticipate public
reporting to impose any notable burden on these groups.
We believe these patient surveys are important tools for assessing
beneficiary experience of care and outcomes, and under our authority
under section 1848(m)(3)(C) of the Act to select the measures for which
a group practice must report under the PQRS, we seek to encourage
groups of 25 or more eligible professionals to report CG-CAHPS by
proposing to make these measures available for reporting the PQRS and
for the Value Based Payment Modifier. We propose to publicly report CY
2014 CG-CAHPS data for any group practice (regardless of size) that
voluntarily chooses to report CG-CAHPS; however, CMS will not fund the
surveys for these groups. CMS proposes to publically report comparable
CG-CAHPS data collected by groups of any size collected via a certified
CAHPS vendor.
We are dedicated to publicly reporting accurate, valid, and
reliable data on Physician Compare and are aware that each group
practice is unique in size and scope. We have closely evaluated the
available data collection mechanisms, and are confident that CG-CAHPS
is a well-tested collection mechanism with strong support from the
healthcare community, and that it provides the best opportunity to
collect useful and accurate data for the largest number of group
practices. We propose to use only those survey domains that are
applicable to group practices or ACOs respectively, and believe that
these domains have been well tested, and will therefore provide the
best data for the largest number of groups.
In the CY 2013 PFS final rule with comment period (77 FR 44804), we
indicated our intention to publicly report performance rates on quality
measures included in the 2014 PQRS and for individual eligible
professionals consistent with the requirements under section 10331 of
the Affordable Care Act to provide information about physicians and
other eligible professionals who participate in PQRS. We believe that
individual-level measure data is important in helping consumers make
informed healthcare decisions and that this information should be
posted on the site as soon as technically feasible. Therefore, we
propose to publicly report comparable data, as noted below, collected
for the CY 2014 PQRS via claims, EHR or registry from individual
eligible professionals as early as CY

[[Page 43356]]

2015. Specifically, we propose to post individual measures reported by
individual eligible professionals in line with those measures reported
by groups through the GPRO Web interface. These measures include:
Diabetes: Hemoglobin A1c Poor Control.
Heart Failure (HF): Beta-Blocker Therapy for Left
Ventricular Systolic Dysfunction (LVSD).
Medication Reconciliation.
Preventive Care and Screening: Influenza Immunization.
Pneumococcal Vaccination Status for Older Adults.
Preventive Care and Screening: Breast Cancer Screening.
Colorectal Cancer Screening.
Coronary Artery Disease (CAD): Angiotensin-converting
Enzyme (ACE) Inhibitor or Angiotensin Receptor Blocker (ARB) Therapy--
Diabetes or Left Ventricular Systolic Dysfunction (LVEF < 40%).
Adult Weight Screening and Follow-Up.
Preventive Care and Screening: Screening for Clinical
Depression.
Coronary Artery Disease (CAD): Lipid Control.
Ischemic Vascular Disease (IVD): Use of Aspirin or Another
Antithrombotic.
Preventive Care and Screening: Tobacco Use: Screening and
Cessation Intervention.
Hypertension (HTN): Controlling High Blood Pressure.
Ischemic Vascular Disease (IVD): Complete Lipid Panel and
LDL Control.
Preventive Care and Screening: Screening for High Blood
Pressure and Follow-Up Documented.
Falls: Screening for Fall Risk.
Diabetes Mellitus: Low Density Lipoprotein (LDL-C)
Control.
Diabetes Mellitus: High Blood Pressure Control.
Diabetes Mellitus: Hemoglobin A1c Control (<8%).
Additionally, and in support of the HHS-wide Million Hearts
Initiative, we propose to publicly report, no earlier than 2015,
performance rates on measures in the PQRS Cardiovascular Prevention
measures group (77 FR 44803) at the individual eligible professional
level for data collected in 2014 for the PQRS (Table 50).
We seek comment on posting performance on patient experience
survey-based measures for individual eligible professionals starting
with data collected for CY 2015.
In future years, we will consider expanding public reporting of,
and seek comment on, measures that have been developed and collected by
approved and vetted specialty societies for individual eligible
professionals as well as data collected via the new qualified clinical
data registry option being proposed under the PQRS. Additionally, we
seek comment on publicly reporting participation by individual eligible
healthcare professionals on initiatives such as Choosing Wisely, an
initiative of the American Board of Internal Medicine Foundation.
We are committed to making Physician Compare a constructive tool
for Medicare beneficiaries, successfully meeting the Affordable Care
Act mandate, and providing consumers with information needed to make
informed healthcare decisions. We have developed a plan, and begun
implementing that plan with a phased approach of adding physician
quality data to Physician Compare. We believe this staged approach to
public reporting of physician quality information allows consumers
access to information that is currently available while we continue to
develop the infrastructure necessary to support additional types of
data and information on physicians' quality measure performance. We
intend to implement subsequent phases of the plan in future rulemaking,
as needed.
We invite comments regarding our proposals to: (1) Publicly report
performance rates on all quality measures that group practices submit
through the GPRO web interface in 2014 under the PQRS GPRO and that
ACOs participating in the Medicare Shared Savings Program submit using
the GPRO web interface or another CMS-approved tool or interface; (2)
publicly report performance on certain quality measures collected under
the 2014 PQRS GPRO via registry and EHR reporting mechanisms; (3)
publicly report performance on patient experience measures for 2014
both for group practices and ACOs and for group practices of 25 or more
professionals who choose to voluntarily report CG-CAHPS data as part of
their participation in the PQRS GPRO; (4) publicly report performance
on certain measures that are reported by individual eligible
professionals reporting through an EHR, registry, or claims during 2014
under the PQRS; and (5) in support of the HHS-wide Million Hearts
Initiative, publicly report performance rates for measures included in
the Cardiovascular Prevention measures group reported by individual
eligible professionals participating in the 2014 PQRS.
We seek comment regarding: (1) Publicly report patient experience
survey data under the PQRS for individual eligible professionals,
starting with data reported in 2015; and (2) to publicly report
participation by individual eligible healthcare professionals on
initiatives such as Choosing Wisely, an initiative of the American
Board of Internal Medicine Foundation.
For the above proposals, we note that we would only post data on
Physician Compare as it is technically feasible and as the data are
available.

H. Physician Payment, Efficiency, and Quality Improvements--Physician
Quality Reporting System

There are several healthcare quality improvement programs that
affect physician payments under the Medicare PFS. As we stated
previously, we believe that alignment of these quality improvement
programs--such as the EHR Incentive Program, Value-based Payment
Modifier, and Medicare Shared Savings Program--is critical for programs
involving physicians and other healthcare eligible professionals. The
proposals that follow facilitate the alignment of programs, reporting
systems, and quality measures. We believe that alignment of CMS quality
improvement programs will decrease the burden of participation on
physicians and allow them to spend more time and resources caring for
beneficiaries. Furthermore, as the leaders of care teams and the
healthcare systems, physicians and other clinicians serve beneficiaries
both as frontline and system-wide change agents to improve quality. We
believe that to improve quality, quality measurement and reporting is
an important component. It is our intent that the following
requirements will further improve alignment of physician-focused
quality improvement programs, decrease burden and duplicative reporting
for eligible professionals, increase engagement of physicians and other
eligible professionals in quality improvement, and ultimately, lead to
higher quality care for beneficiaries.
This section contains the requirements for the Physician Quality
Reporting System (PQRS). The PQRS, as set forth in sections 1848(a),
(k), and (m) of the Act, is a quality reporting program that provides
incentive payments and payment adjustments to eligible professionals
based on whether or not they satisfactorily report data on quality
measures for covered professional services furnished during a specified
reporting period. The regulation governing the PQRS is located at Sec.
414.90. The program requirements for the 2007 through 2014 PQRS
incentives and the 2015 PQRS payment adjustment that were

[[Page 43357]]

previously established, as well as information on the PQRS, including
related laws and established requirements, are available at http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/PQRS/index.html. In addition, the 2011 PQRS and eRx
Experience Report, which provides information about eligible
professional participation in PQRS, is available for download at http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/PQRS/index.html.
In the CY 2013 PFS final rule with comment period (77 FR 69170), we
finalized certain requirements for the 2013 and 2014 PQRS incentives,
as well as 2015 and 2016 PQRS payment adjustments. We also finalized
certain requirements for future years, such as the reporting periods
for the PQRS payment adjustment, as well as requirements for the
various PQRS reporting mechanisms. Below, we propose to change some
requirements for the 2014 PQRS incentive and 2016 PQRS payment
adjustment, as well as to make changes to the PQRS measure set.
Furthermore, we introduce our proposals for a new PQRS reporting
option--satisfactory participation in a qualified clinical data
registry. We then seek comment on a general plan for future years for
PQRS, so that we may continue to consider stakeholder feedback as we
develop policies and proposals for the future.
1. Proposed Changes to Sec. 414.90
As noted previously, the regulation governing the PQRS is located
at Sec. 414.90. We are proposing the following changes and technical
corrections to Sec. 414.90:
Under Sec. 414.90(b), we are proposing to modify the
definition of administrative claims to eliminate the words ``the
proposed'' in the phrase ``on the proposed PQRS quality measures.'' We
are proposing to make this technical change because this language was
inadvertently included in the final regulation despite the fact that
the quality measures that eligible professionals report under the PQRS
were finalized in the CY 2013 PFS final rule with comment period (77 FR
69364).
We propose to modify Sec. 414.90(f) to include the term
``for satisfactory reporting'' after the title ``Use of consensus-based
quality measures for satisfactory reporting.'' We are adding the term
``for satisfactory reporting'' so that it is clear that the paragraph
refers to satisfactory reporting, not the new standard of
satisfactorily participating in a qualified clinical data registry.
We propose to modify the paragraph heading of Sec.
414.90(g) to add the term ``satisfactory reporting'', so that the title
of the paragraph reads ``Satisfactory reporting requirements for the
incentive payments.'' We are proposing to make this change so that it
is clear that the paragraph refers to satisfactory reporting, not the
new standard of satisfactorily participating in a qualified clinical
data registry.
We propose to modify the paragraph heading of Sec.
414.90(h) to add the term ``satisfactory reporting'', so that the title
of the paragraph reads ``Satisfactory reporting requirements for the
incentive payments.'' We are proposing to make this change so that it
is clear that the paragraph refers to satisfactory reporting, not the
new standard of satisfactorily participating in a qualified clinical
data registry.
We propose to delete paragraph Sec. 414.90(i)(4), because
Sec. 414.90(i)(4) list requirements that are identical to Sec.
414.90(i)(3). Therefore, Sec. 414.90(i)(4) is redundant.
In addition, we are considering further revising the regulation at
Sec. 414.90 to list all the specific satisfactory reporting
requirements for the 2014 PQRS incentive and 2016 PQRS payment
adjustment, so that the different reporting requirements are specified
in the regulation. We seek public comment on these proposals.
2. Participation as a Group Practice in the Group Practice Reporting
Option (GPRO)
a. Proposed Changes to the Self-nomination, or Registration,
Requirement for Group Practices To Be Selected to Participate in the
GPRO
In the CY 2013 PFS final rule with comment period (77 FR 69172), we
finalized requirements for the self-nomination process group practices
must follow to participate in the PQRS GPRO. We propose to make two
changes to the previously established self-nomination process for group
practices. First, we propose to change the deadline for group practices
to submit a self-nomination statement, or register, to participate in
the PQRS GPRO. We previously established, that in order for a group
practice to participate in PQRS under the GPRO, the group practice must
submit a self-nomination statement, or register, via the web by October
15 of the year in which the reporting period occurs. Starting with
reporting periods occurring in 2014, we propose to change this deadline
to September 30 of the year in which the reporting period occurs (that
is September 30, 2014 for reporting periods occurring in 2014). We
believe that the proposed deadline still gives group practices a
reasonable amount of time to make a decision on whether to participate
in the PQRS GPRO while allowing CMS more time to pull samples to
populate the GPRO web-interface for those group practices that select
that particular reporting mechanism. Second, we propose that group
practices comprised of 25 or more individual eligible professionals
that wish to report the CG CAHPS survey measures (which are discussed
later in this section) would be required to elect to report the CG
CAHPS survey measures via the web as well. The Web site that a group
practice would use to elect to report the CG CAHPS survey measures
would be the same Web site used by group practices to register to
participate in the PQRS GPRO and used by group practices comprised of
10-99 eligible professionals to elect quality tiering for the Value-
based Payment Modifier set forth in section III.M of this proposed
rule. We believe that providing a single Web site whereby group
practices may make multiple elections (such as submitting the self-
nomination statement to register to participate in the PQRS GPRO, be
evaluated for the PQRS GPRO using CG CAHPS measures, and also elect
quality tiering for the Value-based Payment Modifier) would be
desirable for group practices. We seek public comment on the proposed
changes to the PQRS GPRO self-nomination process.
3. Proposed Requirements for the PQRS Reporting Mechanisms
The PQRS includes the following reporting mechanisms: Claims,
registry, EHR (including direct EHR products and EHR data submission
vendor products), administrative claims, and the GPRO web-interface.
Section 414.90(g) and (h) govern which reporting mechanisms are
available for use by individuals and group practices for the PQRS
incentive and payment adjustment. This section contains our proposed
changes to these PQRS reporting mechanisms. In addition, this section
contains our proposals for two new PQRS reporting mechanisms. We
propose a new certified survey vendor reporting mechanism for purposes
of reporting CG CAHPS measures described below and a qualified clinical
data registry reporting mechanism under the new PQRS ``satisfactory
participation'' option.

[[Page 43358]]

a. Registry-Based Reporting Mechanism
In the CY 2013 PFS final rule with comment period, we finalized the
following requirement for registries to become qualified to participate
in PQRS for 2013 and beyond: Be able to collect all needed data
elements and transmit to CMS the data at the TIN/NPI level for at least
3 measures (77 FR 69180). Since, as we describe in more detail below,
we are proposing to increase the number of measures eligible
professionals would be required to report for the 2014 PQRS incentive
from 3 to 9 measures covering at least 3 of the National Quality
Strategy domains, we are proposing to change this registry requirement
as follows: A qualified registry must be able to collect all needed
data elements and transmit to CMS the data at the TIN/NPI level for at
least 9 measures covering at least 3 of the National Quality Strategy
domains. We seek public comment on this proposal.
b. Certified Survey Vendors
As discussed later in this section, we are proposing to allow group
practices comprised of 25 or more eligible professionals to report CG
CAHPS survey measures. The data collected on these CAHPS survey
measures would not be transmitted to CMS via the previously established
PQRS group practice reporting mechanisms (registry, EHR, or GPRO web
interface). Rather, the data must be transmitted through a survey
vendor. Therefore, to allow for the survey vendor to transmit survey
measures data to CMS, we are proposing to modify Sec. 414.90(b), Sec.
414.90(g)(3), and Sec. 414.90(h)(3) to propose a new reporting
mechanism--the certified survey vendor.
In addition, Sec. 414.90(g)(3), and Sec. 414.90(h)(3) currently
requires group practices to use only one mechanism to meet the
requirements for satisfactory reporting (that is, CMS will not combine
data submitted under multiple reporting mechanism to determine if the
requirements for satisfactory reporting are met). As discussed further
below, we propose that a group practice choosing to report CG CAHPS
survey measures would be required to select an additional reporting
mechanism to meet the requirements for satisfactory reporting for both
the 2014 PQRS incentive and the 2016 PQRS payment adjustment.
Therefore, we propose to modify Sec. 414.90(g)(3), and Sec.
414.90(h)(3) to indicate that groups selecting to use the certified
survey vendor would be the exception to this requirement.
Specifically, for purposes of PQRS, we are proposing to modify
Sec. 414.90(b) to define a certified survey vendor as a vendor that is
certified by CMS for a particular program year to transmit survey
measures data to CMS.
To obtain CMS certification, we propose that vendors would be
required to undergo training, meet CMS standards on how to administer
the survey, and submit a quality assurance plan. CMS would provide the
identified vendor with an appropriate sample frame of beneficiaries
from the group. The vendor would also be required to administer the
survey according to established protocols to ensure valid and reliable
results. Survey vendors would be supplied with mail and telephone
versions of the survey in electronic form, and text for beneficiary
pre-notification and cover letters. Surveys can be administered in
English, Spanish, Cantonese, Mandarin, Korean, Russian and/or
Vietnamese. Vendors would be required to use appropriate quality
control, encryption, security and backup procedures to maintain survey
response data. The data would then be securely sent back to CMS for
scoring and/or validation. To ensure that a vendor possesses the
ability to transmit survey measures data for a particular program year,
we propose to require survey vendors to undergo this certification
process for each year in which the vendor seeks to transmit survey
measures data to CMS. We seek public comment on these proposals.
4. Proposed Changes to the Criteria for the Satisfactory Reporting for
Individual Eligible Professionals for the 2014 PQRS Incentive--
Individual Quality Measures Submitted via Claims and Registries and
Measures Groups Submitted via Claims
Individual eligible professionals may currently report PQRS quality
measures data to meet the criteria for satisfactory reporting for the
2014 PQRS incentive via the claims, registry, and EHR-based reporting
mechanisms. This section contains our proposed changes to the criteria
for satisfactory reporting of individual quality measures via claims
and registries by individual eligible professionals for the 2014 PQRS
incentive. Please note that we are not proposing to modify the criteria
for satisfactory reporting of individual quality measures via EHR that
were established in the CY 2013 PFS final rule with comment period (see
Table 91, 77 FR 69194).
a. Proposed Changes to the Criterion for Satisfactory Reporting of
Individual Quality Measures via Claims for Individual Eligible
Professionals for the 2014 PQRS Incentive
For 2014, in accordance with Sec. 414.90(c)(3), eligible
professionals that satisfactorily report data on PQRS quality measures
are eligible to receive an incentive equal to 0.5 percent of the total
estimated Medicare Part B allowed charges for all covered professional
services furnished by the eligible professional or group practice
during the applicable reporting period. In the CY 2013 PFS final rule
with comment period (see Table 91, 77 FR 69194), to maintain the
reporting criterion with which individual eligible professionals are
familiar, we finalized the same satisfactory reporting criterion for
the submission of individual quality measures via claims that we
finalized in previous years: For the 12-month reporting period for the
2014 PQRS incentive, report at least 3 measures, OR, if less than 3
measures apply to the eligible professional, report 1-2 measures, and
report each measure for at least 50 percent of the eligible
professional's Medicare Part B FFS patients seen during the reporting
period to which the measure applies. Measures with a 0 percent
performance rate would not be counted. For an eligible professional who
reports fewer than 3 measures via the claims-based reporting mechanism,
the eligible professional would be subject to the Measures
Applicability Validation (MAV) process, which would allow us to
determine whether an eligible professional should have reported quality
data codes for additional measures (77 FR 69188).
For the reasons described below and based on our authority to
revise the criteria for satisfactory reporting for the 2014 PQRS
incentive under section 1848(m)(3)(d) of the Act, we propose to change
the criterion for the satisfactory reporting of individual, claims-
based measures by individual eligible professionals for the 2014 PQRS
incentive as follows: For the 12-month reporting period for the 2014
PQRS incentive, report at least 9 measures, covering at least 3 of the
National Quality Strategy domains, OR, if less than 9 measures apply to
the eligible professional, report 1-8 measures, and report each measure
for at least 50 percent of the Medicare Part B FFS patients seen during
the reporting period to which the measure applies. Measures with a 0
percent performance rate would not be counted. For an eligible
professional who reports fewer than 9 measures via the claims-based
reporting mechanism, the eligible professional would be subject to the
MAV process, which would allow us to determine whether an eligible
professional should have reported

[[Page 43359]]

quality data codes for additional measures.
We note that this proposal would increase the number of measures an
eligible professional is required to report via the claims-based
reporting mechanism from 3 measures to 9. We understand that this is a
significant increase in the number of measures an eligible
professionals is required to report. However, we believe that the need
to collect enough quality measures data to better capture the picture
of the care being furnished to a beneficiary, especially when this data
may be used to evaluate an eligible professional's quality performance
under the Value-based Payment Modifier, justifies the increase in
measures.
We seek public comment on the proposed change to the criterion for
the satisfactory reporting of individual quality measures via claims
for individual eligible professionals for the 2014 PQRS incentive.
b. Proposed Changes to the Criterion for Satisfactory Reporting of
Individual Quality Measures via Registry for Individual Eligible
Professionals for the 2014 PQRS Incentive
In the CY 2013 PFS final rule with comment period, to maintain
reporting criterion with which individual eligible professionals are
familiar, we finalized the same satisfactory reporting criterion for
individual eligible professionals to report individual quality measures
via registry that we finalized in previous years: For the 12-month
reporting period for the 2014 PQRS incentive, report at least 3
measures and report each measure for at least 80 percent of the
eligible professional's Medicare Part B FFS patients seen during the
reporting period to which the measure applies. Measures with a 0
percent performance rate would not be counted (77 FR 69189). We propose
to change this reporting criterion for individual eligible
professionals reporting via registry for the 2014 PQRS incentive to the
following: For the 12-month reporting period for the 2014 PQRS
incentive, report at least 9 measures, covering at least 3 of the
National Quality Strategy domains and report each measure for at least
50 percent of the eligible professional's Medicare Part B FFS patients
seen during the reporting period to which the measure applies. Measures
with a 0 percent performance rate would not be counted.
We note that this proposal would increase the number of measures an
eligible professional is required to report via the registry-based
reporting mechanism from 3 measures to 9 covering at least 3 of the
National Quality Strategy domains. We understand that this is a
significant increase in the number of measures an eligible professional
is required to report. However, similar to the reasons we provided for
proposing to increase the measure threshold from 3 measures to 9 for
the claims-based reporting mechanism, we believe that the need to
collect enough quality measures data to better capture the picture of
the care being furnished to a beneficiary, especially when this data
may be used to evaluate an eligible professional's quality performance
under the Value-based Payment Modifier, justifies the change. We
believe that collecting data on 9 measures applicable to an eligible
professional's practice as opposed to 3 measures would provide us with
a better picture of the overall quality of care furnished by that
eligible professional for purposes of having PQRS reporting being used
to assess quality performance under the Value-based Payment Modifier.
We also note that, as PQRS has used this same 3-measure criterion since
the registry-based reporting mechanism was introduced in 2010, it would
be conceivable that we would eventually propose to increase the number
of measures an eligible professional is required to report. Our
proposal to increase the number of measures reported via claims and
registry would align with our established reporting option for the EHR-
based reporting mechanism or the 2014 PQRS incentive, which requires
the reporting of 9 measures covering 3 of the National Quality Strategy
domains (77 FR 69189).
In addition, we note that this proposal would also decrease the
number of patients for which an eligible professional must report for
each measure from 80 percent to 50 percent of an eligible
professional's applicable patients. We are proposing to drop the
percentage threshold from 80 to 50 percent primarily to align our
percentage thresholds for registry reporting with the percentage
threshold established for reporting via the claims-based reporting
mechanism. We believe it is appropriate to drop the percentage
threshold to 50, particularly since we are proposing to also increase
the number of measures an eligible professional is required to report
via the registry-based reporting mechanism from 3 to 9 measures
covering at least 3 of the National Quality Strategy domains. The
criteria for satisfactory reporting that we are proposing for the 2014
PQRS incentive payment are described in Table 24.
We seek public comment on the proposed changes to the criterion for
the satisfactory reporting of individual quality measures via registry
for individual eligible professionals for the 2014 PQRS incentive.
c. Proposed Changes to the Criterion for Satisfactory Reporting of
Measures Groups via Claims for Individual Eligible Professionals for
the 2014 PQRS Incentive
In the CY 2013 PFS final rule with comment period, we finalized the
following criteria for satisfactory reporting for individual eligible
professionals to report measures groups via claims: Report at least 1
measures group and report each measures group for at least 20 Medicare
Part B FFS patients. Measures groups containing a measure with a zero
percent performance rate will not be counted (77 FR 69192). Since
finalizing this criterion, we have recently published and analyzed the
2011 PQRS and eRx Experience Report, which provides a summary of PQRS
reporting trends from 2007 through 2011, to determine where we may work
to further streamline the reporting options available under the PQRS.
The PQRS and eRx Experience Report stated that the number of eligible
professionals who participated via claims-based measures groups
reporting mechanism grew more than three-fold between 2008 and 2011.
However, according to Appendix 8 of the PQRS and eRx Experience Report
titled ``Eligible Professionals who Participated by Reporting Measures
Groups through the Claims Reporting Mechanism for the Physician Quality
Reporting System, by Specialty (2008 to 2011),'' only 4,472 eligible
professionals used this reporting option. Meanwhile, the Experience
Report further shows that the option to report measures groups via
registry has grown at an even faster rate with 12,894 participants in
2011. Therefore, in an effort to streamline the reporting options
available under the PQRS and to eliminate reporting options that are
not widely used, we are proposing to remove this satisfactory reporting
criterion for the 2014 PQRS incentive. Please note that, since we are
proposing to remove this reporting criterion, the only manner in which
an eligible professional would be able to report a PQRS measures group
would be via registry. We seek public comment on this proposal.
5. Proposed Criteria for Satisfactory Reporting for the 2016 PQRS
Payment Adjustment for Individual Eligible Professionals Using the
Claims and Registry Reporting Mechanisms
Section 1848(a)(8) of the Act, as added by section 3002(b) of the

[[Page 43360]]

Affordable Care Act, provides that for covered professional services
furnished by an eligible professional during 2015 or any subsequent
year, if the eligible professional does not satisfactorily report data
on quality measures for covered professional services for the quality
reporting period for the year, the fee schedule amount for services
furnished by such professional during the year shall be equal to the
applicable percent of the fee schedule amount that would otherwise
apply to such services. For 2016 and subsequent years, the applicable
percent is 98.0 percent.
In the CY 2013 PFS final rule, we finalized seven different
criteria for the satisfactory reporting by individual eligible
professionals of data in PQRS quality measures for the 2016 PQRS
payment adjustment (see 77 FR 69200-69204 and Table 91 at 77 FR 69194).
Although we are retaining five of the final criteria for satisfactory
reporting by individual eligible professionals of data on PQRS quality
measures for the 2016 PQRS payment adjustment, we propose to eliminate
two criteria, revise another, and include two additional criteria
(based on two of the existing criteria). Specifically, we propose to
remove the following criterion we previously finalized for the CY 2016
payment adjustment for individual eligible professionals reporting
measures groups through claims (77 FR 69200 and Table 91, 77 FR 69164):
Report at least 1 measures group and report each measures group for at
least 20 Medicare Part B FFS patients (Measures groups containing a
measure with a zero percent performance rate will not be counted). Our
proposal to remove this criterion would correspond to the same proposal
we are making, as discussed above, for the 2014 PQRS incentive for
individual eligible professionals. As we indicated, we believe it is
important to streamline the program and eliminate criteria for
reporting options that are not widely used.
We also propose to remove the following criterion we previously
finalized for the 2016 payment adjustment for individual eligible
professionals reporting individual measures through a qualified
registry (77 FR 69200 and Table 91, 77 FR 69164): Report at least 3
measures, and report each measure for at least 80 percent of the
eligible professional's Medicare Part B FFS patients seen during the
reporting period to which the measures applies (Measures with a zero
percent performance rate will not be counted). Finally, to maintain
some consistency and to otherwise align with the criteria we are
proposing for the 2014 PQRS incentive for individual eligible
professionals, we are proposing two other criteria for satisfactory
reporting by individual eligible professionals for the 2016 PQRS
payment adjustment using the claims and registry reporting mechanisms.
Specifically, we propose the following criterion for reporting
individual measures via claims by individual eligible professionals for
the 2016 PQRS payment adjustment: For the 12-month reporting period for
the 2014 PQRS incentive, report at least 9 measures, covering at least
3 of the National Quality Strategy domains, OR, if less than 9 measures
apply to the eligible professional, report 1-8 measures, and report
each measure for at least 50 percent of the Medicare Part B FFS
patients seen during the reporting period to which the measure applies.
Measures with a 0 percent performance rate would not be counted.
Similarly, for the same reasons we discussed previously, we propose the
following criterion for reporting individual measures via qualified
registry by individual eligible professionals for the 2016 PQRS payment
adjustment: For the 12-month reporting period for the 2014 PQRS
incentive, report at least 9 measures, covering at least 3 of the
National Quality Strategy domains and report each measure for at least
50% of the eligible professional's Medicare Part B FFS patients seen
during the reporting period to which the measure applies. Measures with
a 0 percent performance rate would not be counted.
Please note that in the CY 2013 PFS final rule, we finalized the
same criteria for satisfactorily reporting data on quality measures for
covered professional services for the 2016 PQRS payment adjustment as
those for the 2014 PQRS incentive for individual eligible professionals
(77 FR 69200). However, if the proposals we are making in this proposed
rule were finalized, there would be some differences between the
criteria for satisfactory reporting for the 2016 PQRS payment
adjustment and the 2014 PQRS incentive. In particular, there would be
one more criterion for satisfactory reporting for the 2016 payment
adjustment than for the 2014 PQRS incentive with respect to claims-
based reporting, but the other criteria would otherwise align. Although
we considered, as an alternative, to propose to remove the criterion we
previously finalized for the 2016 payment adjustment for individual
eligible professionals reporting individual measures through claims, we
believe it is still important to offer as many options as possible for
the 2016 PQRS payment adjustment, particularly since the penalty phase
is relatively new under the PQRS. We also note that it would remain
true that if an individual eligible professional were to meet any of
the criteria for satisfactory reporting for the 2014 PQRS incentive,
the individual eligible professional would meet the requirements for
satisfactory reporting for the 2016 PQRS payment adjustment (note,
however, that the reverse would not necessarily be true since there
would be one additional criterion for satisfactory reporting for the
2016 PQRS payment adjustment that would not apply to the 2014 PQRS
incentive).
The criteria for satisfactory reporting that we are proposing for
the 2016 PQRS payment adjustment are described in Table 25. We believe
such alignment still serves to reduce reporting burden, and as we have
noted previously, we believe that proposing similar criteria for
satisfactory reporting by individual eligible professionals for the
2014 PQRS incentive and 2016 PQRS payment adjustment is appropriate
because the reporting period for the 2014 PQRS incentive and 2016 PQRS
payment adjustment coincide. As we continue to implement the PQRS
payment adjustment and fully implement the value-based payment modifier
in 2017, it is our intent to ramp up the criteria for satisfactory
reporting for the 2017 PQRS payment adjustment to be on par or more
stringent than the criteria for satisfactory reporting for the 2014
PQRS incentive.
We seek public comment on our proposed satisfactory reporting
criteria for individual eligible professionals for the 2016 PQRS
payment adjustment, including the alternative proposal considered for
individual eligible professionals reporting individual measures through
the claims-based reporting mechanism.
6. Proposals Related to Satisfactory Participation in a Qualified
Clinical Data Registry by Individual Eligible Professionals
Section 601(b) of the American Taxpayer Relief Act of 2012 amends
section 1848(m)(3) of the Act, by redesignating subparagraph (D) as
subparagraph (F) and adding new subparagraph (D), to provide for a new
standard for individual eligible professionals to satisfy the PQRS
beginning in 2014, based on satisfactory participation in a qualified
clinical data registry. Below, we set forth our proposals for
implementing this provision, including the proposed requirements for
qualified clinical data registries and our proposals for individual
eligible professionals to

[[Page 43361]]

satisfactorily participate in a qualified clinical data registry with
respect to the 2014 PQRS incentive and 2016 PQRS payment adjustment.
On February 7, 2013, CMS published a Request for Information titled
``Medicare Program; Request for Information on the Use of Clinical
Quality Measures (CQMs) Reported Under the Physician Quality Reporting
System (PQRS), the Electronic Health Record (EHR) Incentive Program,
and Other Reporting Programs'' (78 FR 9057). The Request for
Information included a solicitation for comments about section 601(b)
of the American Taxpayer Relief Act of 2012. CMS received over 100
comments on this Request for Information, and much of the information
provided in these comments were used to shape the proposals set forth
in this section.
a. Proposed Definition of a Qualified Clinical Data Registry
Under section 1848(m)(3)(D) of the Act, as amended and added by
section 601(b)(1) of the American Taxpayer Relief Act of 2012 (Pub. L.
112-240, enacted January 2, 2013), for 2014 and subsequent years, the
Secretary shall treat an eligible professional as satisfactorily
submitting data on quality measures if, in lieu of reporting measures
under subsection (k)(2)(C), the eligible professional is satisfactorily
participating, as determined by the Secretary, in a qualified clinical
data registry for the year. Section 1848(m)(3)(E) of the Act, as added
by section 601(b)(1) of the American Taxpayer Relief Act of 2012,
authorizes the Secretary to define a qualified clinical data registry
under the PQRS. Specifically, the Secretary is required to establish
requirements for an entity to be considered a qualified clinical data
registry (including that the entity provide the Secretary with such
information, at such times, and in such manner, as the Secretary
determines necessary to carry out the provision). And in establishing
such requirements, the Secretary must take certain factors into
consideration.
Generally, registries are entities that collect data related to
patients with a specific diagnosis, condition, or procedure. In fact,
the collection and submission of PQRS quality measures data on behalf
of eligible professionals are the functions a traditional ``qualified
registry'' currently performs under the PQRS for purposes of eligible
professionals satisfactorily reporting. The majority of commenters in
response to the February 7, 2013 Request for Information stated that
these qualified clinical data registries should serve additional roles
aimed at quality improvement other than collecting and transmitting
quality data to CMS. The commenters saw qualified clinical data
registries as entities that should be at the forefront of quality
improvement. We agree with the commenters. Therefore, we believe that a
``qualified clinical data registry'' specified under section
1848(m)(3)(E) of the Act, as added by section 601(b) of the American
Taxpayer Relief Act of 2012, should serve additional roles that foster
quality improvement in addition to the collection and submission of
quality measures data.
Section 1848(m)(3)(E)(ii) of the Act, as added by section 601(b)(1)
of the American Taxpayer Relief Act of 2012, provides that, when
determining whether an entity should be considered a qualified clinical
data registry, the Secretary shall take into consideration whether the
entity:
Has in place mechanisms for the transparency of data
elements and specifications, risk models, and measures;
Requires the submission of data from participants with
respect to multiple payers;
Provides timely performance reports to participants at the
individual participant level; and
Supports quality improvement initiatives for participants.
As an example of quality improvement initiatives by a clinical data
registry, we note that the Society of Thoracic Surgeons established the
STS National Database in 1989 for the purpose of quality assessment,
improvement, and patient safety among cardiothoracic surgeons. The STS
National Database, which serves a traditional qualified registry under
the PQRS, provides:
A standardized, nationally benchmarked tool for assessing
the care of patients undergoing cardiothoracic operations;
The opportunity to participate in national quality
improvement efforts for cardiothoracic surgery that have an impact at
the local, regional, and national levels;
A mechanism to target specific areas for clinical practice
improvement;
The ability to investigate regional and national practice
patterns in cardiothoracic surgery; and
The ability to conduct clinical and comparative
effectiveness research using national aggregate data set.
While we do not believe that it is necessary for a qualified
clinical data registry to possess all of these characteristics for
purposes of the PQRS, we do believe that it is important for a
qualified clinical data registry to possess the following
characteristics:
Benchmarking capacity for assessing the care furnished to
patients by the eligible professionals participating in the qualified
clinical data registry. We believe it is important that a qualified
clinical data registry possess benchmarking capacity in order to be
able to compare the quality of care furnished by eligible professionals
so that eligible professionals using the qualified clinical data
registry are aware of how the care they furnished is rated as compared
to other professionals. Eligible professionals would be able to use
this information to adjust the care they provide, if appropriate. While
having the capacity to benchmark performance nationally is preferable,
we believe that a qualified clinical data registry should, at a
minimum, possess the capacity to benchmark performance across the
eligible professionals using the qualified clinical data registry.
The ability to provide timely and frequent feedback to its
eligible professionals. We believe it is important for eligible
professionals using a clinical data registry to receive frequent and
timely feedback on the quality measures data they report through the
qualified clinical data registry. A traditional PQRS registry is
required to provide at least 2 feedback reports to eligible
professionals using the registry. Since we believe that qualified
clinical data registries should possess a more robust system, we
believe that qualified clinical data registries should provide timely
feedback at least quarterly so eligible professionals could view their
reporting at least 4 times during the yearly reporting period.
Therefore, based on CMS' authority to define a qualified clinical
data registry under section 1848(m)(3)(E) of the Act, as added by
section 601(b) of the American Taxpayer Relief Act of 2012, and
accounting for the considerations addressed in section
1848(m)(3)(E)(ii) of the Act and for the reasons stated above, we
propose to modify Sec. 414.90(b) to add a proposed definition for a
qualified clinical data registry. Specifically, we propose to define a
``qualified clinical data registry'' for purposes of the PQRS as a CMS-
approved entity (such as a registry, certification board,
collaborative, etc.) that collects medical and/or clinical data for the
purpose of patient and disease tracking to foster improvement in the
quality of care furnished to patients.
First, we propose that a qualified clinical data registry must be
able to submit quality measures data or results to CMS for purposes of
demonstrating that, for a reporting period, its eligible

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professionals have satisfactorily participated in PQRS. We propose that
a qualified clinical data registry must have in place mechanisms for
the transparency of data elements and specifications, risk models, and
measures. Second, with regard to the consideration under section
1848(m)(3)(E)(ii)(II) of the Act, as added by section 601(b) of the
American Taxpayer Relief Act of 2012 that requires the submission of
data from participants with respect to multiple payers, we propose that
the data a qualified clinical data registry submitted to CMS for
purposes of demonstrating satisfactory participation be quality
measures data on multiple payers, not just Medicare patients.
Third, with regard to the consideration under section
1848(m)(3)(E)(ii)(III) of the Act, as added by section 601(b) of the
American Taxpayer Relief Act of 2012, that a qualified clinical data
registry provide timely performance reports to participants at the
individual participant level, we propose that a qualified clinical data
registry must provide timely feedback at least quarterly on the
measures for which the qualified clinical data registry would report on
the individual eligible professional's behalf for purposes of the
eligible professional meeting the criteria for satisfactory
participation under PQRS.
Fourth, to address section 1848(m)(3)(E)(ii)(IV) of the Act, as
added by section 601(b) of the American Taxpayer Relief Act of 2012,
regarding whether a qualified clinical data registry supports quality
improvement initiatives for its participants, we propose to require
that a qualified clinical data registry possess a method to benchmark
the quality of care measures an eligible professional provides with
that of other eligible professionals performing the same or similar
functions. Benchmarking would require that a qualified clinical data
registry provide metrics to compare the quality of care its
participating eligible professional provides. For example, the National
Committee for Quality Assurance (NCQA) provides national and regional
benchmarks for certain measures. Adopting benchmarks such as those
provided by NCQA could serve to satisfy this requirement.
Please note that it is possible for an entity to serve as a
traditional, qualified registry and/or a qualified clinical data
registry under the PQRS.
b. Proposed Requirements for a Qualified Clinical Data Registry
As we noted above, we are required, under section 1848(m)(3)(E)(i)
of the Act, to establish requirements for an entity to be considered a
qualified clinical data registry. Such requirements shall include a
requirement that the entity provide the Secretary with such
information, at such times, and in such manner, as the Secretary
determines necessary to carry out this subsection. Section
1848(m)(3)(E)(iv) of the Act, as added by section 601(b) of the
American Taxpayer Relief Act of 2012, requires CMS to consult with
interested parties in carrying out this provision.
Pursuant to this authority to establish the requirements for an
entity to be considered a qualified clinical data registry, we are
proposing the following requirements that an entity must meet to serve
as a qualified clinical data registry under the PQRS:
First, we are proposing the following requirements to ensure that
the entity seeking to become a qualified clinical data registry is
well-established:
Be in existence as of January 1 the year prior to the year
for which the entity seeks to become a qualified clinical data registry
(for example, January 1, 2013, to be eligible to participate for
purposes of data collected in 2014). This proposed requirement is also
required of a traditional qualified registry. We believe it is
important for an entity to test out its business practices to ensure
that the practices it adopts truly foster the improvement of quality
care prior to seeking to become a qualified clinical data registry. We
believe that entities that have been in existence for less than one
year prior to the year for which the entity seeks to become a qualified
clinical data registry have not had an adequate opportunity to do so.
Have at least 100 clinical data registry participants by
January 1 the year prior to the year for which the entity seeks to
submit clinical quality measures data (for example, January 1, 2013, to
be eligible to participate under the program with regard to data
collected in 2014). Please note that not all participants would be
required to participate in PQRS. We are proposing this requirement to
ensure that the entity seeking to become a qualified clinical data
registry is sufficient in size and technical capability. As we believe
that a qualified clinical data registry should be more robust in
technical capabilities than a traditional PQRS-qualified registry, we
believe that a qualified clinical data registry should be sufficiently
larger in size than a traditional PQRS-qualified registry. Therefore,
whereas we only required a traditional PQRS-qualified registry to have
at least 25 registry participants, we believe it is appropriate that we
require that a qualified clinical data registry have at least 100
participants.
Not be owned or managed by an individual, locally-owned,
single-specialty group (for example, single-specialty practices with
only 1 practice location or solo practitioner practices would be
precluded from becoming a qualified clinical data registry).
In addition, for transparency purposes, we propose that a qualified
clinical data registry must:
Enter into and maintain with its participating
professionals an appropriate Business Associate agreement that provides
for the qualified clinical data registry's receipt of patient-specific
data from the eligible professionals as well as the qualified clinical
data registry's public disclosure of quality measure results.
Describe to CMS the cost for eligible professionals that
the qualified clinical data registry charges to submit data to CMS.
We are also proposing to require qualified clinical data registries
to meet the following requirements pertaining to the transmission of
quality measures data to CMS:
To ensure that the qualified clinical data registry is
compliant with applicable privacy and security laws and regulations,
the entity must describe its plan to maintain Data Privacy and Security
for data transmission, storage and reporting.
Comply with a CMS-specified secure method for quality data
submission.
Provide information on each measure to be reported by an
eligible professional, including a summary of supporting evidence/
rationale, title, numerator, denominator, exclusions/exceptions, data
elements and value sets in addition to measure level reporting rates,
patient-level demographic data and/or the data elements needed to
calculate the reporting rates by TIN/NPI.
Submit an acceptable ``validation strategy'' to CMS by
March 31 of the reporting year the entity seeks qualification (for
example, if an entity wishes to become qualified for participation with
regard to data collected in 2014, this validation strategy would be
required to be submitted to CMS by March 31, 2014). A validation
strategy would detail how the qualified clinical data registry will
determine whether eligible professionals succeed in reporting clinical
quality measures. Acceptable

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validation strategies often include such provisions as the entity being
able to conduct random sampling of their participant's data, but may
also be based on other credible means of verifying the accuracy of data
content and completeness of reporting or adherence to a required
sampling method. For a template for data validation and integrity,
please also see the requirements for certification of an EHR product by
the Office of the National Coordinator for Health Information
Technology (ONC) that are explained at http://www.healthit.gov/policy-researchers-implementers/2014-edition-final-test-method.
Perform the validation outlined in the strategy and send
evidence of successful results to CMS by June 30 of the year following
the reporting period (for example, June 30, 2015, for data collected in
the reporting periods occurring in 2014).
Obtain and keep on file for at least 7 years signed
documentation that each holder of an NPI whose data are submitted to
the qualified clinical data registry has authorized the registry to
submit quality measure results and numerator and denominator data and/
or patient-specific data on beneficiaries to CMS for the purpose of
PQRS participation. This documentation would be required to be obtained
at the time the eligible professional signs up with the qualified
clinical data registry to submit quality measures data to the qualified
clinical data registry and would be required to meet any applicable
laws, regulations, and contractual business associate agreements.
Upon request and for oversight purposes, provide CMS
access to the qualified clinical data registry's database to review the
beneficiary data on which the qualified clinical data registry-based
submissions are based or provide to CMS a copy of the actual data.
Prior to CMS posting the list of qualified clinical data
registries for a particular year, verify the information contained on
the list (includes names, contact information, measures, cost, etc.)
and agree to furnish/support all of the services listed on the list.
Make available to CMS samples of patient level data to
audit the entity for purposes of validating the data submitted to CMS
by the qualified clinical data registry, if determined to be necessary.
The entity must provide information on how the entity
collects quality measurement data, if requested.
By March 31 of the year in which the entity seeks to
participate in PQRS as a qualified clinical data registry, the entity
must publically post (on the entity's Web site or other publication
available to the public) a detailed description (rationale, numerator,
denominator, exclusions/exceptions, data elements) of the quality
measures it collects to ensure transparency of information to the
public.
The entity must report, on behalf of its individual
eligible professional participants, a minimum of 9 measures that cross
3 National Quality Strategy domains.
The entity, on behalf of its individual eligible
professional participants, must report on at least one outcomes-based
measure (defined in this section below).
The entity, on behalf of its individual eligible
professional participants, must report on a set of measures from one or
more of the following categories: CG-CAHPS; NQF endorsed measures
(information of which is available at http://www.qualityforum.org/Home.aspx); current PQRS measures; measures used by boards or specialty
societies; and measures used in regional quality collaboratives.
The entity must demonstrate that it has a plan to publicly
report their quality data through a mechanism where the public and
registry participants can view data about individual eligible
professionals, as well as view regional and national benchmarks. As an
alternative, we considered requiring that the entity must benchmark
within its own registry for purposes of determining relative quality
performance where appropriate.
The entity must demonstrate that it has a plan to risk
adjust the quality measures data for which it collects and intends to
transmit to CMS, where appropriate. Risk adjustment has been described
as a corrective tool used to level the playing field regarding the
reporting of patient outcomes, adjusting for the differences in risk
among specific patients (http://www.sts.org/patient-information/what-risk-adjustment). Risk adjustment also makes it possible to compare
performance fairly. For example, if an 86 year old female with diabetes
undergoes bypass surgery, there is less chance for a good outcome when
compared with a healthy 40 year old male undergoing the same procedure.
To take factors into account which influence outcomes, for example,
advanced age, emergency operation, previous heart surgery, a risk
adjusted model is used to report surgery results.
Should CMS find, pursuant to an audit, that a qualified clinical
data registry has submitted inaccurate data, CMS proposes to disqualify
the qualified clinical data registry, meaning the entity will not be
allowed to submit quality measures data on behalf of its eligible
professionals for purposes of meeting the criteria for satisfactory
participation for the following year. Should an entity be disqualified,
the entity must again become a qualified clinical data registry before
it may submit quality measures data on behalf of its eligible
professionals for purposes of the individual eligible professional
participants meeting the criteria for satisfactory participation under
the PQRS. Additionally, we propose that the inaccurate data collected
would be discounted for purposes of an individual eligible professional
meeting the criteria for satisfactory participation in a qualified
clinical data registry. We seek comments on these proposals.
As we noted, section 1848(m)(3)(E)(i) of the Act, as added by
section 601(b) of the American Tax Relief Act of 2012, requires us to
establish requirements for an entity to be considered a qualified
clinical data registry, including that the entity provide us with such
information, at such times, and in such manner, as we determine
necessary to carry out the provision. Given the broad discretion
afforded under the statute, we propose that qualified clinical data
registries provide CMS with the quality measures data it collects from
its eligible professional participants. We believe it is important that
a qualified clinical data registry provide such data for a number of
reasons. As we discuss in greater detail below, we believe such
information is necessary for purposes of determining whether individual
eligible professionals have satisfactorily participated in a clinical
qualified data registry under the PQRS. In addition, as discussed in
section K, we are proposing to use the quality measures data reported
under the PQRS to assess eligible professionals with regard to applying
the Value-based Payment Modifier in an upward, downward, and neutral
adjustment to an eligible professional's Medicare Part B PFS charges.
Therefore, we propose to require that qualified clinical data
registries submit quality measures data to CMS. Specifically, to
further ensure that the quality measures data elements are reported to
CMS in standardized manner, we propose to require that qualified
clinical data registries be able to collect all needed data elements
and transmit the data on quality measures to CMS, upon request, in one
of two formats, either via a CMS-approved XML format or via the Quality
Reporting

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Document Architecture (QRDA) category III format. The CMS-approved XML
format is consistent with how traditional qualified registries under
the PQRS transmit data on quality measures to CMS. While our preference
would be to receive data on quality measures via the QRDA category III
format only since the QRDA category III format is one of the formats we
require for an EP's EHR or an EHR data submission vendor to submit
quality measures data (see 77 FR 69183), we understand that the quality
measures data collected by qualified clinical data registries vary and
that these qualified clinical data registries may not be equipped to
submit quality measures data to CMS using the QRDA category III format.
In future years, it is our intention to require all qualified clinical
data registries to provide quality measures data via the QRDA category
III format.
To ensure that the data provided by the qualified clinical data
registry is correct, we propose to require that qualified clinical data
registries provide CMS a signed, written attestation statement via
email which states that the quality measure results and any and all
data including numerator and denominator data provided to CMS are
accurate and complete.
We propose that, regardless of whether the eligible professional
uses the XML or QRDA III format to report quality measures data to CMS,
the qualified clinical data registry would be required to submit this
data no later than the last Friday occurring 2 months after the end of
the respective reporting period (that is, February 27, 2015 for
reporting periods occurring in 2014). We also propose that, if a
qualified clinical data registry is submitting quality measures data on
behalf of individual eligible professionals that are part of the same
group practice (but not participating in the PQRS GPRO), the qualified
clinical data registry would have the option to report the quality
measures data to CMS in a batch containing data for each of the
individual eligible professionals within the group practice, rather
than submitting individual files for each eligible professional.
In conjunction with our proposal to require that qualified clinical
data registries be able to provide data on quality measures in a CMS-
approved XML format, we propose to require that qualified clinical data
registries report back to participants on the completeness, integrity,
and accuracy of its participants' data. We believe that it would be
beneficial to the participants to receive feedback on the data
transmission process so that the participants are aware of any
inaccuracies transmitted to CMS.
Alternatively, with respect to the information CMS would require a
qualified clinical data registry to furnish to CMS to determine that
the eligible professionals have met the criteria for satisfactory
participation for the 2014 PQRS incentive and 2016 PQRS payment
adjustment, in lieu of accepting quality measures data for reporting
periods occurring in 2014 only, we considered proposing that a
qualified clinical data registry provide CMS with a list of the
eligible professionals (containing the respective eligible
professionals' TIN/NPI information) who participated in and reported
quality data to the qualified clinical data registry in order to
determine which individual eligible professionals met the criteria for
satisfactory participation for the 2014 PQRS incentive and 2016 PQRS
payment adjustment. We considered this alternative because we do not
have experience collecting data from qualified clinical data
registries, we are unfamiliar with the type of quality data qualified
clinical data registries collect, and we are still building out our
data infrastructure.
We seek public comment on these proposals.
c. Proposed Process for Being Designated as a Qualified Clinical Data
Registry
Section 1848(m)(3)(E)(v) of the Act, as added by section 601(b) of
the American Taxpayer Relief Act of 2012, requires the Secretary to
establish a process to determine whether or not an entity meets the
requirements established under section 1848(m)(3)(E)(i) of the Act.
Such process may involve one or both of the following: (I) A
determination by the Secretary; (II) A designation by the Secretary of
one or more independent organizations to make such determination. This
section sets forth our proposals for our process to determine whether
or not an entity should be designated as a qualified clinical data
registry.
Consistent with what we require of traditional qualified registries
under the PQRS, we propose that an entity must submit a self-nomination
statement that indicates its intent to participate in PQRS as a
qualified clinical data registry. We believe this self-nomination
statement is necessary for CMS to anticipate how many clinical data
registries would participate for a certain year as well as provide
information to eligible professionals about potential participating
clinical data registries. We propose that the self-nomination statement
contain the following information:
The name of the entity seeking to become a qualified
clinical data registry.
The entity's contact information, including phone number,
email, and mailing address.
A point of contact, including the contact's email address
and phone number, for which to notify the entity of the status of its
request to be considered a qualified clinical data registry.
The measure title, description, and specifications for
each measure the qualified clinical data registry would require its
eligible professionals to report for purposes of participating in PQRS.
In addition, the qualified clinical data registry must describe the
rationale and evidence basis to support each measure it would require
its eligible professionals to report.
The reporting period start date the entity will cover as a
clinical data registry.
Since we believe that accepting these statements via email would be
the most efficient method for collecting and processing self-nomination
statements, we propose to accept self-nomination statements via email
only. However, in the event that it is not technically feasible to
collect this self-nomination statement via email, we propose that
entities seeking to become qualified clinical data registries submit
its self-nomination statement via a mailed letter to CMS. The self-
nomination statement would be mailed to the following address: Centers
for Medicare & Medicaid Services, Center for Clinical Standards and
Quality, Quality Measurement and Health Assessment Group, 7500 Security
Boulevard, Mail Stop S3-02-01, Baltimore, MD 21244-1850.
To ensure that CMS is able to process these self-nomination
statements as early as possible, we propose that these self-nomination
statements must be received by CMS by 5:00 p.m. Eastern Standard Time
on January 31 of the year in which the clinical data registry seeks to
be qualified (that is, January 31, 2014 for purposes of becoming a
qualified clinical data registry for the reporting periods for the 2014
PQRS incentive and 2016 PQRS payment adjustment). We understand that
this is an early proposed deadline, particularly since this is a new
reporting mechanism. However, it is necessary for us to propose a
deadline of January 31 to ensure that we have sufficient time to
analyze the self-nomination statements we receive, ensure that the
entity meets the basic requirements for being designated as a qualified
clinical data

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registry, including whether or not the quality measures the entity
intends to report on behalf of eligible professionals meet the
requirements set forth in section I.11 of this proposed rule, and allow
for sufficient time for eligible professionals to view a list of
entities that are qualified as clinical data registries for the year
prior to the end of the applicable reporting period for satisfactory
participation in a qualified clinical data registry. We anticipate
posting a list of the entities that are designated by CMS as qualified
clinical data registries in the Fall of the same year.
Since participation in a qualified clinical data registry is a new
option for individual eligible professionals, we anticipate making
changes to the requirements for becoming a qualified clinical data
registry in future rulemaking as we gain more experience with this
option. Since we believe it is important that the entity keep up with
these changes, at this time, we propose that entities seeking to serve
as qualified clinical data registries must self-nominate for each year
that the entity seeks to participate. In the future, we anticipate
moving towards a 2-year self-nomination process as the requirements for
qualified clinical data registries become firmly established; however,
at this time, we are proposing self-nomination for any year in which a
qualified clinical data registry intends to participate under the PQRS.
We seek public comment on these proposals.
d. Proposed Reporting Period for the Satisfactory Participation by
Individual Eligible Professionals in a Qualified Clinical Data Registry
for the 2014 PQRS Incentive
Section 1848(m)(3)(D) of the Act, as redesignated and added by
section 601(b) of the America Taxpayer Relief Act of 2012, authorizes
the Secretary to treat an individual eligible professional as
satisfactorily submitting data on quality measures under section
1848(m)(A) of the Act if the eligible professional is satisfactorily
participating in a qualified clinical data registry for the year. Given
that satisfactory participation is with regard to the year, and to
provide consistency with the reporting period applicable to individual
eligible professionals who report quality measures data under section
1848(m)(3)(A), we propose to modify Sec. 414.90(c)(5) to specify a 12-
month, calendar year (CY) reporting period from January 1, 2014 through
December 31, 2014 for individual eligible professionals to
satisfactorily participate in a qualified clinical data registry for
purposes of the 2014 PQRS incentive. We are proposing a 12-month
reporting period. Based on our experience with the 12 and 6-month
reporting periods for the PQRS incentives, we believe that data on
quality measures collected based on 12-months provides a more accurate
assessment of actions performed in a clinical setting than data
collected based on shorter reporting periods. In addition, we believe a
12-month reporting period is appropriate given that the full calendar
year would be utilized with regard to the participation by the
individual eligible professional in the qualified clinical data
registry. We invite public comment on the proposed 12-month, CY 2014
reporting period for the satisfactory participation of individual
eligible professionals in a qualified clinical data registry for the
2014 PQRS incentive.
e. Proposed Criteria for Satisfactory Participation for Individual
Eligible Professionals in a Qualified Clinical Data Registry for the
2014 PQRS Incentive
For 2014, in accordance with Sec. 414.90(c)(3), eligible
professionals that satisfactorily report data on PQRS quality measures
are eligible to receive an incentive equal to 0.5 percent of the total
estimated Medicare Part B allowed charges for all covered professional
services furnished by the eligible professional or group practice
during the applicable reporting period. Section 1848(m)(3)(D) of the
Act, as redesignated and added by section 601(b) of the America
Taxpayer Relief Act of 2012, authorizes the Secretary to treat an
individual eligible professional as satisfactorily submitting data on
quality measures under section 1848(m)(A) of the Act if, in lieu of
reporting measures under section 1848(k)(2)(C) of the Act, the eligible
professional is satisfactorily participating in a qualified clinical
data registry for the year. ``Satisfactory participation'' is a new
standard under the PQRS and is a substitute for the underlying standard
of ``satisfactory reporting'' data on covered professional services
that eligible professionals must meet to earn a PQRS incentive or avoid
the PQRS payment adjustment. Therefore, we propose to modify Sec.
414.90 to add paragraph (c)(5) to indicate that individual eligible
professionals shall be treated as satisfactorily reporting data on
quality measures if individual eligible professionals satisfactorily
participate in a qualified clinical data registry for purposes of the
PQRS incentive. This section also contains the criterion we are
proposing for individual eligible professionals to meet to
satisfactorily participate in a qualified clinical data registry for
purposes of the 2014 PQRS incentive.
We understand that qualified clinical data registries may have
different ways to measure success in quality reporting among its
registry participants. However, for purposes of the 2014 PQRS
incentive, CMS must establish a standard for satisfactory participation
in a qualified clinical data registry. Therefore, we propose that, to
meet the criteria for satisfactory participation for the 2014 PQRS
incentive, an individual eligible professional would be required to:
For the 12-month 2014 reporting period, report at least 9 measures
available for reporting under the qualified clinical data registry
covering at least 3 of the National Quality Strategy domains, and
report each measure for at least 50 percent of the eligible
professional's applicable patients. Of the measures reported via a
qualified clinical data registry, the eligible professional must report
on at least 1 outcome measure. We further propose that a qualified
clinical data registry may submit data on more than 9 quality measures
on behalf on an eligible professional. However, we propose that a
qualified clinical data registry may not submit data on more than 20
measures on behalf of an eligible professional. We propose to place a
limit on the number of measures that a qualified clinical data registry
may submit on behalf of an eligible professional at this time because
we have no experience with qualified clinical data registries and the
types of data on quality measures that they collect.
We note that this proposed criterion for satisfactory participation
is consistent with proposed requirements set forth (for example, the
reporting period as well as the number of individual measures, domains,
and applicable patients proposed to be reported) for meeting the
criteria for the satisfactory reporting of individual PQRS quality
measures using the traditional claims, registry, and EHR-based
reporting mechanisms for the 2014 PQRS incentive (for example, the
reporting period as well as the number of individual measures, domains,
and applicable patients proposed to be reported). We believe it is
important to propose a similar quality data reporting criterion for
individual eligible professionals to satisfactorily participate in a
qualified clinical data registry as for satisfactory reporting for the
2014 PQRS incentive so that this proposed satisfactory participation
option to

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satisfy the PQRS is not disproportionately more advantageous or less
burdensome than the other proposed criteria for satisfactory reporting
for the 2014 PQRS incentive. However, this proposed criterion for
satisfactory participation departs from the proposed criteria for
satisfactory reporting for the 2014 PQRS incentive in a number of ways.
First, an eligible professional using a qualified clinical data
registry is required to report on at least 1 outcome measure. Second,
whereas the proposed criteria for satisfactory reporting on individual
PQRS quality measures require the reporting of at least 1 Medicare Part
B FFS patient, this proposed criterion for satisfactory participation
in a qualified clinical data registry for the 2014 PQRS incentive would
not require reporting on Medicare patients. Please note that because we
are also proposing more stringent requirements for an entity to become
a qualified clinical data registry than a traditional qualified
registry, such as requiring benchmarking capacity, we believe that
individual eligible professionals who participate in a qualified
clinical data registry would be doing more than just reporting quality
data to the qualified data registry for PQRS purposes. Over time, as we
gain more experience with the capabilities of qualified clinical data
registries, we anticipate that the criteria for satisfactory
participation will further depart from the criteria for satisfactory
reporting under PQRS and incorporate other quality improvement
functions that may be provided by a qualified clinical data registry to
its participants as this option evolves.
We seek public comment on the proposed criterion for the
satisfactory participation by individual eligible professionals in a
qualified clinical data registry for the 2014 PQRS incentive.
f. Proposed Reporting Period for the Satisfactory Participation for
Individual Eligible Professionals in a Qualified Clinical Data Registry
for the 2016 PQRS Payment Adjustment
Section 1848(m)(3)(D) of the Act, as redesignated and added by
section 601(b) of the American Tax Relief Act of 2012, authorizes the
Secretary to treat an individual eligible professional as
satisfactorily submitting data on quality measures under section
1848(m)(A) of the Act if the eligible professional is satisfactorily
participating in a qualified clinical data registry for the year. Given
that satisfactory participation is with regard to the year, and to
provide consistency with how individual eligible professionals report
quality measures data to a qualified clinical data registry, we propose
to modify Sec. 414.90(e)(2) to specify a 12-month, calendar year (CY)
reporting period from January 1, 2014 through December 31, 2014, for
individual eligible professionals to satisfactorily participate in a
qualified clinical data registry for purposes of the 2016 PQRS payment
adjustment. We are proposing a 12-month reporting period because, based
on our experience with the 12 and 6-month reporting periods for the
PQRS incentives, we believe that data on quality measures collected
based on 12-months provides a more accurate assessment of actions
performed in a clinical setting than data collected based on shorter
reporting period. We also believe that a 12-month reporting period is
appropriate given that the full calendar year would be utilized with
regard to the participation by the individual eligible professional in
the qualified clinical data registry.
We are proposing a 12-month reporting period occurring 2 years
prior to the application of the 2016 PQRS payment adjustment for
individual eligible professionals to allow time to perform all
reporting analyses, and make determinations about whether the
individual eligible professional satisfactorily participated in a
qualified clinical data registry, prior to applying payment adjustments
on eligible professionals' Medicare Part B PFS claims in 2016. However,
in future years, we may propose alternative reporting periods that
could occur closer in time to the application of the PQRS payment
adjustment. We invite public comment on the proposed 12-month, CY 2014
reporting period (that is, January 1, 2014-December 31, 2014) for the
satisfactory participation of individual eligible professionals in a
qualified clinical data registry for the 2016 PQRS payment adjustment.
g. Proposed Criteria for the Satisfactory Participation for Individual
Eligible Professionals in a Qualified Clinical Data Registry for the
2016 PQRS Payment Adjustment
Section 1848(a)(8) of the Act provides that for covered
professional services furnished by an eligible professional during 2015
or any subsequent year, if the eligible professional does not
satisfactorily report data on quality measures for covered professional
services for the quality reporting period for the year, the fee
schedule amount for services furnished by such professional during the
year shall be equal to the applicable percent of the fee schedule
amount that would otherwise apply to such services. For 2016 and
subsequent years, the applicable percent is 98.0 percent.
Section 1848(m)(3)(D) of the Act, as redesignated and added by
section 601(b) of the American Tax Relief Act of 2012, authorizes the
Secretary to treat an individual eligible professional as
satisfactorily submitting data on quality measures under section
1848(m)(A) of the Act if, in lieu of reporting measures under section
1848(k)(2)(C) of the Act, the eligible professional is satisfactorily
participating in a qualified clinical data registry for the year.
``Satisfactory participation'' is a new standard under the PQRS and is
a substitute for the underlying standard of ``satisfactory reporting''
data on covered professional services that eligible professionals must
meet to earn a PQRS incentive or avoid the PQRS payment adjustment.
Therefore, we propose to modify Sec. 414.90 to add paragraph (e)(2) to
indicate that individual eligible professionals shall be treated as
satisfactorily reporting data on quality measures, if the individual
eligible professional satisfactorily participates in a qualified
clinical data registry. This section also contains the criterion we are
proposing for individual eligible professionals to meet to
satisfactorily participate in a qualified clinical data registry for
purposes of the 2016 PQRS payment adjustment.
We propose that, for purposes of the 2016 PQRS payment adjustment
(which would be based on data reported during the 12-month period that
falls in CY 2014), the exact same requirement we proposed above for
satisfactory participation for the 2014 PQRS incentive. We believe it
is appropriate to propose identical criteria for meeting the new
standard for satisfactory participation given that the proposed 12-
month reporting period for satisfactory participation in a qualified
clinical data registry for the respective 2014 PQRS incentive and 2016
PQRS payment adjustments coincide.
We seek public comment on the proposed criterion for the
satisfactory participation by individual eligible professionals in a
qualified clinical data registry for the 2016 PQRS payment adjustment.
Tables 24 and 25 provide a summary of the proposed criteria for
satisfactory reporting and satisfactory participation we discussed
above for individual eligible professionals for the 2014 PQRS incentive
and 2016 PQRS payment adjustment respectively.

[[Page 43367]]

Table 24--Summary of Proposals for the 2014 PQRS Incentive: Proposed Criteria for Satisfactory Reporting of
Individual Quality Measures via Claims and Registries and Proposed Satisfactory Participation Criterion for
Individual Eligible Professionals in Qualified Clinical Data Registries
----------------------------------------------------------------------------------------------------------------
Proposed satisfactory
reporting criteria and
Reporting period Measure type Reporting mechanism satisfactory participation
criteria
----------------------------------------------------------------------------------------------------------------
12-month (Jan 1-Dec 31)............ Individual Measures... * Claims.............. Report at least 9 measures
covering at least 3 of the
National Quality Strategy
domains, OR, If less than
9 measures apply to the
eligible professional,
then the eligible
professional must report 1-
8 measures for which there
is Medicare patient data;
and Report each measure
for at least 50 percent of
the Medicare Part B FFS
patients seen during the
reporting period to which
the measure applies.
Measures with a 0 percent
performance rate would not
be counted.
12-month (Jan 1-Dec 31)............ Individual Measures... Qualified Registry.... Report at least 9 measures,
covering at least 3 of the
National Quality Strategy
domains and report each
measure for at least 50%
of the eligible
professional's Medicare
Part B FFS patients seen
during the reporting
period to which the
measure applies. Measures
with a 0 percent
performance rate would not
be counted.
12-month (Jan 1-Dec 31)............ Measures selected by Qualified Clinical Report at least 9 measures
Qualified Clinical Data Registry. available for reporting
Data Registry. under a qualified clinical
data registry covering at
least 3 of the National
Quality Strategy domains,
and report each measure
for at least 50% of the
eligible professional's
patients. Of the measures
reported via a clinical
data registry, the
eligible professional must
report on at least 1
outcome measure.
----------------------------------------------------------------------------------------------------------------
*Subject to the MAV process.

Table 25--Summary of Proposals for the 2016 PQRS Payment Adjustment: Proposed Criteria for Satisfactory
Reporting of Individual Quality Measures via Claims and Registries and Proposed Satisfactory Participation
Criterion for Individual Eligible Professionals in Qualified Clinical Data Registries
----------------------------------------------------------------------------------------------------------------
Proposed satisfactory
Reporting period Measure type Reporting mechanism reporting and
participation criteria
----------------------------------------------------------------------------------------------------------------
12-month (Jan 1-Dec 31)............ Individual Measures... *Claims............... Report at least 9 measures
covering at least 3 of the
National Quality Strategy
domains, OR, If less than
9 measures apply to the
eligible professional,
then the eligible
professional must report 1-
8 measures for which there
is Medicare patient data;
and Report each measure
for at least 50 percent of
the Medicare Part B FFS
patients seen during the
reporting period to which
the measure applies.
12-month (Jan 1-Dec 31)............ Individual Measures... Registry.............. Report at least 9 measures,
covering at least 3 of the
National Quality Strategy
domains and report each
measure for at least 50%
of the eligible
professional's Medicare
Part B FFS patients seen
during the reporting
period to which the
measure applies. Measures
with a 0 percent
performance rate would not
be counted.
12-month (Jan 1-Dec 31)............ Measures selected by Qualified Clinical Report at least 9 measures
the Qualified Data Registry. available for reporting
Clinical Data under a qualified clinical
Registry. data registry covering at
least 3 of the National
Quality Strategy domains,
and report each measure
for at least 50 percent of
the eligible
professional's patients.
Of the measures reported
via a clinical data
registry, the eligible
professional must report
on at least 1 outcome
measure.
----------------------------------------------------------------------------------------------------------------
*Subject to the MAV process.

7. Proposed Criteria for Satisfactory Reporting for the 2014 PQRS
Incentive for Group Practices in the GPRO
For 2014, in accordance with Sec. 414.90(c)(3), eligible
professionals that satisfactorily report data on PQRS quality measures
are eligible to receive an incentive equal to 0.5 percent of the total
estimated Medicare Part B allowed charges for all covered professional
services furnished by the eligible professional or group practice
during the applicable reporting period. We finalized criteria for the
satisfactory reporting for group practices participating in the GPRO
for the 2014 PQRS incentive in the CY 2013 PFS final rule with comment
period (see

[[Page 43368]]

Table 93, 77 FR 69195). In this section, we propose to change some of
the criteria for satisfactory reporting for group practices under the
GPRO using the registry and GPRO Web interface reporting mechanisms.
Group practices may currently report PQRS quality measures data to
meet the criteria for satisfactory reporting for the 2014 PQRS
incentive via the registry, EHR, and GPRO web interface reporting
mechanisms. For the 2014 PQRS incentive, we finalized the following
criterion for the satisfactory reporting of PQRS quality measures via
the GPRO web interface for group practices comprised of 25-99 eligible
professionals: Report on all measures included in the web interface;
and populate data fields for the first 218 consecutively ranked and
assigned beneficiaries in the order in which they appear in the group's
sample for each module or preventive care measure. If the pool of
eligible assigned beneficiaries is less than 218, then report on 100
percent of assigned beneficiaries (77 FR 69195). We established this
same criterion for the group practices of 25-99 eligible professionals
for the 2013 PQRS incentive. Unfortunately, there has been low
participation for this reporting option. We believe this is due to the
fact that reporting using the GPRO web interface is more beneficial to
larger practices because larger practices are better able to report on
a more varied patient population. Therefore, to streamline the PQRS and
eliminate reporting options that are largely unused, we propose to
eliminate this criterion under the GPRO for the 2014 PQRS incentive. As
a result, group practices comprised of 25-99 eligible professionals
would no longer have the option to report PQRS quality measures using
the GPRO web interface for the 2014 PQRS incentive. We do not believe
this harms these smaller groups' practices, as group practices in the
GPRO would still be able to report PQRS quality measures using either
the registry or EHR-based reporting mechanisms.
For reporting under the GPRO using the registry-based reporting
mechanism, we finalized the following criterion for the satisfactory
reporting of PQRS quality measures for group practices comprised of 2
or more eligible professionals for the 2014 PQRS incentive in the CY
2013 final rule with comment period: Report at least 3 measures, and
report each measure for at least 80 percent of the group practice's
Medicare Part B FFS patients seen during the reporting period to which
the measure applies. Measures with a 0 percent performance rate will
not be counted (77 FR 69196). For the same reasons we are proposing to
increase the number of measures an individual eligible must report as
well as decrease the percentage threshold for individual eligible
professionals reporting via registry for the 2014 PQRS incentive, we
propose the following modified criteria for the satisfactory reporting
of individual quality measures under the GPRO for the registry-based
reporting mechanism: Report at least 9 measures covering at least 3 of
the National Quality Strategy domains, and report each measure for at
least 50% of the group practice's applicable seen during the reporting
period to which the measure applies. Measures with a 0 percent
performance rate will not be counted.
In addition, patient surveys are important tools for assessing
beneficiary experience of care and outcomes. Many surveys are being
used in both the private and public sectors, including the Medicare
Health Outcomes Survey used by Medicare Advantage (MA) plans, Consumer
Assessment of Healthcare Providers and Systems (CAHPS) survey tools,
and Health Resources Services Administration's (HRSA's) Health Center
Patient Satisfaction Survey. Over the past two years, we have developed
a Consumer Assessment of Healthcare Providers and Systems (CAHPS)
survey for use with the Medicare Shared Savings Program and the PQRS.
In 2012, we field tested the survey with a sample of 6,750 Medicare
Fee-for-Service beneficiaries receiving care from nine group practices
that participated in the Physician Group Practice Transition
Demonstration. Subsequent to the field test, we refined the survey and
in the spring of 2013 administered it for all Accountable Care
Organizations (ACOs) participating in the Pioneer ACO program and the
Medicare Shared Savings Program during 2012. More information about the
survey is available at the Federal Register (77 FR 73032 and 78 FR
17676).
Because we believe these patient surveys are important tools for
assessing beneficiary experience of care and outcomes, under our
authority under section 1848(m)(3)(C)(i) of the Act to select the
measures for which a group practice must report, we propose to provide
group practices comprised of 25 or more eligible professionals with a
new satisfactory reporting criterion that would include the option to
complete the CG CAHPS survey along with reporting 6 other PQRS measures
for purposes of meeting the criteria for satisfactory reporting for the
2014 PQRS incentive and 2016 PQRS payment adjustment.
We further propose that the survey would be administered following
the close of the PQRS registration period. CMS also would provide each
group a detailed report about the results of the survey. In addition,
we propose to assign beneficiaries to a group practice using the same
assignment methodology that we use for the GPRO web interface (77 FR
69195) . This method focuses on assigning beneficiaries to a group
based on whether the group provided the plurality of primary care
services. Because we propose to assign beneficiaries to a group based
on the provision of primary care services, this survey is not an
appropriate option for groups of physicians (for example, such as a
group of surgeons) that do not provide primary care services. In
accordance with section 1848(m)(3)(C)(ii) of the Act, which requires
the GPRO to provide for the use of a statistical sampling model, we
propose that the survey would be administered by certified survey
vendor on behalf of the group practice for a sample of group's assigned
beneficiaries. As noted earlier, to complete this survey, a group
practice must indicate its intent to report the CG CAHPS survey when it
registers to participate in the PQRS via the GPRO.
Please note that the CAHPS survey measures only cover 1 National
Quality Strategy domain. In order to be consistent with other group
practice reporting criteria we are proposing that require the reporting
of measures covering at least 3 National Quality Strategy domains, we
are proposing that, if a group practice reports the CAHPS measures via
a certified survey vendor, the group practice would be required to
report on at least 6 additional measures covering at least 2 National
Quality Strategy domains.
Specifically, we are proposing the following criteria for
satisfactory reporting for the 2014 PQRS incentive: For the 12-month
reporting period for the 2014 PQRS incentive, report all CAHPS survey
measures via a certified vendor, and report at least 6 measures
covering at least 2 of the National Quality Strategy domains using the
qualified registry, direct EHR product, EHR data submission vendor, or
GPRO web interface reporting mechanisms.
We seek public comment on our proposed criterion for the
satisfactory reporting of data on these PQRS quality measures under the
GPRO for the 2014 PQRS incentive.

[[Page 43369]]

8. Criteria for Satisfactory Reporting for the 2016 PQRS Payment
Adjustment for Group Practices in the GPRO
This section addresses the proposed criteria for satisfactory
reporting for group practices in the GPRO for the 2016 PQRS payment
adjustment using the registry, GPRO web interface, and certified survey
vendor reporting mechanisms. In the CY 2013 PFS final rule with comment
period, we finalized the same criteria for satisfactorily reporting
data on quality measures for the 2016 PQRS payment adjustment that
apply for the 2014 PQRS incentive for the PQRS GPRO (77 FR 69200). We
are making three of the same proposals for the criteria for
satisfactory reporting under the GPRO for the 2016 PQRS payment
adjustment that we are proposing for the 2014 PQRS incentive.
Specifically, we propose to eliminate the following criterion for
satisfactory reporting of PQRS quality measures via the GPRO web
interface for group practices comprised of 25-99 eligible
professionals: Report on all measures included in the web interface;
and populate data fields for the first 218 consecutively ranked and
assigned beneficiaries in the order in which they appear in the group's
sample for each module or preventive care measure. If the pool of
eligible assigned beneficiaries is less than 218, then report on 100
percent of assigned beneficiaries. For the same reasons discussed
previously and to maintain consistent criteria for the 2016 PQRS
payment adjustment and 2014 PQRS incentive, we believe this proposed
change is appropriate. We also note that if this proposal is finalized,
only groups of 100 or more eligible professionals would be able to use
the web interface reporting mechanism to report quality data under the
GPRO.
Second, we propose to remove the following criterion for
satisfactory reporting via registry under the GPRO for the 2016 PQRS
payment adjustment: Report at least 3 measures, and report each measure
for at least 80 percent of the group practice's Medicare Part B FFS
patients seen during the reporting period to which the measure applies.
Measures with a 0 percent performance rate will not be counted. This
would allow us to maintain consistent criteria for the 2016 PQRS
payment adjustment and 2014 PQRS incentive.
Consistent with our proposal to provide group practices comprised
of 25 or more eligible professionals with a new satisfactory reporting
criterion that would include the option to complete the CG CAHPS survey
along with reporting 6 other PQRS measures for purposes of meeting the
criteria for satisfactory reporting for the 2014 PQRS incentive, we
also propose the same criterion for purposes of meeting the criteria
for satisfactory reporting for the 2016 PQRS payment adjustment.
Specifically, we are proposing the following criteria for satisfactory
reporting for the 2016 PQRS payment adjustment: For the 12-month
reporting period for the 2016 PQRS payment adjustment, report all CAHPS
survey measures via a certified vendor, and report at least 6 measures
covering at least 2 of the National Quality Strategy domains using the
qualified registry, direct EHR product, EHR data submission vendor, or
GPRO web interface reporting mechanisms. As noted earlier, to complete
this survey, a group practice must indicate its intent to report the CG
CAHPS survey when it registers to participate in the PQRS via the GPRO.
In addition, we are proposing the same criteria for satisfactory
reporting of individual quality measures under the GPRO for the
registry-based reporting mechanism for the 2016 PQRS payment adjustment
that we proposed above for the 2014 PQRS Incentive: Report at least 9
measures covering at least 3 of the National Quality Strategy domains,
and report each measure for at least 50 percent of the group practice's
applicable patients seen during the reporting period to which the
measure applies. Measures with a 0 percent performance rate will not be
counted. In addition to the reasons we noted previously for modifying
the existing registry satisfactory reporting criterion to increase the
number of measures reported from 3 to 9, we believe it is appropriate
to continue to align, as closely as possible, the criteria for
satisfactory reporting for both the 2016 PQRS payment adjustment and
2014 PQRS Incentive.
We note that the criteria for satisfactory reporting under the GPRO
for the 2014 PQRS incentive and the 2016 PQRS payment adjustment would
align (such that a group practice would avoid the 2016 PQRS payment
adjustment by meeting any of the criteria for satisfactory reporting
adopted for the 2014 PQRS incentive for the 12-month reporting period).
We believe this is appropriate since the reporting period for the 2014
PQRS incentive and 2016 PQRS payment adjustment coincide. We seek
public comment on these proposals as well as on whether we should offer
alternative criteria for group practices participating in the PQRS GPRO
to satisfy the 2016 PQRS payment adjustment similar to what we have
established for individual eligible professionals reporting via claims.
Tables 26 and 27 provides a summary of our proposed criteria for
the satisfactory reporting of data on PQRS quality measures via the
GPRO for the 2014 PQRS incentive and 2016 PQRS payment adjustment.

Table 26--Summary of Proposals for the 2014 PQRS Incentive: Proposed Criteria for Satisfactory Reporting of Data
on PQRS Quality Measures via the GPRO
----------------------------------------------------------------------------------------------------------------
Reporting period Reporting mechanism Group practice size Proposed reporting criteria
----------------------------------------------------------------------------------------------------------------
12-month (Jan 1-Dec 31)............ Qualified Registry.... 2 + eligible Report at least 9 measures
professionals. covering at least 3 of the
National Quality Strategy
domains, and report each
measure for at least 50
percent of the group
practice's applicable
patients seen during the
reporting period to which
the measure applies.
Measures with a 0 percent
performance rate will not
be counted.
12-month (Jan 1-Dec 31)............ Certified Survey 25+ eligible Report all CG CAHPS survey
Vendor + Qualified professionals. measures via certified
Registry, direct EHR survey vendor, and report
product, EHR data at least 6 measures
submission vendor, or covering at least 2 of the
GPRO web interface. National Quality Strategy
domains using the
qualified registry, direct
EHR product, EHR data
submission vendor, or GPRO
web interface reporting
mechanisms.
----------------------------------------------------------------------------------------------------------------

[[Page 43370]]

Table 27--Summary of Proposals for the 2016 PQRS Payment Adjustment: Proposed Criteria for Satisfactory
Reporting of Data on PQRS Quality Measures via the GPRO
----------------------------------------------------------------------------------------------------------------
Reporting period Reporting mechanism Group practice size Proposed reporting criteria
----------------------------------------------------------------------------------------------------------------
12-month (Jan 1-Dec 31)............ Qualified Registry.... 2 + eligible Report at least 9 measures
professionals. covering at least 3 of the
National Quality Strategy
domains, and report each
measure for at least 50
percent of the group
practice's applicable
patients seen during the
reporting period to which
the measure applies.
Measures with a 0 percent
performance rate will not
be counted.
12-month (Jan 1-Dec 31)............ Certified Survey 25+ eligible Report all CG CAHPS survey
Vendor + Qualified professionals. measures via certified
Registry, direct EHR survey vendor, and report
product, EHR data at least 6 measures
submission vendor, or covering at least 2 of the
GPRO web interface. National Quality Strategy
domains using the
qualified registry, direct
EHR product, EHR data
submission vendor, or GPRO
web interface reporting
mechanisms.
----------------------------------------------------------------------------------------------------------------

9. Statutory Requirements and Other Considerations for the Selection of
PQRS Quality Measures for Meeting the Criteria for Satisfactory
Reporting for 2013 and Beyond for Individual Eligible Professionals and
Group Practices
CMS undergoes an annual Call for Measures that solicits new
measures from the public for possible inclusion in the PQRS for 2014
and beyond. During the Call for Measures, we request measures for
inclusion in PQRS that meet the following statutory and non-statutory
criteria.
Sections 1848(k)(2)(C) and 1848(m)(3)(C)(i) of the Act,
respectively, govern the quality measures reported by individual
eligible professionals and group practices reporting under the PQRS.
Under section 1848(k)(2)(C)(i) of the Act, the PQRS quality measures
shall be such measures selected by the Secretary from measures that
have been endorsed by the entity with a contract with the Secretary
under section 1890(a) of the Act (currently, that is the National
Quality Forum, or NQF). However, in the case of a specified area or
medical topic determined appropriate by the Secretary for which a
feasible and practical measure has not been endorsed by the NQF,
section 1848(k)(2)(C)(ii) of the Act authorizes the Secretary to
specify a measure that is not so endorsed as long as due consideration
is given to measures that have been endorsed or adopted by a consensus
organization identified by the Secretary, such as the AQA alliance. In
light of these statutory requirements, we believe that, except in the
circumstances specified in the statute, each PQRS quality measure must
be endorsed by the NQF. Additionally, section 1848(k)(2)(D) of the Act
requires that for each PQRS quality measure, ``the Secretary shall
ensure that eligible professionals have the opportunity to provide
input during the development, endorsement, or selection of measures
applicable to services they furnish.''
The statutory requirements under section 1848(k)(2)(C) of the Act,
subject to the exception noted previously, require only that the
measures be selected from measures that have been endorsed by the
entity with a contract with the Secretary under section 1890(a) (that
is, the NQF) and are silent for how the measures that are submitted to
the NQF for endorsement were developed. The basic steps for developing
measures applicable to physicians and other eligible professionals
prior to submission of the measures for endorsement may be carried out
by a variety of different organizations. We do not believe there needs
to be any special restrictions on the type or make-up of the
organizations carrying out this basic process of development of
physician measures, such as restricting the initial development to
physician-controlled organizations. Any such restriction would unduly
limit the basic development of quality measures and the scope and
utility of measures that may be considered for endorsement as voluntary
consensus standards for purposes of the PQRS.
In addition to section 1848(k)(2)(C) of the Act, section 1890A of
the Act, which was added by section 3014(b) of the Affordable Care Act,
requires that the entity with a contract with the Secretary under
subsection 1890(a) of the Act (currently that, is the NQF) convene
multi-stakeholder groups to provide input to the Secretary on the
selection of certain categories of quality and efficiency measures.
These categories are described in section 1890(b)(7)(B) of the Act, and
include such measures as the quality measures selected for reporting
under the PQRS. Pursuant to section 3014 of Affordable Care Act, the
NQF convened multi-stakeholder groups by creating the Measure
Applications Partnership (MAP). Section 1890(A)(a) of the Act requires
that the Secretary establish a pre-rulemaking process in which the
Secretary must make publicly available by December 1st of each year a
list of the quality and efficiency measures that the Secretary is
considering for selection through rulemaking for use in the Medicare
program. The NQF must provide CMS with the MAP's input on selecting
measures by February 1st of each year. The list of measures under
consideration for 2013 is available at http://www.qualityforum.org/map/
.
As we noted above, section 1848(k)(2)(C)(ii) of the Act provides an
exception to the requirement that the Secretary select measures that
have been endorsed by the entity with a contract under section 1890(a)
of the Act (that is, the NQF). We may select measures under this
exception if there is a specified area or medical topic for which a
feasible and practical measure has not been endorsed by the entity, as
long as due consideration is given to measures that have been endorsed
or adopted by a consensus organization identified by the Secretary.
Under this exception, aside from NQF endorsement, we requested that
stakeholders apply the following considerations when submitting
measures for possible inclusion in the PQRS measure set:
High impact on healthcare.
Measures that are high impact and support CMS and HHS
priorities for improved quality and efficiency of care for Medicare
beneficiaries.
Measures that address gaps in the quality of care
delivered to Medicare beneficiaries.
Address Gaps in the PQRS measure set.
Measures impacting chronic conditions (chronic kidney
disease, diabetes mellitus, heart failure, hypertension and
musculoskeletal).

[[Page 43371]]

Measures applicable across care settings (such as,
outpatient, nursing facilities, domiciliary, etc.).
Broadly applicable measures that could be used to create a
core measure set required of all participating eligible professionals.
Measures groups that reflect the services furnished to
beneficiaries by a particular specialty.
10. Proposed PQRS Quality Measures
Taking into consideration the statutory and non-statutory criteria
we described previously, this section contains our proposals for the
inclusion or removal of measures in PQRS for 2014 and beyond. We are
classifying all proposed measures against six domains based on the
National Quality Strategy's six priorities, as follows:
(1) Person and Caregiver-Centered Experience and Outcomes. These
are measures that reflect the potential to improve patient-centered
care and the quality of care delivered to patients. They emphasize the
importance of collecting patient-reported data and the ability to
impact care at the individual patient level as well as the population
level through greater involvement of patients and families in decision
making, self-care, activation, and understanding of their health
condition and its effective management.
(2) Patient Safety. These are measures that reflect the safe
delivery of clinical services in both hospital and ambulatory settings
and include processes that would reduce harm to patients and reduce
burden of illness. These measures should enable longitudinal assessment
of condition-specific, patient-focused episodes of care.
(3) Communication and Care Coordination. These are measures that
demonstrate appropriate and timely sharing of information and
coordination of clinical and preventive services among health
professionals in the care team and with patients, caregivers, and
families to improve appropriate and timely patient and care team
communication.
(4) Community/Population Health. These are measures that reflect
the use of clinical and preventive services and achieve improvements in
the health of the population served. These are outcome-focused and have
the ability to achieve longitudinal measurement that will demonstrate
improvement or lack of improvement in the health of the US population.
(5) Efficiency and Cost Reduction. These are measures that reflect
efforts to significantly improve outcomes and reduce errors. These
measures also impact and benefit a large number of patients and
emphasize the use of evidence to best manage high priority conditions
and determine appropriate use of healthcare resources.
(6) Effective Clinical Care. These are measures that reflect
clinical care processes closely linked to outcomes based on evidence
and practice guidelines.
Please note that the PQRS quality measure specifications for any
given proposed PQRS individual quality measure may differ from
specifications for the same quality measure used in prior years. For
example, for the proposed PQRS quality measures that were selected for
reporting in 2013 and beyond, please note that detailed measure
specifications, including the measure's title, for the proposed
individual PQRS quality measures for 2013 and beyond may have been
updated or modified during the NQF endorsement process or for other
reasons. In addition, due to our desire to align measure titles with
the measure titles that were proposed for 2013, 2014, 2015, and
potentially subsequent years of the EHR Incentive Program, we note that
the measure titles for measures available for reporting via EHR may
change. To the extent that the EHR Incentive Program updates its
measure titles to include version numbers (77 FR 13744), we intend to
use these version numbers to describe the PQRS EHR measures that will
also be available for reporting for the EHR Incentive Program. We will
continue to work toward complete alignment of measure specifications
across programs whenever possible.
Through NQF's measure maintenance process, NQF endorsed measures
are sometimes updated to incorporate changes that we believe do not
substantively change the nature of the measure. Examples of such
changes could be updated diagnosis or procedure codes or changes to
exclusions to the patient population or definitions. We believe these
types of maintenance changes are distinct from more substantive changes
to measures that result in what are considered new or different
measures, and that they do not trigger the same agency obligations
under the Administrative Procedure Act. In the CY 2013 PFS final rule
with comment period, we finalized our proposal providing that if the
NQF updates an endorsed measure that we have adopted for the PQRS in a
manner that we consider to not substantively change the nature of the
measure, we would use a subregulatory process to incorporate those
updates to the measure specifications that apply to the program (77 FR
69207). We believe this adequately balances our need to incorporate
non-substantive NQF updates to NQF-endorsed measures in the most
expeditious manner possible, while preserving the public's ability to
comment on updates that so fundamentally change an endorsed measure
that it is no longer the same measure that we originally adopted. We
also note that the NQF process incorporates an opportunity for public
comment and engagement in the measure maintenance process. We will
revise the Specifications Manual and post notices to clearly identify
the updates and provide links to where additional information on the
updates can be found. Updates will also be available on the CMS PQRS
Web site at http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/PQRS/index.html.
With respect to the PQRS EHR measures that are also reportable
under the EHR Incentive Program (i.e., electronically specified
clinical quality measures), please note that the updates to these
measures will be provided on the EHR Incentive Program Web site. We
understand that the EHR Incentive Program may accept versions of
electronically specified clinical quality measures that may be
outdated. We propose that for purposes of the PQRS, eligible
professionals must report the most recent, updated version of a
clinical quality measure. For example, for purposes of reporting
clinical quality measures that are electronically specified during the
PQRS reporting periods that occur in 2014, we would only accept the
reporting of clinical quality measures that are electronically
specified using versions of the electronic specifications that were
updated and posted on June 2013, available at http://www.cms.gov/Regulations-and-Guidance/Legislation/EHRIncentivePrograms/eCQM_Library.html. We also understand, for purposes of the EHR Incentive
Program, that once direct EHR products and EHR data submission vendors
are issued a 2014 Edition certification for clinical quality measures,
they will not necessarily be required to have such technology retested
and recertified against the most recent, updated version of a clinical
quality measure when such versions are made available. We propose that
for purposes of PQRS, however, that the eligible professional's direct
EHR product or EHR data submission vendor must be tested and certified
to the most recent, updated version of an electronically specified
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measure. For example, for purposes of reporting clinical quality
measures that are electronically specified during the PQRS reporting
periods that occur in 2014, we would only accept the reporting of
clinical quality measures from direct EHR products or EHR data
submission vendors that have been tested and certified to versions of
the electronic specifications that were updated and posted on June
2013. We seek comment on our proposals to require eligible
professionals to both use the most recent, updated version of an
electronically specified clinical quality measure to report for PQRS
and to use a direct EHR product or EHR data submission vendor that has
been tested and certified to the most recent, updated version of the
clinical quality measure's electronic specifications for PQRS purposes.
a. Proposed Individual PQRS Measures and Measures Within Measures
Groups Available for Reporting for 2014 and Beyond
(1) Proposed PQRS Core Measures Available for Reporting for 2014 and
Beyond
In the CY 2013 PFS final rule with comment period, we finalized the
HHS Million Hearts Measures as a recommended set of core measures for
which we encourage eligible professionals to report in PQRS (77 FR
69209). In addition to the HHS Million Hearts Measures we previously
finalized, we are proposing to include the measures specified in Table
28 as additional recommended core measures for 2014 and beyond (in the
table we also identify the applicable PQRS reporting mechanism through
which each measure could be submitted). These additional proposed
recommended core measures were also finalized as recommended core
measures in the EHR Incentive Program for 2014. Therefore, due to our
desire to align with the recommended measures available under the EHR
Incentive Program, we are proposing the additional recommended measures
specified in Table 28 for 2014 and beyond.
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(2) Proposed Individual PQRS Measures Available for Reporting for 2014
and Beyond
Table 29 contains the measures we are proposing to include in the
PQRS measure set for 2014 and beyond. Please note that our rationale
for proposing each of these measures is found below the measure
description. We have also indicated the PQRS reporting mechanism or
mechanisms through which each proposed measure could be submitted.
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In Table 30, we specify the measures we are proposing to remove
from reporting under the PQRS. Please note that the rationale we have
for each measure we are proposing to remove is specified after the
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b. Proposed PQRS Measures Groups
Section 414.90(b) defines a measures group as ``a subset of four or
more Physician Quality Reporting System measures that have a particular
clinical condition or focus in common. The denominator definition and
coding of the measures group identifies the condition or focus that is
shared across the measures within a particular measures group.'' As we
discussed in section IV.I.4. above, we propose to increase the number
of measures reported by individual eligible professionals via claims
and registry from 3 to 9. Since we are proposing to increase the number
of individual measures to be reported via claims and registry, we
believe it is also appropriate to increase the number of measures that
would be reported in a measures group. Specifically, we propose to
modify the minimum amount of measures that may be included in a PQRS
measures group from four to six. Therefore, we are proposing to modify
the definition of a measures group at Sec. 414.90(b) to indicate that
a measures group would consist of at least six measures. Consequently,
we are proposing to add additional measures to measures groups that
previously contained less than six measures. We believe that, although
it is appropriate to increase the number of measures in a measures
group, we do not believe it would be appropriate to increase the
minimum number of reportable measures in a measures group to 9, such as
we are proposing for individual eligible professionals who report
individual quality measures via claims and registry. Unlike reporting
individual measures, where an eligible professional would be able to
report on any 9 measures of his/her choosing, an eligible professional
is required to report on ALL the measures contained in a measures
group. We believe increasing the number of minimum measures in a
measures group to six is reasonable, as it would only require the
eligible professional to report on an additional two measures.
Tables 31 through 53 specify our proposed measures groups in light
of our proposal to increase the minimum number of measures in a
measures group in previously established measures groups, so that each
measures group contains at least 6 measures (77 FR 69272).
In addition to the measures groups that we finalized for 2013 and
beyond, we are proposing the following three additional measures
groups, which are identified in Tables 54 through 56:
Optimizing Patient Exposure to Ionizing Radiation: This
measures group represents a new clinical theme for eligible
professionals to report and addresses a clinical gap. This measure set
includes measures collecting data for standardized nomenclature, count
of high dose radiation, reporting to a radiation dose index registry,
availability of CT images for follow-up/comparison, and search of CT
images through a secure, authorized, media-free, shared archive, and CT
follow-up for incidental pulmonary nodules. This would be a measures
group that specialty Radiologists and other eligible professionals
within this scope of practice could report.
General Surgery: Addition of a General Surgery Measures
Group including procedures such as ventral hernia, appendectomy, AV
fistula, cholecystectomy, thyroidectomy, mastectomy, lymphadenectomy,
sentinel lymph node biopsy (SLNB), or lumpectomy/breast biopsy would
allow surgeons another opportunity to report via measures group
reporting.
Gastrointestinal Surgery: This measures group could be
reported by specialized general surgical eligible professionals that
focus on bariatric and colectomy procedures. PQRS currently has another
measures group in which Surgeons and other eligible professionals may
report: Perioperative Measures Group. However, these measures address a
gap in that it would produce data that specifically evaluate iatrogenic
injury to adjacent organ, anastomotic leak intervention, and unplanned
reoperation.
Please note that, since we are proposing to eliminate the option to
report measures groups via claims, all measures groups proposed for
2014 and beyond would be reportable through registry-based reporting
only.
[yen] Titles and descriptions in these tables are aligned with the
2014 Physician Quality Reporting System Claims and Registry measure
titles and descriptions, and may differ from existing measures in other
programs. Please reference the National Quality Forum (NQF) and
Physician Quality Reporting System numbers for clarification.
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We seek public comment on these proposals.
c. Proposed Reporting Mechanism Changes to PQRS Individual Measures for
2014 and Beyond
In addition to the measures and measures groups we are proposing to
include or remove from the existing PQRS measure set, we propose to
modify how existing PQRS measures can be reported. Specifically, we
propose that the following measures would no longer be reportable
through the claims-based reporting mechanism:
PQRS 9 (NQF 0105): Major Depressive
Disorder (MDD): Antidepressant Medication during Acute Phase for
Patients with MDD: Percentage of patients aged 18 years and older
diagnosed with new episode of MDD and documented as treated with
antidepressant medication during the entire 84-day (12-week) acute
treatment phase. Rationale: 2012 claims data indicates that a low
threshold of eligible professionals reported this measure. This
proposal is also supported because there are still a sufficient number
of measures for these eligible professionals to report via claims.
PQRS 64 (NQF 0001): Asthma: Assessment
of Asthma Control--Ambulatory Care Setting: Percentage of patients aged
5 through 50 years with a diagnosis of asthma who were evaluated at
least once for asthma control (comprising asthma impairment and asthma
risk). Rationale: 2012 claims data indicates that a low threshold of
eligible professionals reported this measure. This measure is contained
within the asthma measures group.
PQRS 53: Asthma: Pharmacologic Therapy for
Persistent Asthma--Ambulatory Care Setting. Rationale: Changing PQRS
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registry only measure would affect this measure. There would be no way
to use the MAV with this measure because it is part of the MAV cluster
associated with PQRS 64.
PQRS 65 (NQF 0069): Appropriate
Treatment for Children with Upper Respiratory Infection (URI):
Percentage of children aged 3 months through 18 years with a diagnosis
of URI who were not prescribed or dispensed an antibiotic prescription
on or within 3 days of the initial date of service. Rationale: 2012
claims data indicates that a low threshold of eligible professionals
reported this measure. This proposal is also supported because there
are still a sufficient amount of measures for these eligible
professionals to report via claims.
PQRS 66 (NQF 0002): Appropriate Testing
for Children with Pharyngitis: Percentage of children aged 2 through 18
years with a diagnosis of pharyngitis, who were prescribed an
antibiotic and who received a group A streptococcus (strep) test for
the episode. A higher rate represents better performance (that is,
appropriate testing). Rationale: 2012 claims data indicates that a low
threshold of eligible professionals reported this measure. This
proposal is also supported because there are still a sufficient amount
of measures for these eligible professionals to report via claims.
PQRS 87 (NQF 0398): Hepatitis C: HCV
Ribonucleic Acid (RNA) Testing at Week 12 of Treatment: Percentage of
patients aged 18 years and older with a diagnosis of chronic hepatitis
C who are receiving antiviral treatment for whom quantitative HCV RNA
testing was performed at no greater than 12 weeks from the initiation
of antiviral treatment. Rationale: 2012 claims data indicates that a
low threshold of eligible professionals reported this measure. This
proposal is also supported because there are still a sufficient amount
of measures for these eligible professionals to report via claims.
PQRS 89 (NQF 0401): Hepatitis C:
Counseling Regarding Risk of Alcohol Consumption: Percentage of
patients aged 18 years and older with a diagnosis of hepatitis C who
were counseled about the risks of alcohol use at least once within 12-
months. Rationale: 2012 claims data indicates that a low threshold of
eligible professionals reported this measure. This proposal is also
supported because there are still a sufficient amount of measures for
these eligible professionals to report via claims.
PQRS 90 (NQF 0394): Hepatitis C:
Counseling Regarding Use of Contraception Prior to Antiviral Therapy:
Percentage of female patients aged 18 through 44 years and all men aged
18 years and older with a diagnosis of chronic Hepatitis C who are
receiving antiviral treatment who were counseled regarding
contraception prior to the initiation of treatment. Rationale: 2012
claims data indicates that a low threshold of eligible professionals
reported this measure. This proposal is also supported because there
are still a sufficient amount of measures for these eligible
professionals to report via claims
PQRS 116 (NQF 0058): Antibiotic
Treatment for Adults with Acute Bronchitis: Avoidance of Inappropriate
Use: Percentage of adults aged 18 through 64 years with a diagnosis of
acute bronchitis who were not prescribed or dispensed an antibiotic
prescription on or within 3 days of the initial date of service.
Rationale: 2012 claims data indicates that a low threshold of eligible
professionals reported this measure. This proposal is also supported
because there are still a sufficient amount of measures for these
eligible professionals to report via claims.
PQRS 126: DM: Diabetic Foot and Ankle Care,
Peripheral Neuropathy-Neurological Evaluation. Rationale: 2012 claims
data indicates that a low threshold of eligible professionals reported
this measure. This proposal is also supported because there are still a
sufficient amount of measures for these eligible professionals to
report via claims.
PQRS 127 (NQF 0416): Diabetes Mellitus:
Diabetic Foot and Ankle Care, Ulcer Prevention--Evaluation of Footwear:
Percentage of patients aged 18 years and older with a diagnosis of
diabetes mellitus who were evaluated for proper footwear and sizing.
Rationale: 2012 claims data indicates that a low threshold of eligible
professionals reported this measure. This proposal is also supported
because there are still a sufficient amount of measures for these
eligible professionals to report via claims.
PQRS 176 (AQA Adopted): Rheumatoid Arthritis
(RA): Tuberculosis Screening: Percentage of patients aged 18 years and
older with a diagnosis of RA who have documentation of a tuberculosis
(TB) screening performed and results interpreted within 6 months prior
to receiving a first course of therapy using a biologic disease-
modifying anti-rheumatic drug (DMARD). Rationale: 2012 claims data
indicates that a low threshold of eligible professionals reported this
measure. This proposal is also supported because there are still a
sufficient amount of measures for these eligible professionals to
report via claims.
PQRS 177 (AQA Adopted): Rheumatoid Arthritis
(RA): Periodic Assessment of Disease Activity: Percentage of patients
aged 18 years and older with a diagnosis of RA who have an assessment
and classification of disease activity within 12 months. Rationale:
2012 claims data indicates that a low threshold of eligible
professionals reported this measure. This proposal is also supported
because there are still a sufficient amount of measures for these
eligible professionals to report via claims.
PQRS 178 (AQA Adopted): Rheumatoid Arthritis
(RA): Functional Status Assessment: Percentage of patients aged 18
years and older with a diagnosis of RA for whom a functional status
assessment was performed at least once within 12 months. Rationale:
2012 claims data indicates that a low threshold of eligible
professionals reported this measure. This proposal is also supported
because there are still a sufficient amount of measures for these
eligible professionals to report via claims.
PQRS 179 (AQA Adopted): Rheumatoid Arthritis
(RA): Assessment and Classification of Disease Prognosis: Percentage of
patients aged 18 years and older with a diagnosis of RA who have an
assessment and classification of disease prognosis at least once within
12 months. Rationale: 2012 claims data indicates that a low threshold
of eligible professionals reported this measure. This proposal is also
supported because there are still a sufficient amount of measures for
these eligible professionals to report via claims.
PQRS 148 (NQF 0322): Back Pain: Initial
Visit: Percentage of patients aged 18 through 79 years with a diagnosis
of back pain or undergoing back surgery who had back pain and function
assessed during the initial visit to the clinician for the episode of
back pain. Rationale: We believe this measure (which is only reportable
when reporting the entire Back Pain measures group) is more
appropriately reported via registry.
PQRS 149 (NQF 0319): Back Pain: Physical
Exam: Percentage of patients aged 18 through 79 years with a diagnosis
of back pain or undergoing back surgery who received a physical
examination at the initial visit to the clinician for the episode of
back pain. Rationale: We believe this measure (which is only reportable
when reporting the entire Back Pain measures group) is more
appropriately reported via registry.

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PQRS 150 (NQF 0314): Back Pain: Advice
for Normal Activities: Percentage of patients aged 18 through 79 years
with a diagnosis of back pain or undergoing back surgery who received
advice for normal activities at the initial visit to the clinician for
the episode of back pain. Rationale: We believe this measure (which is
only reportable when reporting the entire Back Pain measures group) is
more appropriately reported via registry.
PQRS 151 (NQF 0313): Back Pain: Advice
Against Bed Rest: Percentage of patients aged 18 through 79 years with
a diagnosis of back pain or undergoing back surgery who received advice
against bed rest lasting four days or longer at the initial visit to
the clinician for the episode of back pain. Rationale: We believe this
measure (which is only reportable when reporting the entire Back Pain
measures group) is more appropriately reported via registry.
d. The Clinician Group (CG) Consumer Assessment of Healthcare Providers
and Systems (CAHPS) Survey
Because we believe these patient surveys are important tools for
assessing beneficiary experience of care and outcomes, under our
authority under section 1848(m)(3)(C) of the Act to select the measures
for which a group practice must report, we previously proposed a new
satisfactory reporting criterion in this section to provide group
practices comprised of 25 or more eligible professionals the option to
complete the CG CAHPS survey for purposes of satisfying the 2014 PQRS
incentive and 2016 PQRS payment adjustment. Specifically, the survey
measures that we propose to use for the PQRS program includes the
following 12 summary survey measures:
Getting timely care, appointments, and information;
How well providers Communicate;
Patient's Rating of Provider;
Access to Specialists;
Health Promotion & Education;
Shared Decision Making;
Health Status/Functional Status;
Courteous and Helpful Office Staff;
Care Coordination;
Between Visit Communication;
Helping Your to Take Medication as Directed; and
Stewardship of Patient Resources.
The first seven measures proposed above are the same ones used in
the Medicare Shared Savings Programs. As stated previously, we believe
it is important to align measures across programs to the extent
possible. The remaining five measures proposed above address arreas of
high importance to Medicare and are areas where patient experience can
inform the quality of care related to care coordination and efficiency.
Please note that the group practice would bear the cost of having this
survey administered. We seek public comment on these proposed measures.
11. Statutory Requirements and Other Considerations for the Selection
of PQRS Quality Measures for Meeting the Criteria for Satisfactory
Participation in a Qualified Clinical Data Registry for 2014 and Beyond
for Individual Eligible Professionals
For the measures for which eligible professionals participating in
a qualified clinical data registry must report, section 1848(m)(3)(D)
of the Act, as amended and added by section 601(b) of the American Tax
Relief Act of 2012, provides that the Secretary shall treat eligible
professionals as satisfactorily submitting data on quality measures if
they satisfactorily participate in a qualified clinical data registry.
Section 1848(m)(3)(E) of the Act, as added by section 601(b) of the
American Tax Relief Act of 2012, provides some flexibility with regard
to the types of measures applicable to satisfactory participation in a
qualified clinical data registry, by specifying that with respect to
measures used by a qualified clinical data registry, sections
1890(b)(7) and 1890A(a) of the Act shall not apply, and measures
endorsed by the entity with a contract with the Secretary under section
1890(a) of the Act may be used. We propose to provide to qualified
clinical data registries flexibility with regard to choosing the
quality measures data available for individual eligible professionals
to choose from to report to CMS using these qualified clinical data
registries. We believe it is preferable for the qualified clinical data
registries with flexibility in selecting measures since we believe
these clinical data registries would know best what measures should be
reported to achieve the goal of improving the quality of care furnished
by their eligible professionals. Although we are proposing to allow
these clinical data registries to determine the quality measures from
which individual eligible professionals would choose to have reported
to CMS, to ensure that CMS receives the same type of data that could be
uniformly analyzed by CMS and sufficient measure data, we believe it is
important to set parameters on the measures to be reported on and the
types of measures should be reported to CMS. Therefore, we are
proposing the following requirements for the measures that must be
reported to CMS by a qualified clinical data registry for the purpose
of its individual eligible professionals meeting the criteria for
satisfactory participation under the PQRS:
The qualified clinical data registry must have at least 9
measures, covering at least 3 of the 6 National Quality Strategy
domains, available for reporting. The 6 National Quality Strategy
domains are as follows:
++ Person and Caregiver-Centered Experience and Outcomes. These are
measures that reflect the potential to improve patient-centered care
and the quality of care delivered to patients. They emphasize the
importance of collecting patient-reported data and the ability to
impact care at the individual patient level as well as the population
level through greater involvement of patients and families in decision
making, self-care, activation, and understanding of their health
condition and its effective management.
++ Patient Safety. These are measures that reflect the safe
delivery of clinical services in both hospital and ambulatory settings
and include processes that would reduce harm to patients and reduce
burden of illness. These measures should enable longitudinal assessment
of condition-specific, patient-focused episodes of care.
++ Communication and Care Coordination. These are measures that
demonstrate appropriate and timely sharing of information and
coordination of clinical and preventive services among health
professionals in the care team and with patients, caregivers, and
families in order to improve appropriate and timely patient and care
team communication.
++ Community/Population Health. These are measures that reflect the
use of clinical and preventive services and achieve improvements in the
health of the population served. These are outcome-focused and have the
ability to achieve longitudinal measurement that will demonstrate
improvement or lack of improvement in the health of the US population.
++ Efficiency and Cost Reduction. These are measures that reflect
efforts to significantly improve outcomes and reduce errors. These
measures also impact and benefit a large number of patients and
emphasize the use of evidence to best manage high priority conditions
and determine appropriate use of healthcare resources.
++ Effective Clinical Care. These are measures that reflect
clinical care processes closely linked to outcomes based on evidence
and practice guidelines.

[[Page 43477]]

The qualified clinical data registry must have at least 1
outcome measure available for reporting, which is a measure that
assesses the results of health care that are experienced by patients
(that is, patients' clinical events; patients' recovery and health
status; patients' experiences in the health system; and efficiency/
cost).
The qualified clinical data registry may report on process
measures, which are measures that focus on a process which leads to a
certain outcome, meaning that a scientific basis exists for believing
that the process, when executed well, will increase the probability of
achieving a desired outcome.
The outcome and process measures reported must contain
denominator data. That is, the lower portion of a fraction used to
calculate a rate, proportion, or ratio. The denominator must describe
the population eligible (or episodes of care) to be evaluated by the
measure. This should indicate age, condition, setting, and timeframe
(when applicable). For example, ``Patients aged 18 through 75 years
with a diagnosis of diabetes.''
The outcome and process measures reported must contain
numerator data. That is, the upper portion of a fraction used to
calculate a rate, proportion, or ratio. The numerator must detail the
quality clinical action expected that satisfies the condition(s) and is
the focus of the measurement for each patient, procedure, or other unit
of measurement established by the denominator (that is, patients who
received a particular service or providers that completed a specific
outcome/process).
The qualified clinical data registry must provide
denominator exceptions for the measures, where approriate. That is,
those conditions that should remove a patient, procedure or unit of
measurement from the denominator of the performance rate only if the
numerator criteria are not met. Denominator exceptions allow for
adjustment of the calculated score for those providers with higher risk
populations. Denominator exceptions allow for the exercise of clinical
judgment and should be specifically defined where capturing the
information in a structured manner fits the clinical workflow. Generic
denominator exception reasons used in measures fall into three general
categories: Medical, Patient, or System reasons.
The qualified clinical data registry must provide
denominator exclusions for the measures for which it will report to
CMS, where appropriate. That is, those patients with conditions who
should be removed from the measure population and denominator before
determining if numerator criteria are met. (For example, Patients with
bilateral lower extremity amputations would be listed as a denominator
exclusion for a measure requiring foot exams.)
The qualified clinical data registry must provide to CMS
descriptions for the measures for which it will report to CMS by no
later than March 31, 2014. The descriptions must include: name/title of
measures, NQF (if NQF endorsed), descriptions of the
denominator, numerator, and when applicable, denominator exceptions and
denominator exclusions of the measure.
We request comments on these proposals.
12. Proposals for PQRS Informal Review
Section 414.90(j) provides that eligible professionals and group
practices may request an informal review of the determination that an
eligible professional or group practice did not satisfactorily submit
data on quality measures under the PQRS. Because we believe it is
important to also allow eligible professionals who attempt to
satisfactorily participate in a qualified clinical data registry to be
able to request an informal review of the determination that the
eligible professional satisfactorily participated in a qualified
clinical data registry, we are proposing to modify Sec. 414.90(j) to
allow individual eligible professionals who attempt to satisfactorily
participate in a qualified clinical data registry the opportunity to
request an informal review. We are not proposing to make any changes to
the informal review process itself; rather, we propose to make the
existing informal review process available to individual eligible
professionals with regard to a determination that the individual
eligible professional did not satisfactorily participate in a qualified
clinical data registry.
We seek public comment on this proposal.
13. Plan for the Future of PQRS for the 2017 PQRS Payment Adjustment
and Beyond
a. Future PQRS Reporting Periods
Under Sec. 414.90(h)(1), the reporting period for the PQRS payment
adjustment, for the payment adjustment year, is the 12-month period
from January 1 through December 31 that falls 2 years prior to the year
in which the payment adjustment is applied. When we first proposed the
reporting periods for the PQRS payment adjustment, we received many
comments from stakeholders who opposed basing the PQRS payment
adjustment year on a reporting period occurring two years prior to the
payment adjustment year (77 FR 69176). Stakeholders requested that CMS
establish reporting periods occurring closer to the year in which the
payment adjustment is applied. Although we understood the commenters'
concerns, we stated it was not operationally feasible to create a full
calendar year reporting period for the PQRS payment adjustment any
later than two years prior to the adjustment year and still avoid
retroactive payments or the reprocessing of claims. Although it is
still operationally infeasible to establish a 12-month reporting period
occurring any later than two years prior to the adjustment year for
reporting via claims, we are seeking comment about this issue again. In
particular, in future years, should CMS consider establishing a
reporting period that occurs closer to the adjustment year for certain
PQRS reporting mechanisms, such as the registry, EHR, and GPRO web
interface reporting mechanisms? Also, should the reporting periods
still be structured as 12-month reporting periods occurring in a
calendar year or multiple years? What length of time should be used for
the reporting period? For example, should the PQRS allow for shorter,
quarterly reporting periods? We would consider such comments to the
extent we address or revisit the reporting period for the PQRS payment
adjustment in future rulemaking.
b. Plan for the Future of the PQRS GPRO
The PQRS GPRO has undergone significant changes since it was first
introduced in 2010. Given stakeholder feedback with claims that
constant changes to the GPRO has caused confusion for GPRO
participants, we did not propose many changes to the GPRO for the 2014
PQRS incentive or 2016 PQRS payment adjustment. However, we continue to
receive stakeholder feedback urging CMS to reconsider certain policies
related to the GPRO, such as:
The definition of a PQRS group practice that limits the
practice to a single TIN. A group practice in PQRS is currently defined
at Sec. 414.90(b) as ``a single Tax Identification Number (TIN) with 2
or more eligible professionals, as identified by their individual
National Provider Identifier (NPI), who have reassigned their billing
rights to the TIN.'' Therefore, for group practices, CMS uses the TIN
as the billing unit. Any PQRS incentive payments earned

[[Page 43478]]

are paid to the TIN holder of record. Stakeholders believe that
limiting the definition of a group practice to ``a single TIN'' causes
operational challenges to group practices that may operate as one
healthcare entity but, due to business purposes, bill Medicare using
multiple TINs.
This definition has become increasingly problematic particularly as
some CMS programs with quality reporting components allow group
practices containing multiple TINs to participate in these programs as
a single group practice. We understand this concern. Therefore, we seek
comment on whether we should modify the current definition of group
practice to account for multiple TINs (that is, change the
identification unit(s) to recognize a group practice). In addition, if
we allow groups with multiple TINs to participate in PQRS as a single
group practice, we seek comment on what parameters we should put in
place. For example, if we allow multiple TINs to participate in PQRS as
a single group practice, should we place geographical restrictions?
Should we require that groups wishing to participate as a single group
practice provide care for the same beneficiaries?
Self-Nomination/Registration Process. We currently require
group practices to self-nominate for each program year the group
practices wish to participate in PQRS using the GPRO. Stakeholders have
commented that annual self-nomination is duplicative, particularly when
no changes to a group practice's composition have been made. We
therefore seek comment as to whether, in future years, we should move
away from requiring group practices to self-nominate/register for the
GPRO each year. Once a group practice is approved to participate in
PQRS as a GPRO, should we automatically assume that a group practice
would participate in PQRS as a GPRO for future years until the group
practice indicates otherwise?
Satisfactory Reporting Criterion for Group Practices Using
the GPRO web interface. Currently, if the pool of assigned
beneficiaries for a group practice using the GPRO web interface is less
than the specified reporting threshold (i.e., 411 assigned
beneficiaries for group practices comprised of 100 or more eligible
professionals), then the group practice is required to report on 100
percent of assigned beneficiaries for purposes of both the PQRS
incentive and payment adjustment. Conceivably, a group practice could
have as few as one beneficiary assigned to the group practice and still
qualify for the PQRS incentive or avoid the PQRS payment adjustment as
long as the group practice successfully reports the measures included
in the web interface for that one beneficiary. As data collected from
the GPRO web interface starts getting used to calculate performance
benchmarks for the Value-based Payment Modifier and/or Physician
Compare, we question whether performance results from group practices
with few assigned beneficiaries could skew the benchmark calculations.
We, therefore, invite comment on whether we should establish minimum
reporting thresholds for group practices using the GPRO web interface
as well as seek comment on what the appropriate thresholds should be.
Or, should we consider requiring group practices to be in existence
prior to the start of the reporting period to use the GPRO web
interface?
c. Future of Use of the Claims-Based Reporting Mechanism in PQRS
According to the 2011 PQRS and eRx Experience Report, approximately
72 percent of eligible professionals (229,282 out of 320,422 eligible
professionals) participating in PQRS in 2011 did so using the claims-
based reporting mechanism. The claims-based reporting mechanism is the
most widely used PQRS reporting mechanism. Unfortunately, the claims-
based reporting mechanism is also the reporting mechanism that allows
for the most errors in reporting. Unlike the registry and EHR-based
reporting mechanisms, where the quality measures data is submitted at
the end of the reporting period, eligible professionals must report
quality measures data at the time they submit their claims for payment
for services. Therefore, registry and EHR users are at an advantage as
they are able to analyze their quality data at the end of the year for
any changes that may need to be made due to follow up care. In
addition, it is burdensome for CMS to analyze quality measures data
from the claims-based reporting mechanism because it takes several
months to analyze all claims for which reporting G-codes are submitted
to CMS.
For these reasons, we seek comment as to whether CMS should
eliminate the claims-based reporting mechanism beginning with the
reporting period (calendar year 2017) for the 2019 PQRS payment
adjustment.
d. Future Submission Timelines for the Registry, EHR, GPRO Web
Interface and Qualified Clinical Data Registry Reporting Mechanisms
In the CY 2013 PFS final rule, we finalized the following deadlines
for submitting quality measures data via claims, registry, EHR, and the
GPRO web interface:
For an eligible professional submitting PQRS quality
measures data via claims, an eligible professional is required to
submit no later than the last Friday of the second month after the end
of the reporting period, that is, processed by February 28, 2014 for
the reporting periods that end December 31, 2013 (77 FR 69178).
For eligible professionals and group practices submitting
quality measures data via registry and EHR, the registry or EHR is
required to submit quality measures data no later than the last Friday
of the February following the applicable reporting period (for example,
February 28, 2014 for reporting periods occurring in 2013) (77 FR
69182).
For group practices submitting quality measures data via
the GPRO web interface, we stated we would provide group practices that
are selected to participate in the GPRO using GPRO web interface
reporting option with access to the GPRO web interface by no later than
the first quarter of the year following the end of the reporting period
under which the group practice intends to report (77 FR 69187). For
example, for group practices selected for the GPRO for the 2013
incentive using the GPRO web interface tool, group practices selected
to participate in the GPRO would be provided with access to the GPRO
web interface by no later than the first quarter of 2014 for purposes
of reporting for the applicable 2013 reporting period for the
incentive.
We have received feedback from eligible professionals, group
practices, and vendors that the submission deadlines come too soon
after the close of the reporting period. Vendors, in particular, find
it difficult to meet the submission deadlines in time to submit quality
measures data on behalf of all their participating eligible
professionals and group practices. While it is not technically feasible
to allow for submission of quality measures data reported via claims
any later than the last Friday of the second month after the end of the
respective reporting period, we are exploring alternative deadlines for
quality measures data that is submitted via registry, EHR, the GPRO web
interface, and the newly proposed qualified clinical data registry.

[[Page 43479]]

Specifically, we are exploring ways to collect quality measures data on
a quarterly basis, rather than allowing for submission of quality
measures data only once following a respective reporting period. We
seek public comment on allowing for quarterly submission of quality
measures data as well as other alternatives that would allow CMS with
the time necessary to perform quality measures data analysis prior to
the assessment of PQRS payment adjustments.
e. Integration of Clinical Quality Measures Reported Under the Hospital
Inpatient Quality Reporting (IQR) Program
We received feedback that, for certain hospital-based physicians
who bill Medicare Part B services and therefore are able to participate
in PQRS, the measures CMS has adopted under the PQRS do not adequately
capture the nature of their practice. These physicians believe that
measures such as those available in the Hospital IQR Program are more
relevant to the quality of care these physicians provide. Therefore,
under Section I.9, we proposed to include measures available under the
Hospital IQR Program that have been retooled to be reported under the
PQRS during the 12-month 2014 PQRS incentive and 12-month 2016 PQRS
payment adjustment reporting periods via the registry-based reporting
mechanism. We seek comment on whether additional Hospital IQR measures
should be retooled for use in the PQRS in the same manner. In addition,
we seek comment on whether CMS should attribute the reporting periods
and performance results from the hospital IQR program to individual
eligible professionals or group practices who elect to have their
hospital's performance scores attributed to them.
f. Feedback Reports
For eligible professionals reporting PQRS quality measures data via
claims, CMS provides each eligible professional who submits a valid
reporting quality data code (QDC) two feedback reports each year that
provides detailed information on an eligible professional's reporting
performance. These feedback reports only provide data on PQRS reporting
performance. Given our efforts to align with the Value-based Payment
Modifier, we are exploring ways to merge the feedback reports provided
to participants in the PQRS and Value-based Payment Modifier so that an
eligible professional would receive one, merged feedback report showing
reporting data for the PQRS and performance data for the Value-based
Payment Modifier. We seek public comment on whether feedback reports
for the PQRS and Value-based Payment Modifier should be merged.

I. Electronic Health Record (EHR) Incentive Program

The HITECH Act (Title IV of Division B of the ARRA, together with
Title XIII of Division A of the ARRA) authorizes incentive payments
under Medicare and Medicaid for the adoption and meaningful use of
certified EHR technology (CEHRT). Section 1848(o)(2)(B)(iii) of the Act
requires that in selecting clinical quality measures (CQMs) for
eligible professionals (EPs) to report under the EHR Incentive Program,
and in establishing the form and manner of reporting, the Secretary
shall seek to avoid redundant or duplicative reporting otherwise
required. As such, we have taken steps to establish alignments among
various quality reporting and payment programs that include the
submission of CQMs.
For CY 2012 and subsequent years, Sec. 495.8(a)(2)(ii) requires an
EP to successfully report the clinical quality measures selected by CMS
to CMS or the states, as applicable, in the form and manner specified
by CMS or the states, as applicable. In the EHR Incentive Program Stage
2 Final Rule, we established clinical quality measure reporting options
for the Medicare EHR Incentive Program for CY 2014 and subsequent years
that include one individual reporting option that aligns with the
PQRS's EHR reporting option (77 FR 54058) and two group reporting
options that align with the PQRS GPRO and Medicare Shared Savings
Program (MSSP) and Pioneer ACOs (77 FR 54076 to 54078). In this
proposed rule, we are proposing two additional aligned options for EPs
to report CQMs for the Medicare EHR Incentive Program for CY 2014 and
subsequent years with the intention of minimizing the reporting burden
on EPs.
1. Proposed Qualified Clinical Data Registry Reporting Option
Section 1848(m)(7) of the Act (``Integration of Physician Quality
Reporting'') requires the Secretary to develop a plan to integrate
reporting on quality measures under the PQRS with reporting
requirements related to meaningful use under the EHR Incentive Program.
In response to section 1848(m)(7) of the Act, the PQRS and EHR
Incentive Program have, in particular, taken steps to align their
respective quality measures reporting criteria. For example, in the CY
2013 PFS final rule with comment period (77 FR 69190), the PQRS adopted
criteria for satisfactory reporting for the 2014 PQRS incentive that
aligns with the criteria for meeting the CQM component of achieving
meaningful use under the Medicare EHR Incentive Program in 2014.
Specifically, under the PQRS, an individual EP will meet the criteria
for satisfactory reporting for the 2014 PQRS incentive using a direct
EHR or EHR data submission vendor product that is CEHRT certified to
the 2014 Edition certification criteria if, during the 12-month 2014
PQRS incentive reporting period, the EP reports 9 measures covering at
least 3 National Quality Strategy domains. If an eligible
professional's CEHRT does not contain patient data for at least 9
measures covering at least 3 domains, then the eligible professional
must report the measures for which there is patient data (see Table 91,
77 FR 69194 through 69195).
As further described in section G of this proposed rule, section
1848(m)(3)(D) of the Act, as amended and added by section 601(b) of the
American Taxpayer Relief Act of 2012, includes a provision that
authorizes an additional standard for individual eligible professionals
to meet the PQRS by satisfactorily participating in a qualified
clinical data registry. In section G of this proposed rule, we proposed
criteria for eligible professionals to satisfactorily participate in a
qualified clinical data registry for the 2014 PQRS incentive.
For purposes of meeting the CQM reporting component of meaningful
use for the Medicare EHR Incentive Program in 2014 and subsequent
years, we propose to allow EPs to submit CQM information using
qualified clinical data registries, according to the proposed
definition and requirements for qualified clinical data registries
discussed in section IV.I. of this proposed rule. We are proposing this
new option under the Medicare EHR Incentive Program beginning with the
reporting periods in 2014 for the following reasons: (1) To minimize
duplicative reporting as directed under section 1848(o)(2)(B)(iii) of
the Act for EPs who seek to participate in both the Medicare EHR
Incentive Program and a qualified clinical data registry under the PQRS
in 2014; (2) to further integrate reporting quality reporting options
under the PQRS and the EHR Incentive Program as directed under section
1848(m)(7) of the Act; and (3) because the proposed criteria for the
satisfactory participation in a qualified clinical data registry for
the 2014 PQRS incentive are similar to criteria we finalized for
meeting the CQM component of achieving meaningful use under the

[[Page 43480]]

Medicare EHR Incentive Program for 2014. In the event that the criteria
established for satisfactory participation in a qualified clinical data
registry under PQRS in the final rule are different from the proposed
criteria, we intend to adopt the criteria that are finalized for PQRS
to the extent feasible for the Medicare EHR Incentive Program. In
addition to the criteria that are ultimately established for PQRS, we
propose the following additional criteria that an EP who seeks to
report CQMs for the Medicare EHR Incentive Program using a qualified
clinical data registry must satisfy: (1) The EP must use CEHRT as
required under the Medicare EHR Incentive Program; (2) the CQMs
reported must be included in the Stage 2 final rule (see Table 8, 77 FR
54069) and use the same electronic specifications established for the
EHR Incentive Program, (3) report 9 CQMs covering at least 3 domains,
(4) if an EP's CEHRT does not contain patient data for at least 9 CQMs
covering at least 3 domains, then the EP must report the CQMs for which
there is patient data and report the remaining CQMs as ``zero
denominators'' as displayed by the EP's CEHRT, and (5) an EP must have
CEHRT that is certified to all of the certification criteria required
for CQMs, including certification of the qualified clinical data
registry itself for the functions it will fulfill (for example,
calculation, electronic submission). We note that these proposed
additional criteria are already final policies for the CQM reporting
options that we established for EPs in the EHR Incentive Program Stage
2 final rule. We refer readers to that final rule for further
explanation of the policies related to clinical quality measure
reporting under the EHR Incentive Program (77 FR 54049-54089). The
electronic specifications for the clinical quality measures can be
found at http://www.cms.gov/Regulations-and-Guidance/Legislation/EHRIncentivePrograms/eCQM_Library.html. We are proposing this
qualified clinical data registry reporting option only for those EPs
who are beyond their first year of demonstrating meaningful use (MU).
For purposes of avoiding a payment adjustment under Medicare, EPs who
are in their first year of demonstrating MU in the year immediately
preceding a payment adjustment year must satisfy their CQM reporting
requirements by October 1 of such preceding year (for example, by
October 1, 2014 to avoid a payment adjustment in 2015). The proposed
qualified clinical data registry reporting option would not enable an
EP to meet the deadline to avoid a payment adjustment because these
qualified clinical data registries would be submitting data on CQMs by
the last day of February following the 2014 PQRS incentive reporting
periods, which would occur after October 1, 2013. Therefore, EPs who
are first-time meaningful EHR users must report CQMs via attestation as
established in the EHR Incentive Program Stage 2 final rule (77 FR
54050). The reporting periods established in the EHR Incentive Program
Stage 2 final rule would continue to apply to EPs who would choose to
report CQMs under this proposed qualified clinical data registry
reporting option for purposes of the Medicare EHR Incentive Program (77
FR 54049-54051). Please note that this may not satisfy requirements for
other quality reporting programs that have established 12-month
reporting periods, such as the PQRS.
Under section 1848(o)(2)(A)(iii) of the Act, EPs are required to
use CEHRT to submit information on clinical quality measures for the
EHR Incentive Program. The 2014 Edition certification criteria
established by the Office of the National Coordinator for Health IT
(ONC) set the requirements for certification that cover the
functionality needed to ``capture and export'' (45 CFR 170.314(c)(1)),
``import and calculate'' (45 CFR 170.314(c)(2)), and for ``electronic
submission'' (45 CFR 170.314(c)(3)) of each CQM that will be reported.
As EPs are required to use CEHRT under section 1848(o)(2)(A)(iii)
of the Act, we propose that for the Medicare EHR Incentive Program, an
EP who seeks to report using a qualified clinical data registry that
meets the criteria established for PQRS must also ensure that the
registry selected is certified for the functionality that it is
intended to fulfill and is a certified EHR Module that is part of the
EP's CEHRT. For example, if the registry would collect patient level
data from EPs, calculate the CQMs, then submit to CMS the calculated
results on behalf of the EP in either an aggregate level Quality
Reporting Document Architecture (QRDA) Category III file or patient
level QRDA-I files, then the registry would need to be certified for
the CQM criteria listed at 45 CFR 170.314(c)(2) (``import and
calculate'') for each CQM that will be submitted and 45 CFR
170.314(c)(3) (``electronic submission''). We note that EPs would still
need to include a certified EHR Module as part of their CEHRT that is
certified to the CQM criteria listed at 45 CFR 170.314(c)(1) (``capture
and export'') for each of the CQMs that would be submitted to CMS for
the purposes of meeting the CQM requirements of the Medicare EHR
Incentive Program. If the qualified clinical data registry is
performing the function of data capture for the CQMs that would be
submitted to CMS, then the registry would need to be certified to the
``capture and export'' criteria listed at 45 CFR 170.314(c)(1). The
certified EHR Module must be part of the EP's CEHRT.
We intend to revisit the certification criteria with ONC in the
Stage 3 rulemaking for the purpose of developing a more flexible
clinical data registry reporting option and certification criteria for
the EHR Incentive Program when Stage 3 begins. We welcome public
comment and recommendations on a more flexible clinical data registry
reporting option for meeting the CQM reporting requirement for MU and
on the certification criteria that ONC could incorporate for clinical
data registries.
2. Proposed Group Reporting Option--Comprehensive Primary Care
Initiative
The Comprehensive Primary Care (CPC) Initiative, under the
authority of section 3021 of the Affordable Care Act, is a multi-payer
initiative fostering collaboration between public and private health
care payers to strengthen primary care. Under this initiative, CMS will
pay participating primary care practices a care management fee to
support enhanced, coordinated services. Simultaneously, participating
commercial, State, and other federal insurance plans are also offering
an enhanced payment to primary care practices that provide high-quality
primary care. There are approximately 500 CPC participants across 7
health care markets in the U.S. More details on the CPC Initiative can
be found at http://innovation.cms.gov/initiatives/Comprehensive-Primary-Care-Initiative/index.html.
CPC practice sites will submit a subset of the CQMs that were
selected in the EHR Incentive Program Stage 2 final rule for EPs to
report under the EHR Incentive Program beginning in CY 2014 (77 FR
54069-54075). In a continuing effort to align quality reporting
programs and innovation initiatives, we propose to add a group
reporting option for CQMs for the Medicare EHR Incentive Program
beginning in CY 2014 for EPs who are part of a CPC practice site that
successfully submits at least 9 electronically specified CQMs covering
3 domains. We propose that each of the EPs in the CPC practice site
would satisfy the CQM reporting component of meaningful use for the
relevant

[[Page 43481]]

reporting period if the CPC practice site successfully submits and
meets the reporting requirements of the CPC Initiative. We propose that
only those EPs who are beyond their first year of demonstrating
meaningful use may use this proposed CPC group reporting option, for
the reasons explained in the preceding section in regard to avoiding a
payment adjustment under Medicare. We propose that EPs who successfully
submit as part of a CPC practice site in accordance with the
requirements established for the CPC Initiative and using CEHRT would
satisfy their CQM reporting requirement for the Medicare EHR Incentive
Program. The CPC practice sites must submit the CQM data in the form
and manner required by the CPC Initiative.
If a CPC practice site fails the requirements established for the
CPC Initiative, we note that the EPs who are part of the site would
have the opportunity to report CQMs per the requirements established in
the EHR Incentive Program Stage 2 final rule for EPs to report under
the EHR Incentive Program beginning in CY 2014 (77 FR 54049). We invite
public comment on these proposals.
3. Reporting of Electronically Specified Clinical Quality Measures for
the Medicare EHR Incentive Program
In the EHR Incentive Program Stage 2 final rule, we finalized the
CQMs from which EPs would report beginning in CY 2014 under the EHR
Incentive Program (77 FR 54069, Table 8). These CQMs are electronically
specified and updated routinely to account for issues such as changes
in billing and diagnosis codes and changes in medical practices. The
requirements specified in the EHR Incentive Program Stage 2 final rule
for EPs to report under the EHR Incentive Program beginning in CY 2014
allow for the reporting of different versions of the CQMs. However, it
is not technically feasible for CMS to accept data that is reported
according to the specifications of the older versions of the CQMs,
including versions that may be allowed for reporting under the EHR
Incentive Program. We stated in the EHR Incentive Program Stage 2 final
rule that, consistent with section 1848(o)(2)(B)(ii) of the Act, in the
event that the Secretary does not have the capacity to receive CQM data
electronically, EPs may continue to report CQM data through attestation
(77 FR 54076). Therefore, we propose that EPs who seek to report CQMs
electronically under the Medicare EHR Incentive Program must use the
most recent version of the electronic specifications for the CQMs and
have CEHRT that is tested and certified to the most recent version of
the electronic specifications for the CQMs. For example, for the
reporting periods in 2014, EPs who want to report CQM data
electronically for purposes of satisfying the quality measure reporting
component of meaningful use would be required to use the June 2013
version of the CQMs electronic specifications (available at http://www.cms.gov/Regulations-and-Guidance/Legislation/EHRIncentivePrograms/eCQM_Library.html) and ensure that their CEHRT has been tested and
certified to the June 2013 version of the CQMs for purposes of
achieving the CQM component of meaningful use in 2014. EPs who do not
wish to report CQMs electronically using the most recent version of the
electronic specifications (for example, if their CEHRT has not been
certified for that particular version) would be allowed to report CQM
data to CMS by attestation for the Medicare EHR Incentive Program. For
further explanation of reporting CQMs by attestation, we refer readers
to the EHR Incentive Program Stage 1 final rule (77 FR 44430 through
44434) and the EHR Incentive Program's Registration and Attestation
page (available at https://ehrincentives.cms.gov/hitech/login.action).
We invite public comment on these proposals. Specifically, we
invite comment on whether there would be sufficient time for EHR
technology developers to update their systems and timely distribute the
updated CQM versions in a way that would enable EPs to report on the
updated versions. Additionally, we invite comment on whether there are
any data or logic dependencies in the eCQMs that EHR technology
developers have experienced which, if not built in upfront and deployed
before a reporting period, would result in inaccurate measures, if for
example, an EHR technology was upgraded in the middle of an EP's
reporting period to the newest version of the CQMs (if we finalized our
proposal to only accept the lasted published specification of an CQM).

J. Medicare Shared Savings Program

Under section 1899 of the Act, CMS has established a Medicare
Shared Savings Program (Shared Savings Program) to facilitate
coordination and cooperation among providers to improve the quality of
care for Medicare Fee-For-Service (FFS) beneficiaries and reduce the
rate of growth in healthcare costs. Eligible groups of providers and
suppliers, including physicians, hospitals, and other healthcare
providers, may participate in the Shared Savings Program by forming or
participating in an Accountable Care Organization (ACO). The final rule
implementing the Shared Savings Program appeared in the Federal
Register on November 2, 2011 (Medicare Shared Savings Program:
Accountable Care Organizations Final Rule (76 FR 67802)).
ACOs are required to completely and accurately report on all
quality performance measures for all quality measurement reporting
periods in each performance year of their agreement period. There are
currently 33 quality performance measures under the Shared Savings
Program. For Shared Savings Program ACOs beginning their agreement
period in April or July, 2012, there will be two reporting periods in
the first performance year, corresponding to calendar years 2012 and
2013. For ACOs beginning their agreement periods in 2013 or later, both
the performance year and reporting period will correspond to the
calendar year. Reporting on measures associated with a reporting period
will generally be done in the spring of the following calendar year.
For example, an ACO will submit quality measures for the 2015 reporting
period in the spring of 2016.
1. Medicare Shared Savings Program and Physician Quality Reporting
System Payment Adjustment
Section 1899(b)(3)(D) of the Act affords the Secretary discretion
to ``* * * incorporate reporting requirements and incentive payments
related to the physician quality reporting initiative (PQRI), under
section 1848, including such requirements and such payments related to
electronic prescribing, electronic health records, and other similar
initiatives under section 1848 * * *'' and permits the Secretary to
``use alternative criteria than would otherwise apply [under section
1848 of the Act] for determining whether to make such payments.'' Under
this authority, we incorporated certain Physician Quality Reporting
System (PQRS) reporting requirements and incentive payments into the
Shared Savings Program, including (1) The 22 GPRO quality measures
identified in Table 1 of the final rule (76 FR 67889 through 67890);
(2) reporting via the GPRO web interface; (3) criteria for satisfactory
reporting; and (4) set January 1 through December 31 as the reporting
period. The regulation governing the incorporation of PQRS incentives
and reporting requirements

[[Page 43482]]

under the Shared Savings Program is set forth at Sec. 425.504.
Under section 1848(a)(8) of the Act, a payment adjustment will
apply under the PQRS beginning in 2015 based on quality reporting
during the applicable reporting period. Eligible professionals who are
not satisfactory reporters will be subject to a payment adjustment
applied to the PFS amount for covered professional services furnished
by the eligible professional during 2015. For eligible professionals
subject to the 2015 PQRS payment adjustment, the fee schedule amount is
equal to 98.5 percent (and 98 percent for 2016 and each subsequent
year) of the fee schedule amount that would otherwise apply to such
services. To continue to align Shared Savings Program requirements with
PQRS, for the 2013 reporting period (which will be used to determine
the 2015 PQRS payment adjustment to PFS amounts), in the CY 2013 PFS
final rule with comment (77 FR 69372), we amended Sec. 425.504 to
include the PQRS reporting requirements necessary for eligible
professionals in an ACO to avoid the 2015 PQRS payment adjustment.
Specifically, we required ACOs on behalf of eligible professionals that
are ACO providers/suppliers to successfully report one ACO GPRO measure
in 2013 to avoid the payment adjustment in 2015. We also provided that
ACO providers/suppliers that are eligible professionals may only
participate under their ACO participant TIN as a group practice under
the PQRS GPRO for purposes of avoiding the payment adjustment in 2015.
Thus, ACO providers/suppliers who are eligible professionals may not
seek to avoid the payment adjustment by reporting either as an
individual under the traditional PQRS or under the traditional PQRS
GPRO under their ACO participant TIN. We note, however, that eligible
professionals may bill Medicare under more than one TIN (for example,
eligible professionals may bill Medicare under a non-ACO participant
TIN in one practice location and also bill Medicare under the TIN of an
ACO participant at another practice location). As a result, ACO
provider/suppliers who are eligible professionals that bill under a
non-ACO participant TIN during the year could participate under the
traditional PQRS as either individual EPs or a group practice for
purposes of avoiding the PQRS payment adjustment for the claims billed
under the non-ACO participant TIN. In fact, such EPs would have to do
so to avoid the PQRS payment adjustment with respect to those claims
because the regulation at Sec. 425.504 only applies to claims
submitted by ACO providers/suppliers that are eligible professionals
billing under an ACO participant TIN. If eligible professionals within
an ACO meet the requirements for the PQRS payment adjustment
established under the Shared Savings Program, only the claims billed
through the TIN of the ACO participant will avoid the payment
adjustment in 2015.
For the 2014 reporting period and subsequent reporting periods
(which would apply to the PQRS payment adjustment for 2016 and
subsequent payment years), we propose to align with the requirements
for reporting under the traditional PQRS GPRO through the CMS web
interface by amending Sec. 425.504 to require that ACOs on behalf of
their ACO providers/suppliers who are eligible professionals
satisfactorily report the 22 ACO GPRO measures during the 2014 and
subsequent reporting periods to avoid the downward PQRS payment
adjustment for 2016 and subsequent payment years. Additionally, we
propose to continue the current requirement that ACO providers/
suppliers who are eligible professionals may only participate under
their ACO participant TIN for purposes of the payment adjustment in
2016 and subsequent years.
We believe that the proposal to modify the requirements for ACOs to
satisfactorily report the 22 ACO GPRO measures to avoid the 2016
payment adjustments would not increase burden on ACOs or on ACO
providers/suppliers that are eligible professionals because ACOs must
already report these measures in order to satisfy the Shared Savings
Program quality performance standard. Thus, this proposal would not
increase the total number of measures that must be reported by the ACO
and its ACO providers/suppliers that are eligible professionals. We
also note that these proposals would not affect the Shared Savings
Program quality performance standard reporting requirement under which
ACOs are currently required to report on 33 quality performance
measures, which include all 22 of the ACO GPRO quality measures.
Additionally, ACOs are required to report certain measures using
the GPRO web interface tool. Specifically, Sec. 425.504(a)(1) and
(b)(1) require that ACOs submit quality measures using the GPRO web
interface to qualify on behalf of their eligible professionals for the
PQRS incentive or to avoid the PQRS payment adjustment. This reporting
mechanism is also referenced in Sec. 425.308(e), which provides that
quality measures that ACOs report using the GPRO web interface will be
reported by CMS on Physician Compare.
Under Sec. 414.90(h)(3)(i), group practices may report data under
the traditional PQRS GPRO through a CMS web interface. The Shared
Savings Program regulations 425.504(a)(1) and (b)(1) and Sec.
425.308(e) specifically reference the use of the GPRO web interface for
quality reporting purposes. We propose to amend these regulations to
replace references to GPRO web interface with CMS web interface. We
believe this change will ensure consistency with the reporting
mechanism used under 414.90(h)(3)(i) and will also allow for the
flexibility to use a similar web interface in the event that
operational issues are encountered with the use of the GPRO web
interface. We invite public comment on this proposal.

2. Medicare Shared Savings Program-Establishing the Quality Performance
Benchmark

Section 1899(b)(3)(C) of the Act directs the Secretary to ``* * *
establish quality performance standards to assess the quality of care
furnished by ACOs * * *'' and to ``improve the quality of care
furnished by ACOs over time by specifying higher standards, new
measures, or both for purposes of assessing such quality of care.'' In
the Shared Savings Program final rule, we finalized the following
requirements with regard to establishing a performance benchmark for
measures: (1) During the first performance year for an ACO, the quality
performance standard is set at the level of complete and accurate
reporting; (2) during subsequent performance years, the quality
performance standard will be phased in such that ACOs will be assessed
on their performance on each measure; (3) CMS designates a performance
benchmark and minimum attainment level for each measure, and
establishes a point scale for the measures; and (4) contingent upon
data availability, performance benchmarks are defined by CMS based on
national Medicare fee-for-service rates, national Medicare Advantage
(MA) quality measure rates, or a national flat percentage. In the final
rule, we indicated that we would not compare an ACO's quality
performance to the performance of other ACOs for purposes of
determining an ACO's overall quality score. We acknowledged, however,
that in future program years, we should seek to incorporate actual ACO
performance on quality measures into the quality benchmarks after
seeking industry input through rulemaking.

[[Page 43483]]

a. Data Sources Used To Establish Performance Benchmarks
The regulation governing the data that CMS will use to establish
the performance benchmarks for quality performance measures under the
Shared Savings Program is set forth at Sec. 425.502(b)(2). This
provision states that CMS will define the performance benchmarks based
on national Medicare fee-for-service rates, national MA quality measure
rates, or a national flat percentage. In the Shared Savings Program
final rule, we responded to comments suggesting that quality
performance benchmarks be set based on actual historical data submitted
by ACOs. We stated that although we agreed that we should seek to
incorporate actual ACO performance on quality scores into the quality
benchmark, we would do so only in future rulemaking so that we could
seek industry input. In addition, we noted that we expected to update
the quality benchmarks over time, consistent with section 1899(b)(3)(C)
of the Act, which requires CMS to seek to improve the quality of care
furnished by ACOs participating in the Shared Savings Program over
time.
Consistent with our stated intention to incorporate actual ACO
experience into quality measure benchmarks, for the 2014 reporting
period, we propose to amend Sec. 425.502(b)(2) to permit CMS to use
all available and applicable national Medicare Advantage and Medicare
FFS performance data to set the quality performance benchmarks.
Specifically, in addition to using available national Medicare FFS
rates, which include data reported through PQRS, and national MA
quality measure rates, we propose to use data submitted by Shared
Savings Program and Pioneer ACOs in 2013 for the 2012 reporting period
to set the performance benchmarks for the 2014 reporting period. We
propose to publish the quality benchmarks based upon these data prior
to the beginning of the 2014 reporting period through subregulatory
guidance. As stated in the Shared Savings Program final rule, we will
establish benchmarks using the most currently available data source and
the most recent available year of benchmark data prior to the start of
the reporting period. In other words, data collected in 2014 from the
2013 reporting period would be used in conjunction with other available
data to set benchmarks for the 2015 reporting period, and so on. We
propose to retain the option of using flat percentages when data are
unavailable, inadequate or unreliable to set quality performance
benchmarks. Further, we clarify our intent to combine data derived from
national Medicare Advantage and national Medicare FFS to set
performance benchmarks when the measure specifications used under
Medicare Advantage and FFS Medicare are the same. We propose to revise
Sec. 425.502(b)(2)(i) to reflect this clarification. We seek comment
on these proposals, and whether there are other data sources that
should be considered in setting performance benchmarks.
b. Ensuring Meaningful Differences in Performance Rates
Data collected by CMS from the GPRO and Physician Group Practice
Demonstration participants in 2012 coupled with previous CMS experience
indicates that using actual data to calculate quality performance may
result in some measures' performance rates being tightly clustered. In
this case, quality scores for the measure may not reflect clinically
meaningful differences between the performance rates achieved by
reporters of quality. For example, for some measures, the distribution
of performance rates may have a spread of less than 2.0 percentage
points between the 30th and 90th percentiles. In such an instance, even
though there is little distinction in actual performance rates, a
slight difference in performance on the measure may result in a
significant difference in the number of quality points obtained for the
Shared Savings Program. For example, two separate ACOs at the 50th
percentile and the 90th percentile may have only a few tenths of a
percentage point difference in their actual performance, but under the
Shared Savings Program scoring methodology, the difference between
their quality scores for that measure would be more noteworthy (1.4
points versus 2.0 points).
We continue to believe it is desirable to use performance rates for
measures based on actual data because doing this creates benchmarks
that are simple to understand and apply, even if the rates are
clustered, as the data reflect achievable performance on quality
measures. However, allowing clustered performance rates for a measure
may result in payment differences that are not be associated with
clinically meaningful differences in patient care, as noted in the
example above.
Keeping these issues in mind, we propose to develop a methodology
to spread clustered performance on measures. The first step in
developing that methodology is to identify when performance on a
measure is clustered. Clustering could be defined as less than a
certain spread between performance rates in an identified range, for
example, less than 6.0 percentage points between the performance rates
associated with the 30th and 90th percentiles, or less than 10.0
percentage points between the minimum and maximum values achieved by
previous reporters of the quality measure. Alternatively, clustering
could be defined as a spread of performance rates of less than x
percentage points between any two deciles, for example, less than a 1.0
percentage point difference between the 60th and 70th decile.
Once a clustered measure has been identified, the next step is to
apply a methodology to spread or separate the performance rates within
the measure. It is important to establish a meaningful performance
rate, or starting point, around which to differentiate or spread the
performance. For example, selecting a certain percentile or median
value may represent one option for establishing a reasonable starting
point. Once the starting point is set, then we could implement a series
of fixed percentage point intervals around the starting point in both a
positive and negative direction to increase the spread, for example,
applying a fixed 1.0 percentage point interval between scored deciles.
For example, if the starting point is the 60th percentile, and the
performance rates at the 60th and 70th percentiles were observed to be
77.15 and 77.65 respectively, there would be only a 0.5 spread between
the deciles. In contrast, applying a fixed 1.0 percentage point
interval to increase spread would result in a 1.0 difference between
these rates, and the new performance rates would be 77.15 and 78.15 at
the 60th and 70th percentiles, respectively. In the alternative, we
could take the spread calculated from a subset (for example, ACO
performance only) of the underlying performance data if we believe that
data reported by ACOs show a different variability than other data
sources. For example, the spread between the measure's percentiles
could be based on historical ACO distribution only, not the historical
distribution of Medicare Advantage and/or national fee-for-service,
PQRS, and ACO data. The historical ACO distribution could then be
applied to the Medicare Advantage and/or national fee-for-service,
PQRS, and ACO percentile distribution to establish the measure's
percentiles.
We believe that a clinically meaningful assessment of ACO quality
is important. We also are interested in providing a pathway for ACOs
new to quality reporting to achieve the quality reporting standard, and
an incentive for

[[Page 43484]]

experienced ACOs to continue improving and performing at high levels.
We are therefore proposing to use a standardized method for calculating
benchmark rates when a measure's performance rates are tightly
clustered. We propose that the application of a methodology to reduce
measure clustering would only apply to quality measures whose
performance rates are calculated as percentiles, that is, the
methodology would not apply to measures whose performance rates are
calculated as ratios, for example, measures such as the two ACO
Ambulatory Sensitive Conditions Admissions and the All Condition
Readmission measure. We believe that measures whose performance rates
are calculated as ratios already demonstrate a high degree of
clinically meaningful differences because they are risk adjusted to
reflect the health status of the patient population being measured.
We propose to define a tightly clustered measure, including
clinical process and outcome measures reported through the GPRO web
interface and CAHPS measures, as one that demonstrates less than a 6.0
percentage point spread in performance rates between the 30th and 90th
percentiles. We believe using the 30th and 90th percentiles as the
lower and upper bounds is reasonable because these bounds have been
given some significance in earlier rulemaking; specifically, the Shared
Savings Program rule sets the ACO's minimum attainment level at the
30th percentile, below which the ACO achieves no points, and the ACO
achieves full points for quality reporting at or above the 90th
percentile. Further, we propose to establish the starting point at the
60th percentile, the midpoint between the 30th and 90th percentiles,
and then apply a positive 1.0 fixed percentage point interval for each
decile above the 60th percentile and a negative 1.0 fixed percentage
point interval for each decile below the 60th percentile.
We recognize that spreading tightly clustered performance measures
would decrease the lower bound necessary to meet the minimum attainment
level for the measure, giving ACOs new to quality reporting a greater
opportunity to meet the quality performance standard. At the same time,
spreading tightly clustered performance rates would increase the upper
bound necessary for achieving the maximum available quality points for
the measure, giving already experienced ACOs an incentive to continue
improving quality. Applying a 1.0 fixed percentage point interval
achieves the goal of creating meaningful differences in performance.
Further, we believe that applying a 1.0 fixed percentage point interval
represents a tempered and reasonable interval that does not spread
performance rates to levels that are too easy to achieve on the lower
bound or too difficult to achieve on the upper bound.
For example, Table 57 demonstrates the original spread of a quality
measure, based on all available data, which is compressed from a range
of 75.83 at the 30th percentile to 79.23 at the 90th percentile, that
is, a spread of less than 6.0 percentage points. When the proposed
methodology is applied, the 60th percentile (or 77.15 percent), serving
as the starting point, remains unchanged. The spread increases 6.0
percentage points from 74.15 at the 30th percentile to 80.15 at the
90th percentile. As demonstrated and explained above, this methodology
improves the distinction in performance between the minimum attainment
level (30th percentile) and the maximum attainment level (90th
percentile).

Table 57--Proposed Methodology To Reduce Clustered Performance Rates
----------------------------------------------------------------------------------------------------------------
Percentile 30th 40th 50th 60th 70th 80th 90th
----------------------------------------------------------------------------------------------------------------
Original performance rates using all available 75.83 76.21 76.76 77.15 77.65 78.21 79.23
data............................................
Performance rates using methodology to reduce 74.15 75.15 76.15 77.15 78.15 79.15 80.15
clustering......................................
----------------------------------------------------------------------------------------------------------------
*Example is for illustration purposes only and is not based on actual data.

We propose to amend Sec. 425.502(b) to reflect this methodology to
reduce clustering. We are seeking comment on these proposals.
Specifically, we are seeking comment on whether or not a methodology
should be applied to spread out clustered performance on measures. We
are also seeking comment on the proposal to define clustered
performance on a measure as one in which the spread of performance
rates between the 30th and 90th percentiles is less than 6.0 percentage
points, or whether other values should be used to define clustered
measure performance, for example, when the minimum and maximum reported
values are spread by less than 10.0 percentage points. We are seeking
comment on whether there are alternative methodologies that should be
considered to spread out clustered performance on measures. In
addition, we are seeking comment on whether measures that are
calculated as ratios should be excluded from this methodology. We are
also seeking comment on whether all available relevant data should be
considered when developing the spread between measures, or whether only
the relevant performance data from a subset of reporters, such as ACO-
reported data, as discussed above, should be used to determine the
appropriate spread between deciles.
c. Scoring CAHPS Measures Within the Patient Experience of Care Domain
The preamble to the Shared Savings Program final rule (76 FR 67895-
67900) outlines the total potential points available per domain as
demonstrated in Table 58. As indicated in Table 58, under the final
rule the Patient/Caregiver Experience Domain is weighted equally with
other three quality domains at 25 percent and consists of 2 measures: a
composite of six Clinician and Group (CG) CAHPS summary survey measures
(1) Getting Timely Care, Appointments and Information, (2) How Well
Your Doctors Communicate, (3) Patient's Rating of Doctor, (4) Access to
Specialists, (5) Health Promotion and Education, (6) Shared Decision
Making) and a Health Status/Functional Status measure. The six measures
included in the composite will transition to pay-for-performance
starting in the second year of an ACO's agreement period. In contrast,
the Health Status/Functional Status measure will remain pay-for-
reporting throughout the ACO's entire agreement period.

[[Page 43485]]

Table 58--Total Points for Each Domain Within the Quality Performance Standard
----------------------------------------------------------------------------------------------------------------
Total Total
individual Total measures for scoring potential Domain
Domain measures purposes points per weight
(table F1) domain (percent)
----------------------------------------------------------------------------------------------------------------
Patient/Caregiver Experience............ 7 1 measure, with 6 survey module 4 25
measures combined, plus 1
individual measure.
Care Coordination/...................... 6 6 measures, plus the EHR 14 25
Patient Safety.......................... measure double-weighted (4
points).
Preventative Health..................... 8 8 measures..................... 16 25
At Risk Population...................... 12 7 measures, including 5 14 25
component diabetes composite
measure and 2 component CAD
composite measure.
-----------------------------------------------------------------------
Total................................... 33 23............................. 48 100
----------------------------------------------------------------------------------------------------------------
*From Table 4 in the Shared Savings Program Final Rule (76 FR 67899).

The result of this point system is that performance on the six
patient experience measures is worth only 12.5 percent of an ACO's
total performance score because the other 12.5 percent of the Patient/
Caregiver Experience domain is the Health Status/Functional Status
measure, which is a pay-for-reporting measure for all program years.
However, we believe that each of these seven measures is equally
important within the Patient/Caregiver Experience domain, and that
scoring within the domain should better reflect performance on these
measures, thereby placing a greater emphasis on the voice of the
patient through patient-reported outcomes and experiences. We believe
that increasing the weight of the 6 measures that will become pay-for-
performance in the second year of the agreement period will incentivize
ACOs to improve their performance on these measures. A policy to place
a greater emphasis on patient-reported outcomes and experiences is
consistent with our goal to improve the quality of care furnished by
ACOs over time.
Therefore, we are proposing to modify the point scoring for the
Patient/Caregiver Experience domain as demonstrated in Table 59. As
modified, each of the 7 survey module measures within the domain would
be assigned a maximum value of 2 points. The Patient/Caregiver
Experience domain would then be worth a total of 14 points, rather than
4 points. The end result would be that each of the 7 measure modules in
the domain would have equal weight. We note that this change would not
affect the weighting of the domain itself in relationship to the other
three domains; it would remain 25 percent of the ACO's total quality
performance score.

Table 59--Modified Total Points for Each Domain Within the Quality Performance Standard
----------------------------------------------------------------------------------------------------------------
Total Total
individual Total measures for scoring potential Domain
Domain measures purposes points per weight
(table F1) domain (percent)
----------------------------------------------------------------------------------------------------------------
Patient/Caregiver Experience............ 7 7 individual survey module 14 25
measures.
Care Coordination/Patient Safety........ 6 6 measures, plus the EHR 14 25
measure double-weighted (4
points).
Preventative Health..................... 8 8 measures..................... 16 25
At Risk Population...................... 12 7 measures, including 5 14 25
component diabetes composite
measure and 2 component CAD
composite measure.
-----------------------------------------------------------------------
Total............................... 33 28............................. 58 100
----------------------------------------------------------------------------------------------------------------

We believe that giving equal weight to each of the Patient/
Caregiver Experience measures modules is appropriate because it places
greater emphasis on patient-reported experiences, promotes clinically
meaningful differences in ACO performance within the domain, and is
consistent with the statutory mandate to improve quality of care
furnished by ACOs over time. The proposed change would also bring the
total points for the domain in line with the points available in other
domains.
We seek comment on our proposal to modify the point scoring within
the Patient/Caregiver Experience domain.

K. Value-Based Payment Modifier and Physician Feedback Program

1. Overview
Section 1848(p) of the Act requires that we establish a value-based
payment modifier and apply it to specific physicians and groups of
physicians the Secretary determines appropriate starting January 1,
2015 and to all physicians and groups of physicians by January 1, 2017.
On or after January 1, 2017, section 1848(p)(7) of the Act provides the
Secretary discretion to apply the value-based payment modifier to
eligible professionals as defined in section 1848(k)(3)(B) of the Act.
Section 1848(p)(4)(C) of the Act requires the value-based payment
modifier to be budget neutral.
In this proposed rule, we continue to phase in implementation of
the value-based payment modifier by applying it to small groups of
physicians and by increasing the amount of payment at risk. We also
propose to refine the methodologies used in our approach to calculating
the value-based payment modifier in order to better identify both high
and low performers for upward and downward payment adjustments.
2. Governing Principles for Physician Value-Based Payment Modifier
Implementation
In the CY 2013 PFS final rule with comment period (77 FR 69306), we

[[Page 43486]]

stated that the value-based payment modifier has the potential to help
transform Medicare from a passive payer to an active purchaser of
higher quality, more efficient and more effective healthcare by
providing upward payment adjustments under the PFS to high performing
physicians (and groups of physicians) and downward adjustments for low
performing physicians (and groups of physicians). We also noted that
Medicare is implementing value-based payment adjustments for other
types of services, including inpatient hospital services. Further, in
implementing value-based purchasing initiatives generally, we seek to
recognize and reward high quality care and quality improvements, and to
promote more efficient and effective care through the use of evidence-
based measures, the reduction in administrative burden and duplication,
and less fragmented care.
In the CY 2013 PFS final rule with comment period, we established
that the following specific principles should govern the implementation
of the value-based payment modifier (77 FR 69307).
A focus on measurement and alignment. Measures for the
value-based payment modifier should consistently reflect differences in
performance among physicians and physician groups, reflect the
diversity of services furnished, and be consistent with the National
Quality Strategy and other CMS quality initiatives, including the PQRS,
the Medicare Shared Savings Program, and the Medicare EHR Incentive
Program.
A focus on physician choice. Physicians should be able to
choose the level (individual or group) at which their quality
performance will be assessed, reflecting physicians' choice over their
practice configurations. The choice of level should align with the
requirements of other physician quality reporting programs.
A focus on shared accountability. The value-based payment
modifier can facilitate shared accountability by assessing performance
at the group practice level and by focusing on the total costs of care,
not just the costs of care furnished by an individual physician.
A focus on actionable information. The Physician Feedback
reports should provide meaningful and actionable information to help
groups of physicians and physicians identify clinical areas where they
are doing well, as well as areas in which performance could be improved
by providing groups of physicians with feedback reports on the quality
and cost of care they furnish to their patients.
A focus on a gradual implementation. The value-based
payment modifier should focus initially on identifying high and low
performing groups of physicians. Moreover, groups of physicians should
be able to elect how the value-based payment modifier would apply to
their payment under the PFS starting in CY 2015. As we gain more
experience with physician measurement tools and methodologies, we can
broaden the scope of measures assessed, refine physician peer groups,
create finer payment distinctions, and provide greater payment
incentives for high performance.
3. Overview of Existing Policies for the Physician Value-Based Payment
Modifier
In the CY 2013 PFS final rule with comment period, we finalized
policies to phase-in the value-based payment modifier by applying it
starting January 1, 2015 to payments under the Medicare PFS for
physicians in groups of 100 or more eligible professionals. We identify
a group of physicians as a single taxpayer identification number (TIN).
For purposes of establishing group size only, we use the definition of
an eligible professional as specified in section 1848(k) of the Act. We
apply the value-based payment modifier to the Medicare paid amounts for
the items and services billed under the PFS at the TIN level so that
beneficiary cost-sharing is not affected. We apply the value-based
payment modifier to the items and services billed by physicians under
the TIN, not to other eligible professionals that also may bill under
the TIN. We identify groups of physicians subject to the value-based
payment modifier for CY 2015 based on a query of Medicare's Provider
Enrollment, Chain, and Ownership System (PECOS) on October 15, 2013,
and we remove any groups from this list if, based on a claims analysis,
the group of physicians did not have 100 or more eligible professionals
that submitted claims during the performance period (77 FR 69310).
We established CY 2013 as the performance period for the value-
based payment modifier that will be applied to payments during CY 2015
and CY 2014 as the performance period for the value-based payment
modifier that will be applied to payments in CY 2016 (77 FR 69314). We
also finalized that we will not apply the value-based payment modifier
in CYs 2015 and 2016 to any group of physicians that is participating
in the Medicare Shared Savings Program, the Pioneer ACO model, or the
Comprehensive Primary Care Initiative or other similar Innovation
Center initiatives (77 FR 69313). From an operational perspective, we
will apply this policy to any group of physicians in which one or more
physician(s) participate(s) in one of these programs or initiatives
during performance periods CY 2013 or CY 2014.
We finalized policies to determine the amount of the value-based
payment modifier for CY 2015 by categorizing groups of physicians with
100 or more eligible professionals into two categories. Category 1
includes groups of physicians that either (a) self-nominate for the
PQRS as a group and report at least one measure or (b) elect the PQRS
Administrative Claims option as a group. Category 2 includes groups
that do not fall within either of the two subcategories (a) or (b) of
Category 1. Groups within Category 1 may elect to have their value-
based payment modifier for CY 2015 calculated using the quality-tiering
methodology, which could result in an upward, neutral, or downward
adjustment amount. For groups that make this election, we use the
performance rates on the quality measures reported through the PQRS
reporting mechanism that the group selects for 2013 (that is, group
practice reporting option (GPRO) web-interface, CMS-qualified registry,
or PQRS Administrative Claims option) and the performance rates on
three outcome measures to calculate the group's quality composite under
the quality-tiering approach. If a group in Category 1 that elects
quality-tiering self-nominates for the GPRO web-interface or CMS-
qualified registry and does not meet the satisfactory reporting
criteria for the PQRS incentive payment, we use the group's performance
on the Administrative Claims option to calculate the group's quality
composite under the quality-tiering approach. The value-based payment
modifier for groups of physicians in Category 1 that do not elect-
quality tiering is 0.0 percent, meaning that these groups will not
receive a payment adjustment under the value-based payment modifier for
CY 2015. Category 2 includes groups that do not fall within either of
the two subcategories (a) or (b) of Category 1. For the groups that are
in Category 2, the value-based payment modifier for the CY 2015 payment
adjustment period is -1.0 percent.
We also finalized the following policies to calculate the value-
based payment modifier using the quality-tiering approach. The quality-
tiering approach requires creation of quality and cost composites for
each group of physicians subject to the value-based payment modifier.
The following brief summary describes the policies adopted in last
year's final rule with comment

[[Page 43487]]

period (77 FR 69320 through 69326). To create the quality composite, we
create a standardized score for each quality measure reported through
the group's selected PQRS reporting mechanism, as well as the group's
performance on three outcome measures (two composite measures of
potentially preventable hospital admissions for acute and chronic
conditions and a measure of all-cause hospital readmissions). The
standardized score for each quality measure is calculated by dividing
the difference between the group's performance rate and the measure's
benchmark (the national mean of the measure's performance rate from the
previous year) by the measure's standard deviation. The standardized
scores for each measure are classified into one of six domains based on
the national priorities related to clinical care, patient experience,
population/community health, patient safety, care coordination, and
efficiency established in the National Quality Strategy. Within each
domain, we weight each measure's standardized score equally to arrive
at a domain score. The domains are then equally weighted to form a
quality of care composite. When a domain does not contain quality
measures (for example, when a group chooses a reporting mechanism that
does not contain measures in the domain), the remaining domains would
be equally weighted to form the quality of care composite.
Additionally, we finalized a policy to construct the cost composite
using five measures of total per capita costs for beneficiaries
attributed to the group practice. The five measures are total per
capita costs (both Parts A and B) and total per capita costs for
beneficiaries with four specific chronic conditions: chronic
obstructive pulmonary disease (COPD), heart failure, coronary artery
disease (CAD), and diabetes. We attribute beneficiaries to each group
using a two-step process that examines whether the group furnished the
plurality (that is, more than any other group) of primary care services
to the beneficiary. This attribution methodology is similar to the
attribution rule we use for the Medicare Shared Savings Program and the
PQRS GPRO web interface. We create a standardized score for each
measure by dividing the difference between the group's performance rate
and the measure's benchmark (the national mean of the measure's
performance rate for the performance period) by the measure's standard
deviation. We then classify each measure's standardized score into one
of two domains: total per capita costs for all attributed beneficiaries
(one measure) and total per capita costs for all attributed
beneficiaries with specific conditions (four measures). Within each
cost domain, each measure is equally weighted. In those instances in
which we cannot calculate a particular cost measure because, for
example, the number of cases is fewer than 20, we will weight the
remaining cost measures in the domain equally. Similar to the quality
of care composite, each cost domain is weighted equally to form the
cost composite, unless one of the domains contains no measures, in
which case the remaining domain will be weighted at 100 percent.
Under the quality-tiering approach, each group's quality and cost
composites are classified into high, average, and low categories
depending upon whether the composites are one or more standard
deviations above or below the mean. We compare the group's quality of
care composite classification with the cost composite classification to
determine the value-based payment modifier adjustment for the CY 2015
payment adjustment period according to the amounts in Table 60.

Table 60--2015 Value Modifier Amounts for the Quality-Tiering Approach
------------------------------------------------------------------------
Average
Quality/cost Low cost cost High cost
------------------------------------------------------------------------
High quality..................... +2.0x* +1.0x* +0.0%
Average quality.................. +1.0x* +0.0% -0.5%
Low quality...................... +0.0% -0.5% -1.0%
------------------------------------------------------------------------
* Groups of physicians eligible for an additional +1.0x if (1) reporting
Physician Quality Reporting System quality measures through the GPRO
web-interface or CMS-qualified registry, and (2) average beneficiary
risk score is in the top 25 percent of all beneficiary risk scores.

To ensure budget neutrality, we first aggregate the downward
payment adjustments in Table 60 for those groups in Category 1 that
have elected quality tiering with the -1.0 percent downward payment
adjustments for groups of physicians subject to the value-based payment
modifier that fall within Category 2. Using the aggregate downward
payment adjustment amount, we then calculate the upward payment
adjustment factor (x). These calculations will be done after the
performance period has ended. Accordingly, because the performance
period for the CY 2015 value-based payment modifier is CY 2013, these
calculations will be performed after December 31, 2013.
This scoring methodology also provides an additional upward payment
adjustment of +1.0x to groups of physicians that care for high-risk
patients (as evidenced by the average HCC risk score of the attributed
beneficiary population) and submit data on PQRS quality measures
through PQRS via the GPRO using the web-interface or CMS-qualified
registry. We will increase the upward payment adjustment from +2.0x to
+3.0x for groups of physicians classified as high quality/low cost and
from +1.0x to +2.0x for groups of physicians that are either high
quality/average cost or average quality/low cost if the group of
physicians' attributed beneficiary population has an average risk score
that is in the top 25 percent of the distribution of beneficiary risk
scores nationwide. This additional upward payment adjustment (+1.0x for
the CY 2015 payment adjustment period) will not apply to groups of
physicians that select the PQRS Administrative Claims reporting
mechanism. Finally, we provide an informal review process to enable a
group of physicians to inquire about the calculation of its value-based
payment modifier.
Since adopting these policies, the Institute of Medicine released a
new report, ``Interim Report of the Committee on Geographic Variation
in Health Care Spending and Promotion of High-Value Care: Preliminary
Committee Observations,'' observing that to improve value, ``payment
reforms need to create incentives to encourage behavioral change at the
locus of care (providers and patient).'' \2\ Our approach to
implementing the value-based payment modifier is consistent with this
vision because it ties a group practice's payment to its

[[Page 43488]]

actions by rewarding high performing groups of physicians and
penalizing low-performing groups of physicians.
---------------------------------------------------------------------------

\2\ Institute of Medicine, ``Interim Report of the Committee on
Geographic Variation in Health Care Spending and Promotion of High-
Value Health Care: Preliminary Committee Observations,'' (2013),
p.29.
---------------------------------------------------------------------------

On January 31, 2013, we submitted two cost measures--the total per
capita costs for all attributed beneficiaries measure and the Medicare
Spending per Beneficiary measure--to the National Quality Forum for
endorsement. We have gained valuable feedback on a variety of issues
(for example, attribution and risk adjustment) as we work with the
National Quality Forum on the endorsement process for our cost
measures. CMS is committed to refining our cost measures through future
rulemaking based on feedback we receive from NQF and other
stakeholders.
As discussed below in section K.5, we provided 2011 Quality and
Resource Use Reports (QRURs) to 54 large group practices and to over
31,000 individual physicians in nine states that practice in group of
physicians with 25 or more eligible professionals. These reports
contained performance information on the quality of care furnished, and
the cost of that care, to Medicare beneficiaries by these physicians
and groups of physicians. Overall findings and results from these
reports confirm that we can develop reliable and valid quality and cost
measures at the group and individual physician level on which to base
the value-based payment modifier. Moreover, group report recipients
have found the reports informative and they have suggested ways to
improve them to facilitate care coordination and quality improvement.
We have adopted many of these suggestions in the QRUR reports that we
plan to make available later this year.
4. Provisions of This Proposed Rule
In this proposed rule, we propose additions and refinements to the
existing value-based payment modifier policies. These proposals
continue our phased-in implementation of the value-based payment
modifier by reinforcing our emphasis on quality measurement, alignment
with the PQRS, physician choice, and shared accountability.
Specifically, this proposed rule includes the following proposals:
To apply the value-based payment modifier to groups of
physicians with 10 or more eligible professionals in CY 2016.
To make quality-tiering mandatory for groups within
Category 1 for the CY 2016 value-based payment modifier, except that
groups of physicians with between 10 and 99 eligible professionals
would be subject only to any upward or neutral adjustment determined
under the quality-tiering methodology, and groups of physicians with
100 or more eligible professionals would be subject to upward, neutral,
or downward adjustments determined under the quality-tiering
methodology.
To increase the amount of payment at risk under the value-
based payment modifier from 1.0 percent to 2.0 percent in CY 2016.
To align the quality measures and quality reporting
mechanisms for the value-based payment modifier with those available to
groups of physicians under the PQRS during the CY 2014 performance
period.
To include the Medicare Spending Per Beneficiary (MSPB)
measure in the total per capita costs for all attributed beneficiaries
domain of the cost composite.
To refine the cost measure benchmarking methodology to
account for the specialties of the physicians in the group.
a. Group Size
In the CY 2013 PFS final rule with comment period, we stated that
we would gradually phase in the value-based payment modifier in CY 2015
by first applying it to large groups (77 FR 69308), which we defined as
groups of physicians with 100 or more eligible professionals. We noted
our view that it would be reasonable to focus on groups with 100 or
more eligible professionals before expanding the application of the
value-based payment modifier to more groups and solo practitioners in
CY 2016 and beyond.
To continue our phase-in of the value-based payment modifier, we
believe it is appropriate to lower the group size threshold for CY 2016
payment adjustments, which will be based on performance during CY 2014.
Table 61 shows the number of groups, eligible professionals (EPs) and
physicians in groups of various sizes based on an analysis of calendar
year 2011 claims with a 90-day run-out period. We note that the number
of EPs includes other practitioners, such as physician assistants and
nurse practitioners, in addition to physicians.

Table 61--Eligible Professional/Physician Group Size Distribution
[2011 claims]
----------------------------------------------------------------------------------------------------------------
Number of Eligible Number of Percent of Cumulative
Group size groups (TINs) professionals physicians physicians percentage
----------------------------------------------------------------------------------------------------------------
100+ EPs........................ 1,132 311,094 215,936 25.7 25.7
50-99EPs........................ 1,622 110,862 76,318 9.1 34.8
25-49 EPs....................... 3,729 126,596 88,065 10.5 45.3
20-24 EPs....................... 1,890 41,334 28,756 3.4 48.7
10-19 EPs....................... 8,653 116,379 81,829 9.7 58.4
2-9 EPs......................... 68,702 241,732 174.758 20.8 79.2
1 EP............................ 222,097 222,097 175,115 20.8 100.0
-------------------------------------------------------------------------------
Total....................... 307,825 1,170,094 840,777 100 ..............
----------------------------------------------------------------------------------------------------------------

We propose to apply the value-based payment modifier in CY 2016 to
groups of physicians with 10 or more eligible professionals. We
estimate that this proposal would cause approximately 17,000 groups
(TINs) and nearly 60 percent of physicians to be affected by the value-
based payment modifier in CY 2016. We believe this proposal continues
our policy to phase in the value-based payment modifier by ensuring
that the majority of physicians are covered in CY 2016 before it
applies to all physicians in CY 2017. As discussed below in Section
K.5, CMS conducted statistical reliability analyses on the PQRS quality
measures and the cost measures contained in the 2010 and 2011 groups
and individual Quality and Resource Use Reports (QRURs). These reports
contained the same PQRS quality measures and cost measures that we will
use for the value-based payment modifier. Both the quality and cost
measures in the group reports were statistically reliable at a high
level. Moreover, the average reliability score

[[Page 43489]]

was high for 98 percent of the individually reported PQRS measures and
all of the cost measures (with a case size of at least 20) included in
the individual feedback reports. Given these results, we believe that
we can reliably apply a value-based payment modifier to groups of
physicians with 10 or more eligible professionals in CY 2016 and to
smaller groups and to solo practitioners in future years. Accordingly,
we propose to revise the regulations at Sec. 414.1210 to reflect that
the CY 2016 value-based payment modifier would be applicable to
physicians that are in groups with ten or more eligible professionals.
We seek comments on this proposal.
We propose to identify groups of physicians that would be subject
to the value-based payment modifier (for example, for CY 2016, groups
of physicians with 10 or more eligible professionals) using the same
procedures that we finalized in the CY 2013 PFS final rule with comment
period (for a description of those procedures, we refer readers to 77
FR 69309 through 69310). Rather than querying Medicare's PECOS data
base as of October 15 or another date certain, however, we propose to
perform the query within 10 days of the close of the PQRS group self-
nomination/registration process during the relevant performance period
year. For example, for the CY 2016 value-based payment modifier, within
10 days of the close of the PQRS group self-nomination/registration
process that will occur during the fall of CY 2014. We propose to
revise the regulations at Sec. 414.1210(c) to reflect that
identification of the groups of physicians subject to the value-based
payment modifier is based on a query of PECOS at the close of the PQRS
registration period and that groups of physicians are removed from this
list if, based on a claims analysis, the group of physicians did not
have the required number of eligible professionals, as defined in Sec.
414.1210(a), that submitted claims during the performance period for
the applicable calendar year payment adjustment period. We seek comment
on this proposal.
b. Approach to Setting the Value-Based Payment Modifier Adjustment
Based on PQRS Participation
In the CY 2013 PFS final rule with comment period (77 FR 69311), we
adopted a policy to categorize groups of physicians subject to the
value-based payment modifier in CY 2015 based on a group's
participation in the PQRS. Specifically, we categorize groups of
physicians eligible for the CY 2015 value-based payment modifier into
two categories. Category 1 includes groups that either (a) self-
nominate for the PQRS as a group and report at least one measure or (b)
elect the PQRS Administrative Claims option as a group for CY 2013.
Groups of physicians in Category 1 may elect to have their value-based
payment modifier for CY 2015 calculated using the quality-tiering
methodology, which could result in an upward, neutral, or downward
adjustment amount. The value-based payment modifier for groups of
physicians in Category 1 that do not elect quality tiering is 0.0
percent, meaning that physicians in these groups will not receive a
payment adjustment under the value-based payment modifier for CY 2015.
Category 2 includes groups of physicians that do not fall within
Category 1. For those groups of physicians in Category 2, the value-
based payment modifier for CY 2015 is -1.0 percent.
We propose to use a similar two-category approach for the CY 2016
value-based payment modifier based on a group of physicians'
participation in the PQRS but with different criteria for inclusion in
Category 1. Category 2 would include those groups of physicians that
are subject to the CY 2016 value-based payment modifier and do not fall
within Category 1. Our proposal is intended to accommodate the various
ways in which physicians can participate in the PQRS in CY 2014--either
as a group practice participating in the PQRS GPRO or individually. We
established in the CY 2013 PFS final rule with comment period that
groups of physicians that wish to participate as a group in the PQRS
during CY 2014 must self-nominate and select one of three PQRS GPRO
reporting mechanisms: GPRO web interface, qualified registry, or EHR
(77 FR 69199 through 69200 (Table 93)). We also established the
criteria for satisfactory reporting of data on PQRS quality measures
via the GPRO for the PQRS payment adjustment for CY 2016 (77 FR 69200
through 69202) and we have proposed to modify these criteria as
described in Table 27 of this proposed rule. In order to maintain
alignment with the PQRS, for purposes of the CY 2016 value-based
payment modifier, we propose that Category 1 would include those groups
of physicians that meet the criteria for satisfactory reporting of data
on PQRS quality measures via the GPRO (through use of the web-
interface, EHRs, or qualified registry reporting mechanisms) for the CY
2016 PQRS payment adjustment.
We understand that not all groups of physicians may want to
participate in PQRS as a group under the GPRO in CY 2014. These groups
of physicians may prefer to have all of their eligible professionals
continue to report PQRS measures as individuals so that physicians and
other eligible professionals in the group are able to report data on
quality measures that reflect their own clinical practice. For example,
a thoracic surgeon in a multi-specialty group practice may wish to
report data on different quality measures than those on which a
dermatologist or urologist in the same group practice may wish to
report data. In addition, eligible professionals in these groups of
physicians may wish to use different reporting mechanisms to report
data for PQRS, such as the claims-based reporting mechanism, EHRs,
qualified registries, or the proposed qualified clinical data registry
reporting mechanism. Therefore, for the CY 2016 value-based payment
modifier, we propose to include in Category 1 groups of physicians that
do not self-nominate to participate in the PQRS as a group practice in
CY 2014 and that have at least 70 percent of the group's eligible
professionals meet the criteria for satisfactory reporting of data on
PQRS quality measures as individuals for the CY 2016 PQRS payment
adjustment, or in lieu of satisfactory reporting, satisfactorily
participate in a PQRS-qualified clinical data registry for the CY 2016
PQRS payment adjustment. The criteria for satisfactory reporting by
individual eligible professionals for the claims, qualified registry,
and EHR reporting mechanisms for the CY 2016 PQRS payment adjustment
were established in the CY 2013 PFS final rule with comment period (77
FR 69194 through 69195 (Table 91), 69200-69202). We are proposing in
Table 25 of this proposed rule the criteria for satisfactory
participation in a qualified clinical data registry and other proposed
changes to the criteria for satisfactory reporting for the CY 2016 PQRS
payment adjustment. Another way to state this proposal is that a group
of physicians subject to the CY 2016 value-based payment modifier would
be in Category 1 if at least 70 percent of the individual eligible
professionals in the group avoid the CY 2016 PQRS payment adjustment by
any of the reporting options available under the PQRS.
We are proposing a 70 percent threshold for three reasons. First,
although we expect 100 percent of a group's eligible professionals to
participate in PQRS, we believe that we will obtain a reliable
indicator of the

[[Page 43490]]

group's quality if at least 70 percent of the eligible professionals in
the group meet the criteria to avoid the PQRS payment adjustment. We
recognize that many individual eligible professionals may be reporting
data on PQRS measures for the first time in CY 2014 and we do not seek
to impose too high a burden on these groups that does not increase the
reliability of the group's quality performance data for purposes of the
value-based payment modifier. Second, the vast majority of eligible
professionals participate in the PQRS as individuals, not as members of
a group practice. Third, based on an examination of 2011 PQRS data, at
least 63 percent of groups of physicians (TINs) participating in the
PQRS with fewer than 50 eligible professionals would meet the 70
percent threshold already. At a 70 percent threshold, however, only 29
percent of groups of physicians participating in the PQRS of more than
100 eligible professionals have at least 70 percent of their eligible
professionals meeting the criteria for satisfactory reporting in 2011.
We believe that this result is consistent with our policy to encourage
group reporting by the very largest groups of physicians. Indeed, these
large groups have several reporting mechanisms available under the PQRS
GPRO including the web interface, registries, and EHRs. Accordingly, we
also propose to revise the regulation text at Sec. 414.1225, which was
previously specific to the CY 2013 performance period and only referred
to quality measures reported by groups of physicians rather than
individual eligible professionals within a group. We seek comment on
these proposals.
For a group of physicians that would be subject to the CY 2016
value-based payment modifier to be included in Category 1, the criteria
for satisfactory reporting (or the criteria for satisfactory
participation, in the case of the 70 percent option described above)
would need to be met during the CY 2014 performance period for the PQRS
CY 2016 payment adjustment. We note that any reporting periods that are
established under the PQRS would continue to apply for purposes of the
PQRS. In the event that the criteria that are finalized for the CY 2016
PQRS payment adjustment differ from what is proposed for the PQRS in
this proposed rule, our intention is to align the criteria for
inclusion in Category 1 to the extent possible with the criteria that
are ultimately established for the CY 2016 PQRS payment adjustment.
We propose to more fully phase-in the quality-tiering methodology
for calculating the value-based payment modifier for CY 2016 based on
the number of eligible professionals in the group. We propose that
groups in Category 1 would no longer have the option to elect quality
tiering for the CY 2016 value-based payment modifier (as was the case
for the CY 2015 value-based payment modifier) and instead would be
subject to mandatory quality tiering. We propose to apply the quality-
tiering methodology to all groups in Category 1 for the value-based
payment modifier for CY 2016, except that groups of physicians with
between 10 and 99 eligible professionals would be subject only to
upward or neutral adjustments derived under the quality-tiering
methodology, while groups of physicians with 100 or more eligible
professionals would be subject to upward, neutral, or downward
adjustments derived under the quality-tiering methodology. In other
words, we propose that groups of physicians in Category 1 with between
10 and 99 eligible professionals would be held harmless from any
downward adjustments derived from the quality-tiering methodology for
the CY 2016 value-based payment modifier. We believe this proposed
approach would reward groups of physicians that provide high-quality/
low-cost care, reduce program complexity, and more fully engage groups
of physicians in our plans to implement the value-based payment
modifier. Accordingly, we propose to revise the regulations at Sec.
414.1270 to reflect the proposal to make the quality-tiering
methodology mandatory, with the exception noted above, for all groups
of physicians subject to the value-based payment modifier in CY 2016
that fall within Category 1. We seek comment on this proposal. We are
also revising the regulations at Sec. 414.1270 to clarify that for the
CY 2015 payment adjustment period a group may be determined under the
quality-tiering methodology to have poor performance based on low
quality and high costs, low quality and average costs, or average
quality and high costs.
For groups of physicians with 100 or more eligible professionals,
we believe it is appropriate to begin to phase in both the upward and
the downward payment adjustments under the quality-tiering methodology
for the CY 2016 value-based payment modifier. Based on 2011 claims, we
estimate that there are approximately 1,100 groups of 100 or more
eligible professionals. We believe that such large groups should
already be focused on quality improvement and that they have ample
ability to do so. These groups should have developed the internal means
to track and improve the quality of care they furnish to Medicare FFS
beneficiaries. For example, several large group practices that have
participated in the PQRS GPRO have redesigned their electronic medical
records systems to capture data to continually monitor their
performance on those quality measures and provide alerts at the point
of care to physicians and practitioners to further facilitate provision
of high quality care to Medicare beneficiaries. Moreover under the
quality-tiering methodology for calculating the value-based payment
modifier as we established in the CY 2013 PFS final rule with comment
period and have updated in this proposed rule, groups of physicians
that furnish high quality care will not have a downward adjustment,
even if they furnish such care at high costs. Thus, we believe it is
appropriate to apply both upward and downward adjustments under the
quality-tiering methodology to groups of physicians with 100 or more
eligible professionals in 2016. We seek comments on our proposals and,
in the alternative, whether we should treat groups of physicians with
100 or more eligible professionals in the same manner as we propose to
treat groups of physicians with between 10 and 99 eligible
professionals under the quality-tiering methodology as described
previously.
Accordingly, we propose to revise Sec. 414.1270 to reflect these
proposals, including our proposals regarding mandatory quality-tiering.
We seek comment on these proposals.
c. Payment Adjustment Amount
Section 1848(p) of the Act does not specify the amount of payment
that should be subject to the adjustment for the value-based payment
modifier; however, section 1848(p)(4)(C) of the Act requires the value-
based payment modifier be implemented in a budget neutral manner.
Budget neutrality means that payments will increase for some groups of
physicians based on high performance and decrease for others based on
low performance, but the aggregate amount of Medicare spending in any
given year for physicians' services will not change as a result of
application of the value-based payment modifier.
In the CY 2013 PFS final rule with comment period, we adopted a
modest payment reduction of 1.0 percent for groups of physicians in
Category 1 that elected quality tiering and were classified as low
quality/high cost and for groups of physicians in Category 2 (77 FR
69323-24). Although we received comments suggesting that larger payment
adjustments (both

[[Page 43491]]

upward and downward) would be necessary to more strongly encourage
quality improvements, we finalized our proposed adjustments as we
believed they better aligned with our goal to gradually phase in the
value-based payment modifier. However, we noted that as we gained
experience with our value-based payment modifier methodologies, we
would likely consider ways to increase the amount of payment at risk
(77 FR 69324).
Since last year, we have further considered comments on ways to
better encourage improvements in physician efficiency and quality while
still gradually phasing in the value-based payment modifier. We agree
with commenters on the value of gradually strengthening the incentives
to improve performance by offering greater rewards for strong
performance along with increased financial risk for poorer performance.
As discussed below in section K.5, CMS conducted statistical
reliability analysis on the PQRS quality measures and the cost measures
contained in the 2010 and 2011 groups and individual physician feedback
reports. These reports contained the same PQRS quality measures and
cost measures that we will use for the value-based payment modifier.
The quality and cost measures in the group reports were statistically
reliable at a high level. Moreover, the average reliability score was
high for 98 percent of the individually reported PQRS measures and for
all of the cost measures (with a case size of at least 20) included in
the individual feedback reports. Thus, we believe that we can increase
the amount of payment at risk because we can reliably apply a value-
based payment modifier in CY 2016 to groups of physicians with 10 or
more eligible professionals and to smaller groups and to solo
practitioners in future years. Therefore, we propose to increase the
downward adjustment under the value-based payment modifier from 1.0
percent in CY 2015 to 2.0 percent for CY 2016. That is, for CY 2016, a
-2.0 percent value-based payment modifier would apply to groups of
physicians subject to the value-based payment modifier that fall in
Category 2. In addition, we propose to increase the maximum downward
adjustment under the quality-tiering methodology to -2.0 percent for
groups of physicians classified as low quality/high cost and to set the
adjustment to -1.0 percent for groups classified as either low quality/
average cost or average quality/high cost. We propose to revise Sec.
414.1270 and Sec. 414.1275(c) and (d) to reflect the proposed increase
to a 2.0 percent adjustment under the value-based payment modifier for
the CY 2016 payment adjustment period. We are also making a technical
correction to Sec. 414.1275(c) to clarify the PQRS GPRO reporting
mechanisms available in CY 2013. Table 62 shows the proposed quality-
tiering payment adjustment amounts for CY 2016 (based on CY 2014
performance).

Table 62--2016 Value-Based Payment Modifier Amounts
------------------------------------------------------------------------
CY 2016
-------------------------------------------------------------------------
Average
Quality/cost Low cost cost High cost
------------------------------------------------------------------------
High quality..................... * +2.0x * +1.0x +0.0%
Average quality.................. * +1.0x +0.0% -1.0%
Low quality...................... +0.0% -1.0% -2.0%
------------------------------------------------------------------------
* Groups of physicians eligible for an additional +1.0x if reporting
Physician Quality Reporting System quality measures and average
beneficiary risk score is in the top 25 percent of all beneficiary
risk scores.

Consistent with the policy adopted in the CY 2013 PFS final rule
with comment period, the upward payment adjustment factor (``x'') would
be determined after the performance period has ended based on the
aggregate amount of downward payment adjustments. We note that any
funds derived from the application of the downward adjustments to
groups of physicians with 100 or more eligible professionals and the
downward 2.0 percent adjustment applied to those groups of physicians
subject to the value-based payment modifier that fall in Category 2,
would be available to all groups of physicians eligible for value-based
payment modifier upward payment adjustments. The quality-tiering
methodology would continue to provide an additional upward payment
adjustment of +1.0x to groups of physicians that care for high-risk
beneficiaries (as evidenced by the average HCC risk score of the
attributed beneficiary population). We seek comments on our proposal to
increase the downward value-based payment modifier to 2.0 percent for
those groups of physicians with 10 or more eligible professionals that
are in Category 2 and for groups of physicians with 100 or more
eligible professionals that are classified as low quality/high cost
groups for the CY 2016 payment adjustment period.
d. Performance Period
In the CY 2013 PFS final rule with comment period (77 FR 69314), we
adopted a policy that performance on quality and cost measures in CY
2014 will be used to calculate the value-based payment modifier that is
applied to items and services for which payment is made under the PFS
during CY 2016. We received comments requesting us to close the gap
between the end of the performance period (for example, December 31,
2014) and the beginning of the payment adjustment period (for example,
January 1, 2016), in order to strengthen the connection between the
performance of physicians and groups of physicians and the financial
incentives for quality improvement.\3\ We understand that many private
sector plans start to provide payment adjustment within seven months of
close of the performance period.\4\
---------------------------------------------------------------------------

\3\ See, e.g., Comment of the American College of Surgeons
comment on the CY 2013 PFS proposed rule (Aug. 31, 2012).
\4\ US GAO, Medicare Physician Payment: Private-Sector
Initiatives Can Help Inform CMS Quality and Efficiency Incentive
Efforts, GAO-13-160 (Dec. 2012), available at http://www.gao.gov/assets/660/651102.pdf.
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Because the payment adjustment periods for the value-based payment
modifier are tied to the PFS, which is updated on an annual calendar
year basis, options to close the one year gap between the close of the
performance period and the start of the payment adjustment period
center around altering the start and end dates of the performance
period, and not the payment adjustment period. As discussed previously
in this proposed rule, one option could be to adjust the performance
period for quality data reported through the PQRS. In addition, we
could calculate the total per capita

[[Page 43492]]

cost measures on an April 1 through March 31 basis, thus closing the
gap by three months.
However, a byproduct of altering the performance periods is that
the deadline for submitting quality information would have to occur at
the end of the performance period. In addition, the review period
during which groups of physicians will be able to review the
calculation of the value-based payment modifier would be shortened to
allow the necessary system changes to implement the adjustment by the
January 1 deadline for implementation of the annual PFS. We seek
comment on the potential merits of altering our current performance
periods.
Though we appreciate the comments requesting that we shorten the
gap between the performance period and the payment adjustment period,
we propose to use CY 2015 as the performance period for the value-based
payment modifier adjustments that will apply during CY 2017. We believe
it is important to propose the performance period for the payment
adjustments that will apply in CY 2017, because section
1848(p)(4)(B)(iii) of the Act requires all physicians and groups of
physicians to be subject to the value-based payment modifier beginning
not later than January 1, 2017. Accordingly, we propose to add a new
paragraph (c) to Sec. 414.1215 to indicate that the performance period
is CY 2015 for value-based payment modifier adjustments made in the CY
2017 payment adjustment period. We seek comment on this proposal.
We also are striving to provide more timely feedback to
stakeholders regarding their cost and quality of care they furnish to
Medicare beneficiaries. We note that in CY 2013, we plan to provide
physician feedback reports (Quality and Resource Use Reports (QRURs))
starting in mid-September, which is eight and one-half months from the
close of the CY 2012 reporting period (that is, December 31, 2012) and
five months from the close of the quality data submission period (April
15, 2013) for the GPRO web interface. These QRURs will be made
available to all groups of 25 or more eligible professionals and will
preview how the groups of physicians would fare under the value-based
payment modifier policies, albeit on CY 2012 data, that we established
in the CY 2013 final rule with comment period. Moreover, we anticipate
that these reports will contain actionable information regarding
beneficiaries attributed to the group, thereby enabling physicians in
the group to better coordinate care and improve the quality of care
furnished. We also are in the process of enhancing our quality
reporting and report dissemination infrastructure such that we expect
to provide QRURs in 2014 even closer to the end of the performance
period.
Despite these efforts, we expect there will always be a gap between
the close of the performance period and the beginning of the payment
adjustment period to account for various operational processes, albeit
one that we are striving to reduce. During this gap, we allow for a
three-month claim run out so that physicians are evaluated on complete
and accurate information. We standardize the amounts on these claims in
order to calculate the cost measures. This process takes one month.
Concurrent with these two processes, we obtain the data reported for
quality measurement and calculate the PQRS measures--a process which
takes at least six months. In addition, we then calculate each group's
cost and quality composites and implement the quality-tiering
methodology. We then produce and verify the reports. These processes
combined take approximately eight to nine months. We are striving to
find ways to make these processes more efficient as we gain more
experience producing these reports.
e. Quality Measures
In the CY 2013 PFS final rule with comment period (77 FR 69315), we
aligned our policies for the value-based payment modifier for CY 2015
with the PQRS reporting mechanisms available to groups of physicians in
CY 2013, such that data that a group of physicians submitted for
quality reporting purposes through any of the PQRS group reporting
mechanisms in CY 2013 would be used for calculating the quality
composite under the quality-tiering approach for the value-based
payment modifier for CY 2015. Moreover, all of the quality measures for
which groups of physicians are eligible to report under the PQRS are
used to calculate the group of physicians' value-based payment modifier
for CY 2015, to the extent the group of physicians submits data on such
measures. We also established a policy to include three additional
quality measures (outcome measures) for all groups of physicians
subject to the value-based payment modifier: (1) A composite of rates
of potentially preventable hospital admissions for heart failure,
chronic obstructive pulmonary disease, and diabetes; (2) a composite
rate of potentially preventable hospital admissions for dehydration,
urinary tract infections, and bacterial pneumonia, and (3) rates of an
all-cause hospital readmissions measure (77 FR 69315).
We believe it is important to continue to align the value-based
payment modifier for CY 2016 with the requirements of the PQRS, because
quality reporting is a necessary, but not sufficient, component of
quality improvement. We also seek not to place an undue burden on
physicians to report such data so that they can furnish care to
beneficiaries in an efficient manner. We propose to include, therefore,
for purposes of the value-based payment modifier for CY 2016, all of
the PQRS GPRO reporting mechanisms available to group practices for the
PQRS reporting periods in CY 2014 and all of the PQRS reporting
mechanisms available to individual eligible professionals for the PQRS
reporting periods in CY 2014. Accordingly, we also propose to update
our regulations at Sec. 414.1220 to reflect this proposal. We note
that the criteria for satisfactory reporting of data on PQRS quality
measures for individual eligible professionals via qualified registries
for the CY 2014 PQRS incentive and CY 2016 PQRS payment adjustment
permits the use of a 6-month reporting period (Tables 24 and 25). We
believe that data submitted via qualified registries for this 6-month
reporting period would be sufficiently reliable on which to base a
group of physicians' quality composite score under the value-based
payment modifier because in order for us to use the data to calculate
the score, we would require data for each quality measure on at least
20 beneficiaries, which is the reliability standard for the value-based
payment modifier (77 FR 69322-69323). Given this level of reliability,
we believe a six-month reporting period would be comparable to a 12-
month reporting period for the purpose of evaluating the quality of
care furnished by a group of physicians subject to the value-based
payment modifier. We seek comment on this proposal.
We also propose to utilize all of the quality measures that are
available to be reported under these various PQRS reporting mechanisms,
including quality measures reported through qualified clinical data
registries, to calculate a group of physicians' value-based payment
modifier in CY 2016 to the extent that a group of physicians submits
data on these measures. In addition, we propose that groups of
physicians with 25 or more eligible professionals will be able to elect
to have included in their value-based payment modifier for CY 2016 the
patient experience of care measures collected through the PQRS CAHPS

[[Page 43493]]

survey for CY 2014. These reporting mechanisms and the patient
experience measures are described in Tables 24 through 27. We note that
the three outcome measures that we finalized in the CY 2013 PFS final
rule with comment period and in Sec. 414.1230--the two composites of
rates of potentially preventable hospital admissions and the all-cause
hospital readmission measure--would continue to be included in the
quality measures used for the value-based payment modifier in CY 2016.
Although we have received comments to require a core set of quality
measures for the value-based payment modifier, we believe it is
premature to require reporting on limited set of measures by all
physicians until physicians have had a chance to choose measures that
are meaningful to their practice. As we indicated previously, our
primary focus is on measurement and alignment during the phase-in of
the value-based payment modifier, because we believe it is difficult to
maintain high-quality care and improve quality and performance without
measurement. Thus, it is important to provide physicians and groups of
physicians flexibility on the data they report for quality measures.
For those groups of physicians subject to the value-based payment
modifier in CY 2016 whose eligible professionals participate in the
PQRS as individuals rather than as a group practice under the GRPO
(that is, groups of physicians that are assessed under the 70 percent
threshold), we propose to calculate the group's performance rate for
each measure reported by at least one eligible professional in the
group of physicians by combining the weighted average of the
performance rates of those eligible professionals reporting the
measure. If all of the eligible professionals in a group of physicians
subject to the CY 2016 value-based payment modifier satisfactorily
participate in a PQRS qualified clinical data registry in CY 2014 and
we are unable to receive quality performance data for those eligible
professionals for the reasons discussed above, for purposes of the
value-based payment modifier, we propose to classify the group's
quality composite score as ``average'' under the quality-tiering
methodology, because we would not have data to reliably indicate
whether the group should be classified as high or low quality under the
quality-tiering methodology. Accordingly, we also propose to add a new
subsection to our regulations at Sec. 414.1270 to reflect our
proposals about how to assess quality performance for groups assessed
under the 70 percent threshold. We seek comment on these proposals.
We note that when the value-based payment modifier applies to all
physicians and groups of physicians in CY 2017 based on performance
during CY 2015, we anticipate continuing our policy to align with the
PQRS group reporting for all groups of physicians of two or more
eligible professionals, and we anticipate permitting physicians who are
solo practitioners to use any of the PQRS reporting mechanisms
available to them under the PQRS for reporting periods in CY 2015 for
purposes of the value-based payment modifier in CY 2017. Although we
are not proposing to adopt this policy in this proposed rule, we seek
comment on this approach to align the quality measures and reporting
mechanisms used in the PQRS for purposes of the value-based payment
modifier.
f. Inclusion of the Medicare Spending per Beneficiary Measure in the
Value-Based Payment Modifier Cost Composite
In the CY 2013 PFS final rule with comment period (77 FR 69316), we
established a policy to include five cost measures in the value-based
payment modifier cost composite. The five measures are total per capita
costs (both Parts A and B) and total per capita costs for beneficiaries
with four specific chronic conditions: Chronic obstructive pulmonary
disease (COPD), heart failure, coronary artery disease (CAD), and
diabetes. We stated that the value-based payment modifier should
incorporate additional measures that are consistent with the National
Quality Strategy and other CMS quality initiatives. As a step toward
that goal, beginning with the CY 2016 value-based payment modifier, we
propose to expand the cost composite to include an additional measure,
the Medicare Spending per Beneficiary (MSPB) measure (with one
modification as discussed below). This section discusses the background
of the MSPB measure and our proposals to incorporate it into the value-
based payment modifier beginning with the CY 2016 payment adjustment
period and beyond.
Background on the implementation of the MSPB measure for other CMS
quality programs. We finalized the MSPB measure for use in the Hospital
IQR Program in the FY 2012 IPPS final rule to further Medicare's
transformation from a system that rewards volume of service to one that
rewards efficient, effective care and reduces delivery system
fragmentation and to help address the critical issue of health care
costs (76 FR 51618-27). We finalized the MSPB measure for inclusion in
the Hospital VBP Program in the FY 2013 IPPS final rule as an important
first step toward identifying value in healthcare. In that rule, we
expressed our belief that this measure provides an incentive for
hospitals to build stronger relationships with and better understand
the providers and suppliers that furnish care for their patients before
and after an acute care hospitalization (77 FR 53585). When viewed in
light of other quality measures, as a part of the value-based payment
modifier measure set, we believe that the measure would enable us to
align incentives and similarly recognize physician groups involved in
the provision of high-quality care at a lower cost to Medicare. This
measure also addresses physician care associated with acute inpatient
hospitalizations and post-acute care. In its recently-released
``Interim Report of the Committee on Geographic Variation in Health
Care Spending and Promotion of High-Value Care: Preliminary Committee
Observations,'' the Institute of Medicine (IOM) observed that,
``Geographic variation in total Medicare spending is strongly
influenced by the utilization of post-acute care.'' \1\ Medicare
spending post-hospital discharge is a significant source of variation
in the MSPB measure rates, with spending unrelated to readmissions
being the largest source of variation in those post-discharge Medicare
payments. As part of the value-based-payment modifier measure set, the
MSPB measure would recognize and enable CMS to assess groups of
physicians' performance relating to post-acute care spending, which is
a ``major source of unexplained variation in Medicare spending.'' \1\
We propose that this measure would be added to the total per capita
costs for all attributed beneficiaries domain of the value-based
payment modifier. Thus, there would be two measures in the total per
capita costs for all attributed beneficiaries domain--the total per
capita costs measure and the MSPB measure--each weighted equally in the
domain. We considered placing this measure in the total per capita
costs for all attributed beneficiaries with specific conditions domain;
however, we are not proposing to do so because the MSPB measure is
similar to the total per capita costs measure (because it includes all
costs incurred by a beneficiary), albeit one that is related to the
totality of services furnished surrounding an inpatient
hospitalization, and thus belongs in the total per capita costs for all
attributed beneficiaries domain. Moreover, we intend to propose in
future rulemaking

[[Page 43494]]

to replace the four measures in the total per capita costs for all
attributed beneficiaries with specific conditions domain with cost
measures derived from the CMS Episode Grouper and other episode-based
costs derived from our recent and ongoing work with many specialty
societies.\5\ We solicit comments on these potential changes to the
condition-specific cost measures as well as on the other elements of
the cost composite in preparation for the CY 2015 performance period
affecting payment adjustment year CY 2017.
---------------------------------------------------------------------------

\5\ Our recent activities relating to developing Medicare-
specific episodes using the CMS Episode grouper and development of
other episode costs are discussed in the Physician Feedback Program
section below.
---------------------------------------------------------------------------

We currently use the MSPB measure in two other CMS quality
initiatives, the Hospital Inpatient Quality Reporting (IQR) and
Hospital Value-Based Purchasing (VBP) Programs. We believe that its
inclusion in the value-based payment modifier will help to align
performance incentives across the delivery system. By focusing on the
cost of care and encouraging avoidance of unnecessary services, the
measure also addresses one of the National Quality Strategy aims of
better care: Care that is affordable. This measure has been submitted
to the National Quality Forum for endorsement, and it was supported by
the Measures Application Partnership for inclusion in both the Hospital
IQR and VBP Programs.
Construction of the MSPB measure. The MSPB measure used for the
Hospital IQR and VBP Programs is constructed of services furnished
surrounding hospitalizations (``index admissions''). The measure
includes all Medicare Part A and Part B payments during an MSPB
episode. An MSPB episode spans from 3 days prior to an index admission
at a subsection (d) hospital \6\ through 30 days post discharge with
certain exclusions. Certain hospitalizations at subsection (d)
hospitals do not represent index admissions for the MSPB measure.
Admissions that result in a transfer from one acute hospital to
another, episodes that occur fewer than 30 days before the end of the
performance period, or episodes during which the beneficiary is not
enrolled in both Part A and Part B Medicare do not count as index
admissions. Costs for each episode are risk adjusted for age and
severity of illness, and the included payments are standardized to
remove differences attributable to geographic payment adjustments and
other payment factors. The payment standardization is the same
methodology used for the existing total per capita cost measures
included in the value-based payment modifier.
---------------------------------------------------------------------------

\6\ Section 1886(d)(1)(B) of the Social Security Act defines
such hospitals as those in the 50 States and the District of
Columbia other than psychiatric hospitals, rehabilitation hospitals,
hospitals whose inpatients are predominantly under 18 years old,
hospitals whose average inpatient length of stay exceeds 25 days,
and hospitals involved extensively in treatment for, or research on,
cancer.
---------------------------------------------------------------------------

To calculate a hospital's MSPB amount, the payment-standardized
costs for all index admissions are summed and divided by the sum of the
expected costs from the risk adjustment model. This ratio is then
multiplied by the national average MSPB episode cost to give the
hospital's MSPB amount. Because the Hospital IQR and VBP Programs apply
to subsection (d) hospitals, we attribute a MSPB index admission to the
hospital at which an index admission occurs, and we calculate the MSPB
amount at the hospital level.
After determining an individual hospital's MSPB amount, we divide
it by the national median MSPB amount to calculate a ratio. This ratio
is then converted to a percentage which is the MSPB measure rate that
we report publicly on Hospital Compare under the Hospital IQR Program
and use to generate a measure score for the Efficiency domain under the
Hospital VBP Program. In the context of the value-based payment
modifier, we propose a slightly revised calculation. We propose not to
convert the MSPB amount to a ratio as is done to compute a hospital's
MSPB measure, but rather use the MSPB amount as the measure's
performance rate. We refer readers to the FY 2012 IPPS/LTCH PPS final
rule (76 FR 51618 through 51627) for a detailed description of the MSPB
measure that is used in the Inpatient Quality Reporting program and the
HVBP program. Additional information on the measure, including a
detailed specification document (entitled ``MSPB Measure Information
Form'') and the payment standardization methodology (entitled ``CMS
Price Standardization'') can be found in the ``Measure Methodology''
section at http://qualitynet.org/dcs/ContentServer?c=Page&pagename=QnetPublic%2FPage%2FQnetTier3&cid=1228772053996. We seek comment on our proposals to include the MSPB measure (as
modified per the discussion above) in the value-based payment modifier
cost composite and to add the measure to the total per capita costs for
all attributed beneficiaries domain. We also propose to revise the
regulations at Sec. 414.1235 to include the Medicare Spending per
Beneficiary measure in the set of cost measures for the value-based
payment modifier and Sec. 414.1260(b)(1)(i) to include the Medicare
Spending per Beneficiary measure in the total per capita costs for all
attributed beneficiaries domain. As stated previously, all of our
proposals related to the MSPB measure would apply beginning with the CY
2016 value-based payment modifier.
Attribution of the MSPB measure to physician groups. Unlike the
Hospital IQR and VBP Programs, in which we attribute the MSPB index
admission to the hospital at which the index admission occurred, we
need to develop a method to attribute the MSPB episode to groups of
physicians to include the measure in the value-based-payment modifier.
We propose to attribute an MSPB episode to a group of physicians
subject to the value-based payment modifier (as identified by a single
TIN), when any eligible professional in the group submits a Part B
Medicare claim under the group's TIN for a service rendered during an
inpatient hospitalization that is an index admission for the MSPB
measure during the performance period for the applicable calendar year
payment adjustment period. Thus, the same index admission and MSPB
episode could be attributed to more than one group of physicians.
We believe that attribution of the MSPB episode to all groups of
physicians from which an eligible professional submits a Part B claim
for a service rendered during the hospitalization is the best way to
assign responsibility for, and encourage greater coordination of, care
furnished to Medicare beneficiaries who are hospitalized. Based on CY
2011 claims data, the proposed approach would enable approximately
11,419 groups of physicians with at least 10 eligible professionals to
have an MSPB measure score included in their cost composite.\7\ Our
proposed approach incentivizes hospitals and physicians to furnish
efficient, effective care during a hospitalization and to coordinate
post-discharge care to avoid unnecessary services and preventable
readmissions. Further, we believe that this attribution approach
fosters shared accountability between hospitals and physicians for the
care they furnish to Medicare beneficiaries who are hospitalized. We
propose to add a new paragraph (b) to Sec. 414.1240 to indicate that a
MSPB episode would be attributed to a group

[[Page 43495]]

of physicians subject to the value-based payment modifier if any
eligible professional in the group submits a Part B Medicare claim
under the group's TIN for a service rendered during an inpatient
hospitalization that is an index admission for the MSPB measure during
the performance period for the applicable calendar year payment
adjustment period. Groups of physicians would have a Medicare Spending
per Beneficiary measure score included in their cost composite based on
the proposed attribution methodology for the MSPB. We welcome public
comment on our proposal.
---------------------------------------------------------------------------

\7\ We note that, based on 2011 claims, many of these 11,419
groups would only have the MSPB measure included in the cost
composite because the physicians in the groups do not provide
primary care services and thus do not have attributed beneficiaries
for the five annual total per capita cost measures.
---------------------------------------------------------------------------

We also considered attributing the MSPB episode to physician groups
from which an eligible professional in the group billed a part B claim
for a service rendered at any time during the Medicare Spending per
Beneficiary episode (that is, from 3 days prior to an index admission
through 30 days post-discharge). This attribution approach would place
an even stronger emphasis on shared accountability for care provided to
Medicare beneficiaries who are hospitalized, both during and after
their hospitalization. Based on 2011 claims data, we estimate that
attribution to any physician group from which a eligible professional
billed a part B claim at any time during the episode would enable an
additional 3,017 groups of physicians with 10 or more eligible
professionals to receive an MSPB measure performance rate for inclusion
in the cost composite, as compared to our proposed attribution approach
which considers only those eligible professionals who bill a Part B
claim during the hospitalization. We welcome public comment on the
alternative attribution approach under which we would attribute an MSPB
episode to a physician group if any eligible professional in the group
billed a Part B service during the 3 days prior to an index admission
through 30 days post hospital discharge.
In addition to the proposed attribution method above, we considered
several other methods to attribute the MSPB measure to physician
groups. For example, the MSPB episode could be attributed solely to the
group of physicians that provided the plurality of Part B services
billed either: (1) During the entire MSPB episode (that is three days
prior to hospital admission through 30 days post discharge); or (2)
during the index hospitalization only. By ``plurality'' of services, we
mean the highest total dollar amount paid by Medicare to any group of
physicians who provided Part B services during a given portion of an
episode (either the full episode or the hospitalization only). The
group of physicians need not have provided the majority of the services
paid by Medicare during a given portion of an episode, but rather to
have provided services for which Medicare paid more than it did to any
other group of physicians during that portion of an episode. This
method is a single attribution approach unlike our proposal which is a
multi-attribution approach.
Using 2011 claims, we analyzed the number of TINs, comprised of 10
or more eligible professionals, that would be attributed an MSPB
measure rate under these alternative attribution methods given a
minimum of 20 MSPB episodes required. Our analyses revealed that 7,799
TINs (out of approximately 17,000 TINs (see Table 61)) would be
eligible to receive an MSPB measure rate, if MSPB episodes were
attributed to the group of physicians that received the plurality of
Medicare Part B payments during the entire MSPB episode. This
represents a 46% decrease from the 11,419 TINs that would receive an
MSPB measure rate, were it attributed to a group from which an eligible
professional rendered any Part B service during the entire episode, as
we proposed above. Our analysis also showed that 7,582 TINs would be
eligible to receive an MSPB measure rate, if MSPB episodes were
attributed to the physician group that billed the plurality of Medicare
Part B payments during the index admission. This represents a 34%
decrease from the 14,436 TINs that would receive an MSPB measure rate,
were it attributed to a group from which an eligible professional
rendered any Part B service during the index admission.
We considered these attribution methods because they represent
methods to identify groups of physicians that were ``most responsible''
for the Part B Medicare payments made during the episode. We are not
proposing these methods, because we believe our proposed multiple
attribution approach better incentivizes a team approach to
accountability for Medicare beneficiaries' care during a
hospitalization. We believe our proposed attribution approach is
further supported by the higher number of TINs that will be able to
receive an MSPB measure rate under that methodology. We seek comment,
however, on these two single alternative attribution approaches we
considered: Attributing an MSPB episode to the group of physicians that
provided the plurality of Part B services billed either during the
entire MSPB episode or during the index hospitalization only.
In addition, we considered a hybrid attribution method: Attribute
MSPB episodes to all TINs from which an eligible professional provided
services representing at least 35 percent of the total Medicare Part B
payments made either: (1) During the entire MSPB episode (that is three
days prior to hospital admission through 30 days post discharge); or
(2) during the index hospitalization only. This alternative could
result in multiple attribution, if two eligible professionals from
different TINs each provided services representing at least 35 percent
of the Part B Medicare payments during one of the episode portions
described above (either the full episode or during the index admission
only). The rationale for this attribution approach is that it ensures
that a group of physicians had responsibility for a significant portion
of the Medicare beneficiary's care during a given portion of the MSPB
episode. We are not proposing this alternative, because we believe that
our proposed attribution approach better incentivizes a team approach
to accountability for Medicare beneficiaries' care during and after a
hospitalization. We welcome public comment on this alternative
attribution approach based on provision of services representing at
least 35 percent of Medicare Part B payments made either during the
entire MSPB episode or during the index hospitalization only.
Reliability standard for the Medicare Spending per Beneficiary
measure for the value-based payment modifier. We propose that a group
of physicians would have to be attributed a minimum of 20 MSPB episodes
during the performance period to have their performance on this measure
included in the value-based payment modifier cost composite. Table 63
shows the MSPB measure's reliability at various minimum numbers of
episodes for all Medicare-enrolled TINs with at least one EP (not just
TINs of 10 or more eligible professionals) from May 2011 through
December 2011. In this context, reliability is defined as the extent to
which variation in the measure's performance rate is due to various in
the cost of services furnished by groups of physicians rather than
random variation due to the sample of cases observed. Potential
reliability values range from zero to one, where one (highest possible
reliability) signifies that all variation in the measure's rates is the
result of variation in the difference is performance across groups of
physicians. Generally, reliabilities in the 0.40-0.70 range are often
considered

[[Page 43496]]

moderate and values greater than 0.70 high.

Table 63--Reliability of Medicare Spending per Beneficiary Measure for All TINs With at Least One Eligible
Professional
[May 2011-December 2011]
----------------------------------------------------------------------------------------------------------------
Mean risk-
Number of Percent of adjusted Average
MSPB episodes attributed TINs TINs standardized cost reliability
per MSPB episode
----------------------------------------------------------------------------------------------------------------
1-9................................................... 59,419 47 $20,493 0.65
10-19................................................. 12,332 10 21,260 0.79
20-29................................................. 7,774 6 21,225 0.83
30-39................................................. 5,839 5 21,340 0.85
40-49................................................. 4,511 4 21,324 0.87
50-99................................................. 12,648 10 21,353 0.89
100-124............................................... 3,702 3 21,403 0.91
125-149............................................... 2,761 2 21,342 0.92
150-174............................................... 2,134 2 21,316 0.93
175-199............................................... 1,673 1 21,119 0.93
200+.................................................. 14,933 12 20,562 0.96
----------------------------------------------------------------------------------------------------------------

We also considered a minimum number of 10 episodes. The advantage
of this lower minimum number is that it would enable us to calculate
the MSPB measure for an additional 12,332 physician groups once we
apply the value-based payment modifier to all physicians and groups of
physicians. With a minimum of 10 cases, the measure is still very
reliable, as illustrated in the Table 63. We are proposing the minimum
of 20 cases for initial implementation of this measure in the cost
composite beginning with the CY 2016 value-based payment modifier
because it strikes a balance between maintaining high reliability and
including a large number of physician groups. We note that this
reliability standard we are proposing is the same one we adopted in the
CY 2013 PFS final rule with comment period that applies to quality and
cost measures used in the value-based payment modifier (77 FR 69323).
We welcome public comment on our proposed minimum of 20 episodes for
inclusion of the Medicare Spending per Beneficiary measure in the cost
composite for the value-based payment modifier and on the alternative
10 episode minimum that we considered.
g. Refinements to the Cost Measure Composite Methodology
In the CY 2013 PFS final rule with comment period (77 FR 69322), we
established a policy to create a cost composite for each group of
physicians subject to the value-based payment modifier that includes
five payment-standardized and risk-adjusted cost measures. To calculate
the each group's cost measures, we first attribute beneficiaries to the
group of physicians. We attribute beneficiaries using a two-step
attribution methodology that is used for the Medicare Shared Savings
Program and the PQRS GPRO and that focuses on the delivery of primary
care services (77 FR 69320). We have observed that groups of physicians
that do not provide primary care services are not attributed
beneficiaries or are attributed fewer than 20 beneficiaries and, thus,
we are unable to calculate reliable cost measures for those groups of
physicians (77 FR 69323). Given this development, we propose that, to
the extent that we are unable to attribute a sufficient number of
beneficiaries to a group of physicians subject to the value-based
payment modifier and thus are unable to calculate any of the cost
measures with at least 20 cases, the group of physicians' cost
composite score would be classified as ``average'' under the quality-
tiering methodology. We believe this policy is reasonable because we
would have insufficient information on which to classify the group of
physicians' costs as ``high'' or ``low'' under the quality-tiering
methodology. Moreover, we believe that to the extent a group of
physicians' quality composite is classified as ``high'' or ``low,'' the
groups of physicians' value-based payment modifier should reflect that
classification. Accordingly, we propose to add a new paragraph at Sec.
414.1270 to reflect this proposal that groups of physicians in Category
1 for which we attribute fewer than 20 cases to calculate any cost
measure would have their cost composite classified as ``average'' cost.
We seek comment on this proposal.
Once we calculate the cost measures for each group of physicians
subject to the value-based payment modifier, we create the cost
composite by calculating a standardized score for each cost measure and
then placing the measures into one of two equally weighted domains: (1)
The total per capita costs for all attributed beneficiaries domain; and
(2) the total per capita costs for attributed beneficiaries with
specific conditions domain. This standardized score is referred to in
statistical terms as a Z-score. To arrive at the standardized score for
each cost measure, we compare the performance for each group's cost
measures to the benchmark (national mean) of other groups subject to
the value-based payment modifier (peer group) for the same performance
year. Specifically, we calculate the benchmark for each cost measure as
the national mean of the performance rates among all groups of
physicians to which beneficiaries are attributed and that are subject
to the value-based payment modifier. For example, for CY 2015, the cost
measures of groups of 100 or more eligible professionals (EPs) will be
compared to the cost measures of other groups of 100 or more EPs. We
also noted that we would consider the effects of this policy over the
next several years as we implement this program and may consider
changes to these policies through future rulemaking.
Using 2011 claims data, we have since examined the distribution of
the overall total per capita cost measure among all groups of
physicians with one or more eligible professionals to determine whether
comparisons at the group level would be appropriate once we apply the
value-based payment modifier to smaller groups of physicians and solo
practitioners. We found that our current peer grouping methodology
could have varied impacts on groups of physicians

[[Page 43497]]

that are comprised of different physician specialties. This result
occurs because the peer group for the per capita cost benchmarks is
based on a national mean calculated among all groups of physicians
subject to the value modifier rather than determined more narrowly (for
example, within a physician specialty).
For certain physician specialties, the types of services furnished
typically have higher than average or lower than average costs, and
thus can affect the group's cost measures. For example, medical and
other types of oncologists tend to treat relatively costly
beneficiaries and bill for expensive Part B drugs, which can increase
mean total per capita costs for oncologists as a whole. By contrast,
dermatologists and ophthalmologists, for example, perform relatively
low cost procedures in an outpatient setting and, thus, their total per
capita cost measures are low. Moreover, to the extent that physicians
in groups of physicians work together to provide services to the same
beneficiaries, groups of physicians with a large proportion of high or
low-cost specialists can affect the level of the group's cost measures.
Although the cost data are adjusted to account for the relative risk of
patients, the effects of these adjustments do not fully offset this
result at the physician and physician group level.
To address this issue beginning with the CY 2016 value-based
payment modifier, we considered two methods that account for the group
practice's specialty composition so that our quality-tiering
methodology produces fair peer group comparisons and, ultimately,
correctly ranks group of physicians based on actual performance. Taking
account of physician specialties in making cost comparisons is similar
to the approach we have used in the CY 2010 and CY 2011 Quality and
Resource Use Reports (QRURs) for individual physicians in which we made
cost comparisons at the individual physician specialty level.
The first method, ``specialty adjustment,'' accounts for the
specialty composition of the group prior to computing the standardized
score for each cost measure. This method enables us to develop
comparable benchmarks for the risk-adjusted cost measures against which
to evaluate groups of physicians of smaller size who often have fewer
or single specialty composition. More specifically, we would adjust the
standardized score methodology to account for a group's specialty
composition using three steps:
Step 1: Create a specialty-specific expected cost based on the
national average for each cost measure (referred to as the ``national
specialty-specific expected costs''). To do so, we would attribute
beneficiaries to a group using the plurality of primary care services
methodology that we finalized in the CY 2013 PFS final rule with
comment period (77 FR 69316). For each specialty, we would calculate
the average cost of beneficiaries attributed to groups of physicians
with that specialty, weighted by the number of EPs in each group.
Step 2: Calculate the ``specialty-adjusted expected cost'' for each
group of physicians by weighting the national specialty-specific
expected costs by the group's specialty composition of Part B payments.
That is, the specialty-adjusted expected cost for each group is the
weighted average of the national specialty-specific expected cost of
all the specialties in the group, where the weights are each
specialty's proportion of the group's Part B payments. The Part B
payments for each specialty are determined based on the payments to
each EP in the group, and each EP is identified with one specialty
based on its claims.
Step 3: Divide the total per capita cost by the specialty-adjusted
expected cost, and multiply this ratio by the national average per
capita cost so that we can convert this ratio to a dollar amount
(referred to as the ``specialty-adjusted total per capita cost'') that
can then be used in the standardized (Z-) score to determine whether a
group can be classified as high cost, low cost, or average.
Below, we illustrate the three steps of the specialty adjustment to
the standardized score with an example. Assume for simplicity that only
two TINs and two specialties exist: TIN 1 and TIN 2, and Specialty A
and Specialty B. For this example, assume that the total per capita
costs and specialty shares are as shown in Table 64.

Table 64--Example of Calculating Specialty-Adjusted Total per Capita Cost: Assumptions
--------------------------------------------------------------------------------------------------------------------------------------------------------
Number of
TIN Risk-Adjusted attributed Number of EPs in TIN by Specialty share of EPs in Specialty share of part B
per capita cost beneficiaries specialty type A or B TIN payments in TIN
--------------------------------------------------------------------------------------------------------------------------------------------------------
TIN 1........................ $12,000 1,500 A: 10; B: 30............... A: 25%; B: 75%............. A: 35%; B: 65%
TIN 2........................ 8,000 2,000 A: 21; B: 39............... A: 35%; B: 65%............. A: 60%; B: 40%
--------------------------------------------------------------------------------------------------------------------------------------------------------

Step 1: To compute the national specialty-specific expected cost
for a specialty across all TINs, we first calculate the numerator,
which is the product of each TIN's total per capita cost times its
weight (the number of attributed beneficiaries times that specialty's
share of the TIN's EPs times the number of EPs of that specialty in
that TIN), summed across all TINs. This sum is divided by the
denominator, which is the sum across all TINs of the same weights that
were used in the numerator. For this example, the national specialty-
specific expected cost for Specialty A is ($12,000 * 1,500 * 25% * 10 +
$8,000 * 2,000 * 35% * 21)/(1,500 * 25% * 10 + 2,000 * 35% * 21) =
$8,813. Similarly, the national specialty-specific expected cost for
Specialty B is ($12,000 * 1,500 * 75%*30 + $8,000 * 2,000 * 65% * 39)/
(1,500 * 75% * 30 + 2,000 * 65% * 39) = $9,599.

National Specialty-Specific Expected Cost, by Specialty (step 1)
Specialty A: $8,813
Specialty B: $9,599

Step 2: To calculate the specialty-adjusted expected cost for each
group (TIN), we would multiply the above national specialty-specific
expected costs by each group's proportion of specialty-specific Part B
payments. For each TIN, we compute the product of the TIN's proportion
of specialty-specific Part B payments, summed across all specialty
types of the TIN. In our example, the specialty-adjusted expected cost
for TIN 1 would be computed as 35% * $8,813 + 65% * $9,599 = $9,324.
Similarly, the specialty-adjusted expected cost for TIN 2 would be 60%
* $8,813 + 40% * $9,599 = $9,127.

Specialty-Adjusted Expected Cost, by TIN (step 2)
TIN 1: $9,324
TIN 2: $9,127

Step 3: We divide the total per capita cost by the specialty-
adjusted expected cost and multiply this ratio by the national average
per capita cost, to convert this ratio to a dollar amount.

[[Page 43498]]

Assuming the national average per capita cost is $9,714, we can compute
the specialty-adjusted total per capita cost for each TIN, as shown in
Table 65.

Table 65--Example of Calculating Specialty-Adjusted Total per Capita Cost: Calculations
----------------------------------------------------------------------------------------------------------------
COLUMN A B C D
----------------------------------------------------------------------------------------------------------------
Specialty-
adjusted total
Total per Specialty- National per capita cost:
TIN capita cost adjusted average per ((column A/
expected cost capita cost column B) *
column C)
----------------------------------------------------------------------------------------------------------------
TIN 1........................................ $12,000 $9,324 $9,714 $12,502
TIN 2........................................ 8,000 9,127 9,714 8,514
----------------------------------------------------------------------------------------------------------------

The figure in the rightmost column (column D) is the specialty-
adjusted total per capita cost that is used to compute a group's
standardized (Z-) score. As can be seen, the specialty-adjusted total
per capita cost for use in the standardized score is $12,502 for TIN 1
and $8,514 for TIN 2.
To illustrate the impact of the specialty adjustment methodology,
we examined the distribution, by specialty, of the overall specialty-
adjusted total annual per capita cost measure based on 2011 claims for
group of physicians with 1 or more eligible professionals. Table 66
includes the percentage of physicians in each specialty that practice
in groups of 1 or more eligible professionals with 20 or more
attributed beneficiaries and that, based only on this one measure,
would be classified into low, average, and high cost groups. Table 66
does not represent all of the physicians within that specialty, rather
only those that practice in groups of physicians with at least 20
attributed beneficiaries.

Table 66--Percentage of Physicians Practicing in Groups With 1 or More
Eligible Professionals, With at Least 20 Beneficiaries, Classified by
Cost
------------------------------------------------------------------------
Percentage of eligible professionals
in groups (TINs) classified as
--------------------------------------
Specialty Average
Low cost cost High cost
(percent) (percent) (percent)
------------------------------------------------------------------------
Addiction medicine............... 4.7 94.1 1.2
Allergy/immunology............... 5.3 92.4 2.3
Anesthesiology................... 1.6 93.5 4.9
Cardiac Electrophysiology........ 1.9 95.7 2.4
Cardiac surgery.................. 0.5 92.9 6.6
Cardiology....................... 4.4 92.2 3.3
Chiropractic..................... 3.1 88.7 8.2
Colorectal surgery............... 3.1 89.2 7.6
Critical care (intensivists)..... 1.7 91.9 6.4
Dermatology...................... 30.6 68.0 1.4
Diagnostic radiology............. 0.7 92.7 6.6
Emergency medicine............... 3.7 89.1 7.2
Endocrinology.................... 9.2 89.1 1.7
Family practice.................. 1.3 91.7 7.0
Gastroenterology................. 4.4 93.3 2.2
General practice................. 5.7 84.8 9.5
General surgery.................. 1.6 90.1 8.3
Geriatric medicine............... 1.5 83.8 14.7
Geriatric Psychiatry............. 0.0 82.5 17.5
Gynecologist/oncologist.......... 1.7 88.5 9.8
Hand surgery..................... 3.1 95.6 1.3
Hematology....................... 0.7 89.1 10.2
Hematology/oncology.............. 1.0 87.3 11.8
Hospice and Palliative Care...... 0.3 87.9 11.8
Infectious disease............... 2.5 90.6 6.9
Internal medicine................ 1.3 87.4 11.3
Interventional Pain Management... 2.9 89.7 7.4
Interventional radiology......... 0.7 93.0 6.2
Maxillofacial surgery............ 0.9 94.7 4.4
Medical oncology................. 0.5 83.4 16.1
Nephrology....................... 7.6 89.3 3.0
Neurology........................ 5.0 92.4 2.6
Neuropsychiatry.................. 4.0 90.7 5.3
Neurosurgery..................... 1.4 83.7 14.9
Nuclear medicine................. 2.2 90.5 7.3
Obstetrics/gynecology............ 7.7 89.0 3.3

[[Page 43499]]

Ophthalmology.................... 17.7 80.9 1.5
Oral surgery (dentists only)..... 1.5 92.4 6.1
Orthopedic surgery............... 3.1 91.5 5.5
Osteopathic manipulative medicine 5.7 85.8 8.5
Otolaryngology................... 13.4 84.3 2.3
Pain Management.................. 1.5 86.0 12.6
Pathology........................ 2.4 91.2 6.4
Pediatric medicine............... 1.2 92.6 6.2
Peripheral vascular disease...... 0.0 94.4 5.6
Physical medicine and 2.1 87.9 9.9
rehabilitation..................
Plastic and Reconstructive 4.2 90.4 5.4
surgery.........................
Podiatry......................... 2.2 91.3 6.5
Preventive medicine.............. 3.0 91.3 5.6
Psychiatry....................... 5.0 88.8 6.2
Pulmonary disease................ 3.3 92.0 4.7
Radiation oncology............... 4.4 83.5 12.1
Rheumatology..................... 3.9 93.5 2.6
Single or Multispecialty clinic 5.9 85.1 9.1
or group practice...............
Sports Medicine.................. 2.6 94.8 2.6
Surgical oncology................ 1.6 82.5 16.0
Thoracic surgery................. 0.1 92.3 7.6
Urology.......................... 3.9 93.2 2.9
Vascular surgery................. 0.3 93.7 6.0
------------------------------------------------------------------------

Under this methodology, we would perform this specialty adjustment
prior to computing the standardized score for all six cost measures
included in the value-based payment modifier: The total per capita cost
measure, the four total per capita cost measures for beneficiaries with
specific conditions, and the MSPB measure. The specialty adjustment for
the four condition-specific total per capita cost measures is identical
to the total per capita cost measure that was described above. The
specialty adjustment for the MSPB cost measure is analogous to that
described above for the total per capita cost measure, except that
``number of beneficiaries'' is replaced with ``number of episodes'' and
``per capita cost'' is replaced with ``per episode cost.'' Thus, each
cost measure will have its own set of specialty-specific expected
costs.
The second method, ``comparability peer grouping,'' constructs peer
groups for each physician group practice by identifying group practices
with the nearest comparable specialty mix.\8\ After doing so, we would
then calculate a benchmark for the peer group and then use the
benchmark to calculate the group's standardized score for that measure.
Under this approach, two group practices would be considered to have
the same specialty mix if the share of physicians of each specialty is
within a defined range for both group practices. For the purposes of
computing peer groups, group practices also could be stratified by
size, as measured by number of eligible professionals billing under the
group practice's TIN. A group practice's peer group, however, would
include a minimum number of peers (that is, group practices with
similar specialty mixes) to ensure a reliable comparison. If there were
fewer than the designated number of other group practices with the
group practice's same specialty mix in the group practice's size
category, group practices would be added to the peer group based on the
next level of comparability in order to obtain the minimum number of
group practices. Group practices that had a specialty mix more
comparable to the practice's own mix would receive greater weight in
the peer group. Among the identified peers sharing the same specialty
mix, those with the most cases would receive the greatest weight.
---------------------------------------------------------------------------

\8\ For a description of this type of method, see, for example,
Margaret M. Byrne, et al., Method to Develop Health Care Peer Groups
for Quality and Financial Comparisons Across Hospitals. April 2009.
HSR: Health Services Research 44:2, Part I: 577-592.
---------------------------------------------------------------------------

We tested this method, based on 2011 claims, using a sample of 870
group practices of 25 or more EPs. The results showed that the
comparability peer grouping approach reduced the average difference
between the group's performance and benchmark rate compared to the
difference between the group's performance and benchmark as computed
based on the methodology we established in the CY 2013 PFS final rule
with comment period and which does not consider the specialty
composition of the group of physicians. Moreover, further analysis
showed that this methodology consistently ranked groups of physicians.
In other words, groups of physicians in the top and bottom 5th
percentiles were consistent using this approach.
On balance, we believe that the first method, the specialty
benchmarking method, is preferable to account for the specialty
composition of the group of physicians when making peer group
comparisons and creating the standardized score for the cost measures
for the value-based payment modifier. We also believe this methodology
allows us to apply the value-based payment modifier to smaller size
groups and solo practitioners. This methodology creates one national
benchmark for each cost measure. Moreover, all groups of physicians
(regardless of size) are assessed against that benchmark in creating
the group of physicians' standardized score. As discussed in the CY
2013 PFS final rule with comment period, we believe national benchmarks
are appropriate for the value-based payment modifier (77

[[Page 43500]]

FR 69322). Although the calculations discussed above may be very
detailed, they are transparent and we can provide each group of
physicians with information on how its costs were benchmarked in its
Quality and Resource Use Report.
By contrast, the second method, comparability peer grouping,
requires us to develop a transparent way to define which groups of
physicians are similar enough to be included in each group of
physicians' peer group. This approach also creates a different
benchmark for each group of physicians, which may make it more
difficult for groups of physicians to understand how their costs are
benchmarked. Notwith-standing these downsides, the comparability peer
grouping method treats each group of physicians as a whole, rather than
as a sum of its parts as in the specialty benchmarking method, and thus
may have more acceptability among physicians. Moreover, treating the
group of physicians as a whole also reinforces the shared
accountability aspect of the value-based payment modifier.
Given these considerations, we propose to use the first method, the
specialty benchmarking method, to create the standardized score for
each group's cost measures beginning with the CY 2016 value-based
payment modifier. Accordingly, we propose to amend our regulations at
Sec. 414.1255 to include this policy in our cost composite
methodology. We seek comment on our proposals, including comments on
ways to streamline or enhance the calculation mechanics and to make the
specialty adjustments more transparent and easily understood. We also
seek comment on the alternative method, the comparability peer grouping
method. We propose to identify the specialty for each EP based on the
specialty that is listed on the largest share of the EP's Part B
claims. We understand that many physicians believe our current
specialty designations may mask sub-specialist care furnished. We note
that the procedures for obtaining a CMS specialty code are available at
http://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/MedicareProviderSupEnroll/Taxonomy.html.
Regardless of the method chosen, we will continue to monitor the
effects of this policy over the next several years as we implement this
program and may consider changes to these policies through future
rulemaking.
5. Physician Feedback Program
Section 1848(n) of the Act requires us to provide confidential
reports to physicians that measure the resources involved in furnishing
care to Medicare FFS beneficiaries. Section 1848(n)(1)(A)(iii) of the
Act also authorizes us to include information on the quality of care
furnished to Medicare FFS beneficiaries. In CY 2012, we disseminated
both group and individual QRURs, based on CY 2011 performance, to a
wider audience than the CY 2010 reports. These reports contained
improvements and enhancements suggested by the recipients of the CY
2010 reports to provide meaningful and actionable information for
quality improvement. In addition, in May 2013, we provided supplemental
QRURs to the group report recipients that featured episode-based costs
for care of pneumonia and several acute and chronic cardiac conditions.
We derived these episode-based costs using the newly developed CMS
Episode Grouper software required by section 1848(n)(9)(ii) of the Act.
a. CY 2011 Physician Group Feedback Reports Based on CY 2011 Data and
Disseminated in CY 2012
In December 2012, we produced and distributed QRURs to each of the
54 medical group practices that chose to participate in the CY 2011
GPRO under the PQRS. Each report provided information on 30 quality
measures and five resource use (cost) measures for Medicare FFS
beneficiaries treated by the medical groups in CY 2011. For each of the
five cost measures, we standardized the input costs to adjust for
differences in Medicare payments geographically and various Medicare
payment policies such as Indirect Graduate Medical Education and
Disproportionate Share Hospital add-on payments. We also risk adjusted
the cost measures based on the unique mix of patients attributed to the
physician or group of physicians. Costs for beneficiaries with high
risk factors (such as a history of chronic diseases, disability, or
increased age) are adjusted downward, and costs for beneficiaries with
low risk factors are adjusted upward. More information on the payment
standardization and risk adjustment techniques is available at http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeedbackProgram/downloads/2011_group_detail_methodology.pdf.
To participate in the PQRS GPRO in CY 2011, a group practice had to
be a single provider entity, as identified by its TIN, with at least
200 eligible professionals. Fifty-four groups, encompassing 37,745
eligible professionals, participated in the 2011 PQRS GPRO. On average
the group contained the following type of medical professionals:
Primary care physicians (22 percent); medical specialists (22 percent);
surgeons (16 percent); emergency medicine physicians (4 percent); other
physicians (13 percent); and other medical professionals (23 percent).
For each of the 54 GPRO practices, we attributed a Medicare FFS
beneficiary to the group if eligible professionals in the group billed
for at least two of the beneficiary's eligible office visits or other
outpatient evaluation and management (E&M) services provided in CY 2011
and the group practice had the plurality of CY 2011 E&M allowed charges
for that beneficiary. The average beneficiary population attributed to
a group practice was 12,764 beneficiaries, with the smallest group
practice attributed 808 beneficiaries and the largest attributed 33,907
beneficiaries. Highlights of major findings from these 2011 QRURs are
as follows:
The mean group practice performance rate on each PQRS
quality measures was equal to, or better than the individual physician
reported performance rate for 13 of 22 comparable quality measures (60
percent), but lower for the other 9 measures.
Although there is a positive correlation (0.59), risk-
adjusted total per capita costs for each group are fairly dispersed at
any given level of risk (Table 67).

[[Page 43501]]

[GRAPHIC] [TIFF OMITTED] TP19JY13.102

We also constructed a quality composite score for each of
the 54 groups by combining the 26 clinical quality measures, the
chronic conditions ACSC composite \9\ and acute conditions ACSC
composite, and the two hospital discharge measures. Table 68 displays
the relationship between the composite quality score for each group
practice and the total payment-standardized risk-adjusted per capita
cost measure. Although there is a negative correlation (-0.53), total
per capita costs are fairly dispersed at any given level of quality.
---------------------------------------------------------------------------

\9\ The chronic conditions composite was constructed as the sum
of the numerators for diabetes, COPD, and heart failure ACSC
measures divided by the sum of their corresponding denominators.
[GRAPHIC] [TIFF OMITTED] TP19JY13.103

The performance rates for the 54 groups on the quality of care and
cost measures were statistically reliable at a high level across the
vast majority of the measures. More information about findings from
these reports is available at http://www.cms.hhs.gov/physicianfeedbackprogram.html.
b. Individual Physician Feedback Reports Based on CY 2011 Data and
Disseminated in CY 2012.
In December 2012, we provided individual 2011 Quality and Resource
Use Reports to over 94,000 physicians

[[Page 43502]]

affiliated with medical group practices of 25 or more eligible
professionals (that is, these group practices include physicians and
other medical staff such as nurse practitioners and physician
assistants). The physician groups were based in 9 states: California;
Illinois; Iowa; Kansas; Michigan; Minnesota; Missouri; Nebraska; and
Wisconsin. Over the 4-month period during which reports were available,
31,518 individual reports were downloaded.
The QRURs contained performance on PQRS measures for physicians who
participated in the CY 2011 program. They also contained performance
information on 28 quality indicators for preventive care, medication
management, and eight separate condition categories, such as chronic
obstructive pulmonary disease (COPD) and cancer. We calculated rates
for these measures using CY 2010 and CY 2011 Medicare administrative
claims. Of these 28 measures, 14 measures will be included in the PQRS
Administrative Claims reporting mechanism available for groups of
physicians and individual EPs in CY 2013.
The QRURs also provided measures of physician resource use. These
measures were payment-standardized and risk-adjusted total Parts A and
B per capita costs for beneficiaries treated by the physician. Payment
standardization adjusts for differences in Medicare payment rates to
compare service use within or across geographic regions. Risk
adjustment accounts for differences in costs among physician that
result from variation in patient mix. We included five measures of cost
in the QRURs: total per capita costs for all beneficiaries attributed
to the physician and total per capita costs for attributed
beneficiaries with one of four chronic conditions (diabetes, heart
failure, COPD, or coronary artery disease (CAD)). For the cost
measures, we attribute beneficiaries to physicians based on each
physician's degree of involvement with the beneficiary. The three
categories of attribution are directed, influenced, and contributed,
which are based on the percentage of each beneficiary's evaluation and
management services or total professional costs. More information about
the methodologies used in the CY 2011 Individual QRURs is available at
http://www.cms.hhs.gov/physicianfeedbackprogram.
The following is a summary of the highlights from these reports:
Among high-risk Medicare beneficiaries, visiting a primary
care physician during the year was associated with lower costs, but
having a physician who is more involved in one's care (that is, the
physician directed or influenced care) is associated with the lowest
costs, on average. For this analysis a physician directed or influenced
care if the physician billed for 35 percent or more of the patient's
office or other outpatient E&M visits or for 20 percent or more of the
patient's total professional costs.
The average reliability score was high (greater than 0.70)
for 98 percent (125) of the 128 PQRS measures reported by physicians in
the nine states with a case size of at least 20. A total of 109 of the
128 measures (85 percent) had average reliabilities greater than 0.90.
These reliability scores were substantially higher than for the 14
measures that are included in the CY 2013 PQRS Administrative Claims
reporting mechanism. Reliability scores range from zero to one and
measure the extent to which the performance of one physician can be
confidently distinguished from another.
The performance rate for at least 25 percent of physicians
was significantly different from the mean for 5 of the 10 most reported
PQRS measures in the 9 states. However, none of the 14 Administrative
Claims-based measures had performance rates that were significantly
different from the mean for at least 25 percent of physicians. These
results suggest statistically significant variation across physicians
is more likely to be detected using the most common self-reported PQRS
quality measures rather than the Administrative Claims measures.
Across the 9 states, the average of the total per capita
cost (payment-standardized and risk-adjusted) among physicians was
$18,735. Among total per capita costs for beneficiaries with the four
chronic condition, total per capita costs for heart failure were
highest ($34,545), followed by COPD ($32,946), CAD ($25,906), and
diabetes ($25,016).
Across the 9 states, the average reliability for
physicians' total per capita costs was very high at 0.97, when a
physician had at least 20 cases. The average reliability of the total
per capita cost measure (among physicians with 20+ cases) for directed
patients was 0.85, for influenced patients was 0.71, and for
contributed patients was 0.97. These results demonstrate that for the
typical physician profiled with a minimum case size of 20 the overall
per capita cost measure is reliable.
More information about the aggregate findings from these reports is
also available at http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeedbackProgram/ReportTemplate.html.
c. Episode Costs and the Supplemental QRURs
Section 1848(n)(9)(A)(ii) of the Act, as added by section 3003 of
the Affordable Care Act, requires CMS to develop a Medicare episode
grouper by January 1, 2012, and to include episode-based costs in the
QRURs. An episode of care consists of medical and/or procedural
services that address a specific medical condition or procedure that
are delivered to a patient within a defined time period and are
captured by claims data. An episode grouper is software that organizes
claims data into episodes. We have developed a CMS prototype episode
grouper that, for a limited number of conditions, classifies episodes
into three categories: chronic; acute; and procedural.
To illustrate how the CMS Episode Grouper works, in June 2013 we
developed supplemental QRURs and made them available to the 54 large
group practices that we had provided group QRURs in December 2012. The
CY 2011 Supplemental Episode Grouper QRURs included the following five
major episodes along with seven episode sub-types that further
stratified the episode:
Pneumonia (acute condition).
++ With (inpatient) hospital stay.
++ Without hospital stay.
Acute Myocardial Infarction (AMI) (acute condition).
++ Without Percutaneous Coronary Interventions (PCI) or Coronary
Artery Bypass Graft (CABG).
++ With PCI.
++ With CABG.
Coronary Artery Disease (CAD) (chronic condition).
++ Without AMI.
++ With AMI.
CABG (without AMI) (procedural).
PCI (without AMI) (procedural).
The Supplemental QRURs assign, or attribute, responsibility for the
patient's care for each episode to a medical practice group. Episode
assignment to medical practice groups for the Supplemental QRURs was
based on one or more of the following three methods, depending upon the
episode type:
The performance of specific procedures.
The plurality (35 percent) of episode EP fee schedule
(PFS) costs billed.
The plurality or shared majority (35 percent) of E&M
visits.
Each of these methods relies on different criteria to attribute
episodes to groups. We used the first method when a single procedure,
such as a surgery, triggers, or begins, an episode of care. In this
case, the group performing the

[[Page 43503]]

surgery is assumed to be responsible for the care. We used this method
to attribute PCI and CABG episode types to group practices.
The latter two methods attribute the episode based on EPs' relative
billing made during the episode. Attribution using PFS costs assumes
that certain types of EPs who are paid higher amounts during the
episode are likely to have interacted most with the patient and
directed the patient's care. The PFS cost attribution method excludes
costs from laboratories and ambulances, as well as other settings to
reduce the likelihood that non-clinicians, are attributed the episode.
Use of E&M visit attribution assumes that EPs who most frequently visit
the beneficiary during the episode are likely to have substantial
responsibility for the services rendered during the episode. The
chronic CAD episode type used only E&M visits for attribution, while
the acute AMI and pneumonia episodes used both PFS costs and E&M
visits. More information about the group attribution methodologies is
available at: www.cms.gov/physicianfeedbackprogram.
To control for patient case-mix, the CMS Episode Grouper applied a
risk-adjustment methodology. The risk-adjustment methodology calculated
each episode's expected cost based on three factors: patient health
status; demographics; and beneficiary type. Using these factors, the
risk-adjustment model calculated the predicted cost of an episode using
information available at the start of the episode.\10\ The use of such
a prospective risk model avoids allowing providers to influence their
risk-adjusted costs by changing their treatment patterns during the
episode. The risk-adjusted cost amount was defined to be equal to the
average episode cost nationally plus the difference between the episode
cost level and the predicted cost level derived from the risk-
adjustment model. All cost figures used in the risk-adjustment model
are payment-standardized.
---------------------------------------------------------------------------

\10\ CAD episodes are risk-adjusted each quarter, and the data
used for risk adjustment is updated with each new quarter.
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To make the Supplemental QRURs more actionable for medical groups
for quality improvement and care coordination, the Supplemental QRURs
identify a suggested individual provider within the group who is likely
to be directing the care during the episode. This individual is
designated as the ``Suggested Lead Eligible Professional (EP)'' of the
episode. In addition the Supplemental QRURs contained summary
information about each episode type, comparisons to national
benchmarks, as well as specific information describing each episode
attributed to the group of physicians. More information about the
Supplemental QRURs is available at http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeedbackProgram/Episode-Costs-and-Medicare-Episode-Grouper.html.
We view these Supplemental QRURs as the beginning of an extended
process of incorporating episode costs into the QRURs. We intend to
develop the CMS Episode Grouper (based in the CMS' Center for Medicare
and Medicaid Innovation) and to broaden the number of conditions that
could be addressed by episode grouping. The feedback that CMS expects
from the 54 medical practice groups report recipients will inform next
steps.
d. Future Plans for the Physician Feedback Reports
In September, 2013, we plan to provide the QRURs at the TIN level
to all groups of physicians with 25 or more eligible professionals. The
QRURs will be based on CY 2012 performance data. We anticipate that
there will be approximately 6,750 reports (including 1,235 groups of
100 or more EPs) covering approximately 440,000 physicians. These
reports will include a ``first look'' at the value-based payment
modifier methodologies using the group's PQRS measures, outcome
measures, and cost measures.
The reports also incorporate many valuable suggestions we have
received from specialty societies and professional societies on ways to
make these reports more meaningful and actionable. In particular, the
reports will contain details regarding: (1) Beneficiaries attributed to
the group practice (for example, beneficiary identifying information,
information regarding services furnished by the group to the
beneficiary, risk score percentile, last hospital admission, and
chronic conditions); (2) Physicians and non-physician eligible
professionals billing under the group's TIN; and (3) Hospitalizations
for attributed beneficiaries to help each group manage its patients and
potentially reduce hospital admissions (including, for example, (a)
beneficiary identifying information, (b) hospital admission data such
as data of admission, admitting hospital, principal diagnosis, and (c)
discharge disposition information). We plan to provide this additional
information to support the group's quality improvement and care
coordination efforts. As part of its review of these detailed reports,
each group will also be able to compare the data in the reports with
its own records (for example, professionals billing under the group's
TIN) to verify the information in the CMS reports. We note that these
reports are developed following a 90-day claim run-out, meaning that
claims for services furnished during CY 2012 are included in the
reports if the claim was paid by March 31, 2013.
We will continue to develop and refine the annual QRURs in an
iterative manner. As we have done in previous years, we will seek to
further improve the reports by welcoming suggestions from recipients,
specialty societies, professional associations, and others. We have
worked with several specialty societies representing physicians in
anesthesiology, cardiology, cardiothoracic surgery, emergency medicine,
neurosurgery, pathology, and radiology to develop episode costs or
other cost or utilization metrics to include in the annual QRURs. We
believe these efforts could be productive as we use the QRURs to not
only describe how the value-based payment modifier would apply to the
group of physicians, but to provide these groups with utilization and
other statistics that can be used for quality improvement and care
coordination.
In the late summer of 2014, we plan to disseminate the QRURs based
on CY 2013 data to all physicians (that is, TINs of any size) even
though groups of physicians with fewer than 100 eligible professionals
will not be subject to the value-based payment modifier in CY 2015.
These reports will contain performance on the quality and cost measures
used to score the composites and additional information to help
physicians coordinate care and improve the quality of care furnished.
We continue to look at ways to streamline the QRURs supporting the
PQRS and the physician value-based payment modifier programs in order
to create one unified format for quality assessment to increase their
utility in future years.

L. Updating Existing Standards for E-Prescribing Under Medicare Part D

1. Background
a. Legislative History
Section 101 of the Medicare Prescription Drug, Improvement, and
Modernization Act of 2003 (MMA) (Pub. L. 108-173) amended title XVIII
of the Act to establish a voluntary prescription drug benefit program
at section 1860D-4(e) of the Act. Among other things,

[[Page 43504]]

these provisions required the adoption of Part D e-prescribing
standards. Prescription Drug Plan (PDP) sponsors and Medicare Advantage
(MA) organizations offering Medicare Advantage-Prescription Drug Plans
(MA-PD) are required to establish electronic prescription drug programs
that comply with the e-prescribing standards that are adopted under
this authority. There is no requirement that prescribers or dispensers
implement e-prescribing. However, prescribers and dispensers who
electronically transmit prescription and certain other information for
covered drugs prescribed for Medicare Part D eligible beneficiaries,
directly or through an intermediary, are required to comply with any
applicable standards that are in effect.
For a further discussion of the statutory basis for this proposed
rule and the statutory requirements at section 1860D-4(e) of the Act,
please refer to section I. (Background) of the E-Prescribing and the
Prescription Drug Program proposed rule, published February 4, 2005 (70
FR 6256).
b. Regulatory History
(1) Foundation and Final Standards
CMS utilized several rounds of rulemaking to adopt standards for
the e-prescribing program. Its first rule, which was published on
November 7, 2005 (70 FR 67568), adopted three standards that were
collectively referred to as the ``foundation'' standards. We issued a
subsequent rule on April 7, 2008 (73 FR 18918) that adopted additional
standards which are referred to as ``final'' standards. One of these
standards, the NCPDP Formulary and Benefit Standard, Implementation
Guide, Version 1, Release 0 (Version 1.0, hereafter referred to as the
NCPDP Formulary and Benefit 1.0) was a subject of the calendar year
(CY) 2013 Physician Fee Schedule (PFS) final rule with comment period
(77 FR 68892 at 69329) and is the subject of this proposed rule. Please
see the ``Initial Standards Versus Final Standards'' discussion at 70
FR 67568 in the November 7, 2005 rule for a more detailed discussion
about ``foundation'' and ``final'' standards.
(2) Updating e-Prescribing Standards
As noted previously, transaction standards are periodically updated
to take new knowledge, technology and other considerations into
account. As CMS adopted specific versions of the standards when it
adopted the foundation and final e-prescribing standards, there was a
need to establish a process by which the standards could be updated or
replaced over time to ensure that the standards did not hold back
progress in the industry. CMS discussed these processes in its November
7, 2005 final rule (70 FR 67579).
The discussion noted that the rulemaking process will generally be
used to retire, replace or adopt a new e-prescribing standard, but it
also provided for a simplified ``updating process'' when a standard
could be updated with a newer ``backward-compatible'' version of the
adopted standard. In instances in which the user of the later version
can accommodate users of the earlier version of the adopted standard
without modification, it noted that notice and comment rulemaking could
be waived, in which case the use of either the new or old version of
the adopted standard would be considered compliant upon the effective
date of the newer version's incorporation by reference in the Federal
Register.
(3) The NCPDP Formulary and Benefit Standard in the Part D e-
Prescribing Regulations
The backward compatibility concept has been used extensively to
update the NCPDP SCRIPT standard in the Part D e-prescribing program,
but it has not yet been used to update the adopted NCPDP Formulary and
Benefit Standard. We proposed to update the NCPDP Formulary and Benefit
1.0 standard for the first time in the CY 2013 PFS proposed rule (77 FR
44722), but we did not ultimately finalize those proposals.
Specifically, we proposed to recognize NCPDP Formulary and Benefit
Standard 3.0 as a backward compatible version of NCPDP Formulary and
Benefits 1.0 effective 60 days from the publication of the final rule,
and sought comment on when we should retire NCPDP Formulary and
Benefits 1.0 as well as when we should adopt NCPDP Formulary and
Benefits 3.0 as the official Part D e-prescribing standard. As was
noted in that rule, while recognition of backward compatible versions
can be done in an interim final rule in which we waive notice and
comment rulemaking, other Part D e-prescribing proposals that were
being made at that time required full notice and comment rulemaking,
so, as we didn't wish to publish two e-prescribing rules
contemporaneously, we elected to forgo our usual use of our simplified
updating process for backward compatible standards (in which we waive
notice and comment rulemaking and go straight to final) in favor of
putting all of the proposals through full notice and comment
rulemaking.
2. Proposals
a. Proposed Backward Compatible Standards
As was discussed in the CY 2013 PFS final rule with comment period
(77 FR 68892), we were persuaded by commenters to refrain from retiring
Formulary and Benefit Standard 1.0 until NCPDP ceased supporting it on
July 1, 2014. As further noted in that rule, we believed it best to
delay implementing any of our Formulary and Benefits proposals,
including recognitions of NCPDP Formulary and Benefit 3.0 as a backward
compatible standard, until closer to that July 1, 2014 date. Our
actions at that time were based on a belief that an extended period of
use of either 3.0 or 1.0 would be ill-advised.
Having come within roughly a year of the anticipated date upon
which NCPDP will cease supporting NCPDP Formulary and Benefit 1.0, we
believe that it is now appropriate to re-propose the recognition of
NCPDP Formulary and Benefits 3.0 as a backward compatible version of
Formulary and Benefits 1.0 effective 60 days after publication of a
final rule until June 30, 2014, and, as discussed below, to propose the
retirement of NCPDP Formulary and Benefits 1.0, effective July 1, 2014,
and to propose the adoption of NCPDP Formulary and Benefits 3.0 as the
official Part D e-prescribing standard effective July 1, 2014. As was
discussed previously, while the recognition of backward compatible
standards can be done in an interim final rule in which we waive notice
and comment rulemaking, in light of other Part D e-prescribing
proposals being made in this rule that require full notice and comment
rulemaking, we will forgo use of the simplified updating method for
backward compatible standards (in which we waive notice and comment
rulemaking and go straight to final) in favor of putting all of the
proposals through a single notice and comment rulemaking.
Also, as was seen in our prior proposal to recognize backward
compatibility using full notice and comment in place of the backward
compatible methodology, we must also propose to require users of 3.0 to
support users who are still using NCPDP Formulary and Benefit 1.0 until
such time as that version is officially retired as a Part D e-
prescribing standard and NCPDP Formulary and Benefit 3.0 is adopted as
the official Part D e-prescribing standard.

[[Page 43505]]

2. Proposed Retirement of NCPDP Formulary and Benefit Standard 1.0 and
adoption of NCPDP Formulary and Benefit Standard 3.0
As noted in the CY 2013 PFS proposed rule, the NCPDP Formulary and
Benefits standard provides a uniform means for pharmacy benefit payers
(including health plans and PBMs) to communicate a range of formulary
and benefit information to prescribers via point-of-care (POC) systems.
These include:
General formulary data (for example, therapeutic classes
and subclasses);
Formulary status of individual drugs (that is, which drugs
are covered);
Preferred alternatives (including any coverage
restrictions, such as quantity limits and need for prior
authorization); and
Copayment (the copayments for one drug option versus
another).
Also as noted in that proposed rule, standards are updated over
time to take industry feedback and new and modified business needs into
account. See the CY 2013 PFS proposed rule (77 FR 45023-45024) for a
full discussion of the changes to that were made to the NCPDP Formulary
and Benefit 1.0 as it was updated to the NCPDP Formulary and Benefit
3.0.
As noted above, having come within roughly a year of the
anticipated date upon which NCPDP will cease supporting NCPDP Formulary
and Benefit 1.0, we believe that it is now appropriate to re-propose
the retirement of NCPDP Formulary and Benefits 1.0, effective July 1,
2014, and to propose the adoption of NCPDP Formulary and Benefits 3.0
as the official Part D e-prescribing standard, effective July 1, 2014.
To effectuate these proposals, we propose to revise Sec.
423.160(b)(5). We propose to place the existing material in a new
paragraph (b)(5)(i), which would provide the formulary and benefit
standard for Part D e-prescribing until [60 days after publication of
the final rule]. We then propose to create a second new paragraph
((b)(5)(ii)) to recognize NCPDP Formulary and Benefit 3.0. as a
backward compatible version of the official Part D e-prescribing
standard (NCPDP Formulary and Benefit 1.0), effective [60 days after
publication of the final rule] through June 30, 2014. Furthermore, we
propose to create a third new paragraph ((b)(5)(iii)) to reflect the
retirement of NCPDP Formulary and Benefit 1.0 and the adoption of NCPDP
Formulary and Benefit 3.0 as the official Part D e-prescribing
standard, effective July 1, 2014. Finally, we propose to make
conforming changes to Sec. 423.160(b)(1). We seek comment on these
proposals.

M. Discussion of Budget Neutrality for the Chiropractic Services
Demonstration

Section 651 of MMA requires the Secretary to conduct a
demonstration for up to 2 years to evaluate the feasibility and
advisability of expanding coverage for chiropractic services under
Medicare. Current Medicare coverage for chiropractic services is
limited to treatment by means of manual manipulation of the spine to
correct a subluxation described in section 1861(r)(5) of the Act
provided such treatment is legal in the state or jurisdiction where
performed. The demonstration expanded Medicare coverage to include:
``(A) care for neuromusculoskeletal conditions typical among eligible
beneficiaries; and (B) diagnostic and other services that a
chiropractor is legally authorized to perform by the state or
jurisdiction in which such treatment is provided.'' The demonstration
was conducted in four geographically diverse sites, two rural and two
urban regions, with each type including a Health Professional Shortage
Area (HPSA). The two urban sites were 26 counties in Illinois and Scott
County, Iowa, and 17 counties in Virginia. The two rural sites were the
States of Maine and New Mexico. The demonstration, which ended on March
31, 2007, was required to be budget neutral as section 651(f)(1)(B) of
MMA mandates the Secretary to ensure that ``the aggregate payments made
by the Secretary under the Medicare program do not exceed the amount
which the Secretary would have paid under the Medicare program if the
demonstration projects under this section were not implemented.''
In the CY 2006, 2007, and 2008 PFS final rules with comment period
(70 FR 70266, 71 FR 69707, 72 FR 66325, respectively), we included a
discussion of the strategy that would be used to assess budget
neutrality (BN) and the method for adjusting chiropractor fees in the
event the demonstration resulted in costs higher than those that would
occur in the absence of the demonstration. We stated that BN would be
assessed by determining the change in costs based on a pre-post
comparison of total Medicare costs for beneficiaries in the
demonstration and their counterparts in the control groups and the rate
of change for specific diagnoses that are treated by chiropractors and
physicians in the demonstration sites and control sites. We also stated
that our analysis would not be limited to only review of chiropractor
claims because the costs of the expanded chiropractor services may have
an impact on other Medicare costs for other services.
In the CY 2010 PFS final rule with comment period (74 FR 61926), we
discussed the evaluation of this demonstration conducted by Brandeis
University and the two sets of analyses used to evaluate BN. In the
``All Neuromusculoskeletal Analysis,'' which compared the total
Medicare costs of all beneficiaries who received services for a
neuromusculoskeletal condition in the demonstration areas with those of
beneficiaries with similar characteristics from similar geographic
areas that did not participate in the demonstration, the total effect
of the demonstration on Medicare spending was $114 million higher costs
for beneficiaries in areas that participated in the demonstration. In
the ``Chiropractic User Analysis,'' which compared the Medicare costs
of beneficiaries who used expanded chiropractic services to treat a
neuromusculoskeletal condition in the demonstration areas, with those
of beneficiaries with similar characteristics who used chiropractic
services as was currently covered by Medicare to treat a
neuromusculoskeletal condition from similar geographic areas that did
not participate in the demonstration, the total effect of the
demonstration on Medicare spending was a $50 million increase in costs.
As explained in the CY 2010 PFS final rule, we based the BN
estimate on the ``Chiropractic User Analysis'' because of its focus on
users of chiropractic services rather than all Medicare beneficiaries
with neuromusculoskeletal conditions, as the latter included those who
did not use chiropractic services and who may not have become users of
chiropractic services even with expanded coverage for them (74 FR 61926
through 61927). Users of chiropractic services are most likely to have
been affected by the expanded coverage provided by this demonstration.
Cost increases and offsets, such as reductions in hospitalizations or
other types of ambulatory care, are more likely to be observed in this
group.
As explained in the CY 2010 PFS final rule (74 FR 61927), because
the costs of this demonstration were higher than expected and we did
not anticipate a reduction to the PFS of greater than 2 percent per
year, we finalized a policy to recoup $50 million in expenditures from
this demonstration over a 5-year period, from CYs 2010 through 2014 (74
FR 61927). Specifically, we are recouping $10 million for each such
year through adjustments to the

[[Page 43506]]

chiropractic CPT codes. Payment under the PFS for these codes will be
reduced by approximately 2 percent. We believe that spreading this
adjustment over a longer period of time will minimize its potential
negative impact on chiropractic practices.
For the CY 2013 PFS, our Office of the Actuary (OACT) estimated
chiropractic expenditures to be approximately $470 million, which
reflected the statutory 26.5 percent reduction to PFS payments
scheduled to take effect that year. The statute was subsequently
amended to impose a zero percent PFS update for CY 2013 instead of the
26.5 percent reduction. In large part because of the change in the PFS
update, OACT now estimates CY 2013 chiropractic expenditures to be
approximately $580 million. Because of the change in projected
chiropractic expenditures, we now expect to recoup approximately $11.6
million from the 2 percent payment reduction for chiropractic CPT codes
in CY 2013.
We expect to complete the required BN adjustment by recouping the
remainder of the chiropractic expenditures in CY 2014. For each year of
this recoupment, we have provided OACT's projected chiropractic
expenditures based on previous year's data. While OACT's projections
have included the statutory reductions to physician payments, the
statute was amended in each year to avoid these reductions. As a
result, Medicare expenditures for chiropractic services during the
recoupment were higher than the OACT projections. Chiropractic services
expenditures during the recoupment period have been as follows: $540
million in 2010; $520 million in 2011; and $580 million in 2012. In
total, CMS recouped $32.8 million over the years of 2010, 2011 and
2012. OACT now projects chiropractic expenditures to be approximately
$580 million in 2013. A 2 percent recoupment percentage for
chiropractic services would result in approximately $11.6 million in
2013. For the years 2010 through 2013, CMS would have recouped
approximately $44.4 million of the $50 million required for budget
neutrality.
In 2014, CMS is reducing the recoupment percentage for the
chiropractic codes to ensure the recoupment does not exceed the $50
million required for budget neutrality. OACT estimates chiropractic
expenditures in CY 2014 will be approximately $480 million based on
Medicare spending for chiropractic services for the most recent
available year and reflecting an approximate 25 percent reduction to
physician payments scheduled to take effect under current law. CMS
plans to recoup the remaining funds, approximately $5.6 million, and
will reduce chiropractic CPT codes (CPT codes 98940, 98941, and 98942)
by the appropriate percentage, which by our preliminary estimates is
one percent which takes into account the approximately 25 percent
reduction in physician payments scheduled to occur in 2014 as provided
under current law. If the statute is amended to avoid the physician
payment reduction, we will reduce the recoupment percentage as
appropriate to ensure the recoupment does not exceed $50 million. For
instance, if the statute is amended to provide for a zero percent PFS
update, we would reduce the recoupment percentage to approximately 0.7
percent. We will reflect this reduction only in the payment files used
by the Medicare contractors to process Medicare claims rather than
through adjusting the RVUs. Avoiding an adjustment to the RVUs
preserves the integrity of the PFS, particularly since many private
payers also base payment on the RVUs.
Therefore, as finalized in the CY 2010 PFS regulation and
reiterated in the CYs 2011 through 2013 PFS regulations, we are
implementing this methodology and recouping excess expenditures under
the chiropractic services demonstration from PFS payment for the
chiropractor codes as set forth above. This recoupment addresses the
statutory requirement for BN and appropriately impacts the chiropractic
profession that is directly affected by the demonstration. We intend
for CY 2014 to be the last year of this required recoupment.

IV. Collection of Information Requirements

Under the Paperwork Reduction Act of 1995, we are required to
provide 60-day notice in the Federal Register and solicit public
comment before a collection of information requirement is submitted to
the Office of Management and Budget (OMB) for review and approval. In
order to fairly evaluate whether an information collection should be
approved by OMB, section 3506(c)(2)(A) of the Paperwork Reduction Act
of 1995 requires that we solicit comment on the following issues:
The need for the information collection and its usefulness
in carrying out the proper functions of our agency.
The accuracy of our estimate of the information collection
burden.
The quality, utility, and clarity of the information to be
collected.
Recommendations to minimize the information collection
burden on the affected public, including automated collection
techniques.
We are soliciting public comment on each of these issues for the
following sections of this document that contain information collection
requirements (ICRs):

1. ICRs Regarding Medical Services Coverage Decisions That Relate to
Health Care Technology (Sec. 405.211)

The burden associated with the requirements under Sec. 405.211 is
the time and effort it would take a study sponsor that is requesting
Medicare coverage of an FDA-approved IDE to prepare the following as
electronic documents: (1) A copy of the FDA IDE approval letter; (2) a
copy of the IDE study protocol; (3) a copy of IRB approval letter(s);
and (4) the ClinicalTrails.gov identifier. CMS reviews these documents
to determine whether it should cover certain costs in an IDE trial or
study.
Each IDE trial sponsor will have to prepare these documents once.
If the sponsor requests a second review, the documents will have to be
sent again. We estimate that this may happen 5-8 percent of the time.
Since the IDE rule was passed in September 1995 through 2012, there
have been 4,000 IDE applications, averaging 222 per year. Adding
another 8 percent brings the total estimate of about 240 requests per
year.
The study sponsors do not have to create new documents. Rather they
will be required to send us copies of information they have sent to the
FDA and that the FDA has sent to them. Accordingly, we estimate that it
will take 1 hour for an executive administrative assistant in a medical
device company to prepare: (1) A copy of the FDA IDE approval letter;
(2) a copy of the IDE study protocol; (3) a copy of IRB approval
letter(s); and (4) the ClinicalTrails.gov identifier, for electronic
submission.
We estimate that for 240 requests per year, that the total
estimated cost to the public is $7,821 annually. In deriving these
figures, we used the Bureau of Labor Statistics May 2012 estimate of
$24.14 + 35 percent in fringe benefits for estimated hourly wage of
$32.59 for an executive administrative assistant (occupation code 43-
6011).

2. ICRs Regarding the Physician Quality Reporting System (PQRS) (Sec.
414.90)

We are making certain revisions to Sec. 414.90, primarily to
include our proposals for the qualified clinical data registry option.
All of the requirements

[[Page 43507]]

and burden estimates are currently approved by OMB under OCN 0938-1059,
and are not subject to additional OMB review under the authority of the
Paperwork Reduction Act of 1995 (44 U.S.C. 3501 et seq.).
We are revising Sec. 414.90(b), (c), and (e) to indicate our
proposals for the qualified clinical data registry option. While the
sections contain information collection requirements regarding the
input process and the endorsement of consensus-based quality measures,
this rule would not revise any of the information collection
requirements or burden estimates that are associated with those
provisions.
The preamble of this proposed rule discusses the background of the
PQRS, provides information about the measures and reporting mechanisms
that would be available to eligible professionals and group practices
who choose to participate in 2014, and provides the proposed criteria
for satisfactory reporting in 2014 (for the 2014 PQRS incentive and the
2016 PQRS payment adjustment). Below are our burden estimates for
participating in the PQRS in 2014 which are subject to OMB review/
approval under OCN 0938-1059.
a. Participation in the 2013 and 2014 PQRS
In the CY 2013 PFS final rule with comment period, we provided
estimates related to the impact of the requirements we finalized for
the PQRS for 2014. Since we are proposing additional proposals, this
section modifies the impact statement provided in the CY 2013 PFS final
rule with comment period for reporting in 2014. Please note that we
will base our estimates on information found in the 2011 Physician
Quality Reporting System and eRx Reporting Experience and Trends
(hereinafter ``the PQRS Reporting Experience''). This report contains
the latest data we have gathered on PQRS participation. The PQRS
Reporting Experience is available at http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/PQRS/index.html?redirect=/PQRS/. According to the 2011 Reporting Experience
Report, over 1 million professionals were eligible to participate in
the PQRS. A total of $261,733,236 in PQRS incentives was paid by CMS
for the 2011 program year, which encompassed 26,515 practices that
included 266,521 eligible professionals (or approximately 27% of the
professionals eligible to participate). The average incentive earned
for PQRS in 2011 per each individually-participating eligible
professional was $1,059.
As we noted in our impact statement last year, we expect that, due
to the implementation of payment adjustments beginning in 2015,
participation in the PQRS would rise incrementally to approximately
300,000 eligible professionals and 400,000 eligible professionals in
2013 and 2014, respectively. We believe our estimate of 400,000
eligible professionals participating in PQRS in 2014 is accurate.
With respect to the estimated amount of incentives earned, for
2014, eligible professionals can earn a 0.5 percent incentive (i.e., a
bonus payment equal to 0.5 percent of the total allowed part B charges
for covered professional services under the PFS furnished by the
eligible professional during the reporting period) for satisfactory
reporting, a reduction of 1.0 percent from 2011. Based on information
drawn from the 2011 Reporting Experience and our participation
estimate, we believe that, out of the 400,000 eligible professionals we
expect to participate in the PQRS in 2014, the PQRS will distribute
2014 incentives to approximately (27% of 1 million eligible
professionals) 270,000 eligible professionals. At $1,059 per eligible
professional, the PQRS would distribute approximately $286 million in
incentive payments in 2014. We believe these incentive payments will
help offset the cost eligible professionals may undertake for
participating in the PQRS for the applicable year.
We note that the total burden associated with participating in the
PQRS is the time and effort associated with indicating intent to
participate in the PQRS, if applicable, and submitting PQRS quality
measures data. When establishing these burden estimates, we assume the
following:
The proposals for reporting for the PQRS for the 2014
incentive and 2016 payment adjustment would be established as proposed
in this CY 2014 Medicare PFS proposed rule.
For an eligible professional or group practice using the
claims, qualified registry, qualified clinical data registry, or EHR-
based reporting mechanisms, we assume that the eligible professional or
group practice would attempt to report PQRS quality measures data with
the intention of earning the 2014 PQRS incentive. Therefore, an
eligible professional or group practice would report on 9 measures.
With respect to labor costs, we believe that a billing
clerk will handle the administrative duties associated with
participating, while a computer analyst will handle duties related to
reporting PQRS quality measures. According to the Bureau of Labor
Statistics, the mean hourly wage for a billing clerk is approximately
$16/hour whereas the mean hourly wage for a computer analyst is
approximately $40/hour.
Please note that these estimates do not reflect total costs
estimates for participating in PQRS, but rather cost estimates that
would change if our proposals are finalized.
b. Burden Estimate on Participation in the CYs 2013 and 2014 PQRS--New
Individual Eligible Professionals: Preparation
For an eligible professional who wishes to participate in PQRS as
an individual, the eligible professional need not indicate his/her
intent to participate. Instead, the eligible professional may simply
begin reporting quality measures data. Therefore, these burden
estimates for individual eligible professionals participating in PQRS
are based on the reporting mechanism the individual eligible
professional chooses. However, we believe a new eligible professional
or group practice would spend 5 hours--which includes 2 hours to review
PQRS measures list, review the various reporting options, and select a
reporting option and measures on which to report and 3 hours to review
the measure specifications and develop a mechanism for incorporating
reporting of the selected measures into their office work flows.
Therefore, we believe that the initial administrative costs associated
with participating in PQRS would be approximately $80 ($16/hour x 5
hours).
c. Burden Estimate on Participation in the 2013 and 2014 PQRS via the
Claims-Based Reporting Mechanism--Individual Eligible Professionals
Historically, the claims-based reporting mechanism is the most
widely used reporting mechanism in PQRS. In 2011, 229,282 of the
320,422 eligible professionals (or 72 percent of eligible
professionals) used the claims-based reporting mechanism. In the CY
2013 PFS final rule with comment period, we estimated that
approximately 320,000 eligible professionals, whether participating
individually or in a group practice, would participate in PQRS by CY
2014 (77 FR 69338). We believe this estimate should be further modified
to reflect a lower participation estimate in 2014 due to the following
proposals:
We are proposing to eliminate the option to report
measures groups via claims for the 2014 PQRS incentive.

[[Page 43508]]

We are proposing to increase the number of measures that
an eligible professional must report to meet the criteria for
satisfactory reporting for the 2014 PQRS incentive from 3 measures to
9, but lower the reporting threshold to 50%.
We are proposing to remove the claims-based reporting
mechanism as an option for reporting certain individual quality
measures.
Based on these proposals, we estimate that approximately 230,000
eligible professionals (that is, the same number of eligible
professionals who participated in the PQRS using the claims-based
reporting mechanism in 2011) will participate in the PQRS using the
claims-based reporting mechanism. Therefore, we estimate that
approximately 58 percent of the eligible professionals participating in
PQRS will use the claims-based reporting mechanism.
With respect to an eligible professional who participated in PQRS
via claims, the eligible professional must gather the required
information, select the appropriate quality data codes (QDCs), and
include the appropriate QDCs on the claims they submitted for payment.
PQRS will collect QDCs as additional (optional) line items on the
existing HIPAA transaction 837-P and/or CMS Form 1500 (OCN 0938-0999).
Based on our experience with Physician Voluntary Reporting Program
(PVRP), we continue to estimate that the time needed to perform all the
steps necessary to report each measure via claims would range from 0.25
minutes to 12 minutes, depending on the complexity of the measure.
Therefore, the time spent reporting 9 measures would range from 2.25
minutes to 108 minutes. Using an average labor cost of $40/hour, we
estimated that the time cost of reporting for an eligible professional
via claims would range from $1.50 (2.25 minutes or 0.0375 hours x $40/
hour) to $72.00 (108 minutes or 1.8 hours x $40/hour) per reported
case. With respect to how many cases an eligible professional would
report when using the claims-based reporting mechanism, we established
that an eligible professional would need to report on 50 percent of the
eligible professional's applicable cases. The actual number of cases on
which eligible professional reports would vary depending on the number
of the eligible professional's applicable cases. However, in prior
years, when the reporting threshold was 80 percent for claims-based
reporting, we found that the median number of reporting cases for each
measure was 9. Since we reduced the reporting threshold to 50 percent,
we estimated that the average number of reporting cases for each
measure would be reduced to 6. Based on these estimates, we estimated
that the total cost of reporting for an eligible professional choosing
the claims-based reporting mechanism would range from ($1.50/per
reported case x 6 reported cases) $9.00 to ($72.00/reported case x 6
reported cases) $432.
d. Burden Estimate on PQRS Participation in CY 2014 via the Qualified
Registry, Qualified Clinical Data Registry, or EHR Reporting Mechanisms
We noted previously that we estimate a significant reduction in the
number of eligible professionals using the claims-based reporting
mechanism to report PQRS quality measures data in 2014. Specifically,
we estimate that approximately 230,000 eligible professionals will
participate in the PQRS using the claims-based reporting mechanism in
2014. Therefore, we estimate that the remainder of the eligible
professionals (170,000) will participate in PQRS using either the
qualified registry, qualified clinical data registry, EHR (using either
a direct EHR or EHR data submission vendor), or the GPRO web interface
reporting mechanisms.
With respect to participation in a qualified registry or qualified
clinical data registry, we are combining our estimates for the number
of eligible professionals we believe will use the qualified registry
and qualified clinical data registry reporting mechanisms for the 2014
PQRS incentive and 2016 PQRS payment adjustment. We are combining these
estimates because we believe that, at least for this initial year, many
of the registries that become qualified clinical data registries will
also be existing qualified registries. As such, we anticipate there
will be little to no additional registries that will submit quality
measures data to the PQRS for purposes of the 2014 PQRS incentive and
2016 PQRS payment adjustment.
In 2011, approximately 50,215 (or 16 percent) of the 320,422
eligible professionals participating in PQRS used the registry-based
reporting mechanism. We believe the number of eligible professionals
and group practices using a qualified registry or qualified clinical
data registry would remain the same, as eligible professionals use
registries for functions other than PQRS and therefore would obtain a
qualified registry or qualified clinical data registry solely for PQRS
reporting by CY 2014. Please note that this estimate would include
participants choosing the newly proposed qualified clinical data
registry reporting mechanism. At least in its initial stage, we believe
most of the vendors that would be approved to be a qualified clinical
data registry would be existing qualified registries.
In 2011, 560 (or less than 1%) of the 320,422 eligible
professionals participating in PQRS used the EHR-based reporting
mechanism. We believe the number of eligible professionals and group
practices using the EHR-based reporting mechanism would increase as
eligible professionals become more familiar with EHR products and more
eligible professionals participate in programs encouraging use of an
EHR, such as the EHR Incentive Program. In particular, we believe
eligible professionals and group practices would transition from using
the claims-based to the EHR-based reporting mechanisms. We estimate
that approximately 50,000 eligible professionals (which is the same
estimate as we are providing for eligible professionals who use the
qualified registry or qualified clinical data registry-based reporting
mechanisms), whether participating as an individual or part of a group
practice, would use the EHR-based reporting mechanism in CY 2014.
With respect to an eligible professional or group practice who
participated in PQRS via a qualified registry, qualified clinical data
registry, direct EHR product, or EHR data submission vendor's product,
we believe there would be little to no burden associated for an
eligible professional to report PQRS quality measures data to CMS,
because the selected reporting mechanism submitted the quality measures
data for the eligible professional. While we noted that there may be
start-up costs associated with purchasing a qualified registry, direct
EHR product, or EHR data submission vendor, we believe that an eligible
professional or group practice would not purchase a qualified registry,
qualified clinical data registry, direct EHR product, or EHR data
submission vendor product solely for the purpose of reporting PQRS
quality measures. Therefore, we have not included the cost of
purchasing a qualified registry, direct EHR, or EHR data submission
vendor product in our burden estimates.
e. Burden Estimate on PQRS Participation in CY 2014--Group Practices
Please note that with the exception of the estimates associated
with a group self-nominating to participate in the PQRS under the GPRO,
this section only contains our estimates for group

[[Page 43509]]

practices who participate in the PQRS under the GPRO via the GPRO web
interface reporting mechanism. We note that the burden associated with
reporting quality measures for group practices using the qualified
registry or EHR-based reporting mechanisms are included in the
estimates we provided for the qualified registry or EHR-based reporting
mechanisms above. According to the PQRS and eRx Experience report, of
the 101 practices participating in the GPRO, 54 of these practices
participated using the GPRO web interface (formerly the GPRO tool). We
estimate that because we are proposing to apply the value-based payment
modifier to all group practices of 10 or more eligible professionals,
we estimate that approximately 30% of such group practices, or about
5,100 group practices, will participate in the PQRS under the GPRO for
purposes of the 2014 PQRS incentive and the 2016 payment adjustment. In
addition, we estimate that of the 5,100 group practices that are
expected to self-nominate to participate in the PQRS under the GPRO,
approximately 70,000 eligible professionals (i.e. the remainder of the
eligible professionals not participating in PQRS using the claims,
qualified registry, qualified clinical data registry, or EHR-based
reporting mechanisms), representing about 30% of the groups with 100 or
more eligible professionals (or about 340 groups), will choose to
participate in PQRS using the GPRO web interface for purposes of the
2014 PQRS incentive and the 2016 PQRS payment adjustment.
Unlike eligible professionals who choose to report individually, we
noted that we proposed that eligible professionals choosing to
participate as part of a group practice under the GPRO would need to
indicate their intent to participate in PQRS as a GPRO. The total
burden for group practices who submit PQRS quality measures data via
the GPRO web-interface would be the time and effort associated with
submitting this data. To submit quality measures data for PQRS, a group
practice would need to (1) be selected to participate in the PQRS GPRO
and (2) report quality measures data. With respect to the
administrative duties for being selected to participate in PQRS as a
GPRO, we believe it would take approximately 6 hours--including 2 hours
to decide to participate in PQRS as a GPRO; 2 hours to self-nominate,
and 2 hours to undergo the vetting process with CMS officials--for a
group practice to be selected to participate in PQRS GPRO for the
applicable year. Therefore, we estimate that the cost of undergoing the
GPRO selection process would be ($16/hour x 6 hours) $96.
With respect to reporting PQRS quality measures using the GPRO web-
interface, the total reporting burden is the time and effort associated
with the group practice submitting the quality measures data (that is,
completed the data collection interface). Based on burden estimates for
the PGP demonstration, which uses the same data submission methods, we
estimate the burden associated with a group practice completing the
data collection interface would be approximately 79 hours. Therefore,
we estimate that the report cost for a group practice to submit PQRS
quality measures data for an applicable year would be ($40/hour x 79
hours) $3,160.
In addition to the GPRO web interface, please note that we have
proposed a new reporting mechanism that would be available to group
practices comprised of 25+ eligible professionals: the certified survey
vendor. With respect to using a certified survey vendor, we believe
there would be little to no burden associated for a group practice to
report the CG CAHPS survey data to CMS, because the selected reporting
mechanism submitted the quality measures data for the group practice.
While there may be start-up costs associated with purchasing a
certified survey vendor, we believe that a group practice would not
purchase a certified survey vendor solely for the purpose of reporting
the CG CAHPS survey for the PQRS. Therefore, we have not included the
cost of purchasing a certified survey vendor in our burden estimates.
f. Burden Estimate on PQRS Vendor Participation in CY 2014
Aside from the burden of eligible professionals and group practices
participating in PQRS, we believe that entities that wish to become
qualified clinical data registries would incur costs associated with
participating in PQRS. However, we believe that the burden associated
with participating in PQRS for these entities would be very similar to
the burden associated with existing qualified registries participating
in PQRS.
Based on the number of registries that have self-nominated to
become a qualified PQRS registry in prior program years, we estimated
that approximately 50 additional registries would self-nominate to be
considered a qualified registry for PQRS. With respect to qualified
registries and qualified clinical data registries, the total burden for
qualified registries and qualified clinical data registries who
submitted PQRS quality measures data would be the time and effort
associated with submitting this data. To submit quality measures data
for the proposed PQRS program years, a registry would need to (1)
become qualified for the applicable year and (2) report quality
measures data on behalf of its eligible professionals. With respect to
administrative duties related to the qualification process, we
estimated that it would take a total of 10 hours--including 1 hour to
complete the self-nomination statement, 2 hours to interview with CMS,
2 hours to calculate numerators, denominators, and measure results for
each measure the registry wished to report using a CMS-provided measure
flow, and 5 hours to complete an XML submission--to become qualified to
report PQRS quality measures data. Therefore, we estimate that it would
cost a registry approximately ($16.00/hour x 10 hours) $160 to become
qualified to submit PQRS quality measures data on behalf of its
eligible professionals.
With respect to the reporting of quality measures data, the burden
associated with reporting is the time and effort associated with the
registry calculating quality measures results from the data submitted
to the registry by its eligible professionals, submitting numerator and
denominator data on quality measures, and calculating these measure
results. We believe, however, that registries already perform these
functions for its eligible professionals irrespective of participating
in PQRS. Therefore, we believe there is little to no additional burden
associated with reporting PQRS quality measures data. Whether there is
any additional reporting burden would vary with each registry,
depending on the registry's level of savvy with submitting quality
measures data for PQRS.
For CY 2014, we are proposing a new PQRS option that includes a new
reporting mechanism--the qualified clinical data registry. In this
proposed rule, we set forth the requirements for a vendor to become
qualified to become a qualified clinical data registry. Under the
proposed requirements, we note that a vendor can be both a traditional
qualified registry and qualified clinical data registry under the PQRS.
Indeed, as we noted previously, we believe that many of the entities
that will seek to become qualified clinical data registries will be
similar to the existing qualified registries. In addition, at least
initially, we propose that the process for becoming a qualified
clinical data registry would be similar to the process for becoming a
qualified registry. Therefore, we do not believe this new

[[Page 43510]]

reporting mechanism will impact our registry estimates.
h. Summary of Burden Estimates on Participation in the 2013 and 2014
PQRS--Eligible Professionals and Vendors

Table 69--Estimated Costs for Reporting PQRS Quality Measures Data for Eligible Professionals
--------------------------------------------------------------------------------------------------------------------------------------------------------
Number of Cost per Number of
Hours Cases measures Hourly rate respondent respondents Total cost
--------------------------------------------------------------------------------------------------------------------------------------------------------
Individual Eligible Professional (EP): Preparation........... 5.0 1 N/A $16 $80 320,422 $32,000,000
Individual EP: Claims........................................ 0.2 6 3 $40 $144 230,000 $33,120,000
Individual EP: Registry...................................... N/A 1 N/A N/A Minimal 40,422 \1\ N/A
Individual EP: EHR........................................... N/A 1 N/A N/A Minimal 50,000 \1\ N/A
Group Practice: Self-Nomination.............................. 6.0 1 N/A $16 $96 5,100 $489,600
Group Practice: Reporting.................................... 79 1 N/A $40 $3,160 340 $1,074,400
--------------------------------------------------------------------------------------------------------------------------------------------------------
\1\ We believe that eligible professionals who choose to report quality measures data to PQRS using a registry, an EHR, or an EHR data submission vendor
are already doing so for other purposes. Therefore, there would be little to no burden associated with reporting the quality data to CMS under PQRS.

Table 70--Estimated Costs to Registries to Participate in PQRS
----------------------------------------------------------------------------------------------------------------
Number of
Hours Hourly rate Cost respondents Total cost
----------------------------------------------------------------------------------------------------------------
Registry: Self-Nomination.............. 10 $16 $160 50 $8,000
----------------------------------------------------------------------------------------------------------------

3. The Medicare EHR Incentive Program

The Medicare EHR Incentive Program provides incentive payments to
eligible professionals, eligible hospitals, and CAHs that demonstrate
meaningful use of certified EHR technology. We believe any burden or
impact associated with our proposals regarding the EHR Incentive
Program is already absorbed by the currently approved (OCN 0938-1158)
burden and impact estimates provided the EHR Incentive Program.
Consequently, the proposed requirements (and burden) are not subject to
additional OMB review under the authority of the Paperwork Reduction
Act of 1995 (44 U.S.C. 3501 et seq.).

4. Submission of PRA-Related Comments

If you comment on these information collection and recordkeeping
requirements, please do either of the following:
1. Submit your comments electronically as specified in the
ADDRESSES section of this proposed rule; or
2. Submit your comments to the Office of Information and Regulatory
Affairs, Office of Management and Budget, Attention: CMS Desk Officer,
[CMS-1590-FC]
Fax: (202) 395-6974; or Email: [email protected].

V. Response to Comments

Because of the large number of public comments we normally receive
on Federal Register documents, we are not able to acknowledge or
respond to them individually. We considered all comments we received by
the date and time specified in the DATES section of this preamble, and,
when we proceeded with a subsequent document, we responded to the
comments in the preamble to that document.

VI. Regulatory Impact Analysis

A. Statement of Need

This proposed rule is necessary to make payment and policy changes
under the Medicare PFS and to make required statutory changes under the
Affordable Care Act (Pub. L. 111-148), the Middle Class Tax Relief and
Job Creation Act of 2012 (Pub. L. 112-96), the American Taxpayer Relief
Act (ATRA) of 2013 (Pub. L. 112-240), and other statutory changes. This
proposed rule also is necessary to make changes to other Part B related
policies.

B. Overall Impact

We have examined the impact of this rule as required by Executive
Order 12866 on Regulatory Planning and Review (September 30, 1993),
Executive Order 13563 on Improving Regulation and Regulatory Review
(February 2, 2013), the Regulatory Flexibility Act (RFA) (September 19,
1980, Pub. L. 96-354), section 1102(b) of the Social Security Act,
section 202 of the Unfunded Mandates Reform Act of 1995 (March 22,
1995; Pub. L. 104-4), Executive Order 13132 on Federalism (August 4,
1999) and the Congressional Review Act (5 U.S.C. 804(2)).
Executive Orders 12866 and 13563 direct agencies to assess all
costs and benefits of available regulatory alternatives and, if
regulation is necessary, to select regulatory approaches that maximize
net benefits (including potential economic, environmental, public
health and safety effects, distributive impacts, and equity). A
regulatory impact analysis (RIA) must be prepared for major rules with
economically significant effects ($100 million or more in any 1 year).
We estimate, as discussed below in this section, that the PFS
provisions included in this proposed rule will redistribute more than
$100 million in 1 year. Therefore, we estimate that this rulemaking is
``economically significant'' as measured by the $100 million threshold,
and hence also a major rule under the Congressional Review Act.
Accordingly, we have prepared a RIA that, to the best of our ability,
presents the costs and benefits of the rulemaking. The RFA requires
agencies to analyze options for regulatory relief of small entities.
For purposes of the RFA, small entities include small businesses,
nonprofit organizations, and small governmental jurisdictions. Most
hospitals and most other providers and suppliers are small entities,
either by nonprofit status or by having revenues of less than $7.0
million in any 1 year (for details see the SBA's Web site at http://www.sba.gov/content/small-business-size-standards# (refer to the 620000
series)). Individuals and states are not included in the definition of
a small entity.

[[Page 43511]]

The RFA requires that we analyze regulatory options for small
businesses and other entities. We prepare a regulatory flexibility
analysis unless we certify that a rule would not have a significant
economic impact on a substantial number of small entities. The analysis
must include a justification concerning the reason action is being
taken, the kinds and number of small entities the rule affects, and an
explanation of any meaningful options that achieve the objectives with
less significant adverse economic impact on the small entities.
For purposes of the RFA, physicians, NPPs, and suppliers are
considered small businesses if they generate revenues of $10 million or
less based on SBA size standards. Approximately 95 percent of providers
and suppliers are considered to be small entities. There are over 1
million physicians, other practitioners, and medical suppliers that
receive Medicare payment under the PFS. Because many of the affected
entities are small entities, the analysis and discussion provided in
this section as well as elsewhere in this proposed rule is intended to
comply with the RFA requirements.
In addition, section 1102(b) of the Act requires us to prepare an
RIA if a rule may have a significant impact on the operations of a
substantial number of small rural hospitals. This analysis must conform
to the provisions of section 603 of the RFA. For purposes of section
1102(b) of the Act, we define a small rural hospital as a hospital that
is located outside of a Metropolitan Statistical Area for Medicare
payment regulations and has fewer than 100 beds. We are not preparing
an analysis for section 1102(b) of the Act because we have determined,
and the Secretary certifies, that this proposed rule would not have a
significant impact on the operations of a substantial number of small
rural hospitals.
Section 202 of the Unfunded Mandates Reform Act of 1995 also
requires that agencies assess anticipated costs and benefits on state,
local, or tribal governments or on the private sector before issuing
any rule whose mandates require spending in any 1 year of $100 million
in 1995 dollars, updated annually for inflation. In 2013, that
threshold is approximately $141 million. This proposed rule will impose
no mandates on state, local, or tribal governments or on the private
sector.
Executive Order 13132 establishes certain requirements that an
agency must meet when it promulgates a proposed rule (and subsequent
final rule) that imposes substantial direct requirement costs on state
and local governments, preempts state law, or otherwise has Federalism
implications. Since this regulation does not impose any costs on state
or local governments, the requirements of Executive Order 13132 are not
applicable.
We have prepared the following analysis, which together with the
information provided in the rest of this preamble, meets all assessment
requirements. The analysis explains the rationale for and purposes of
this proposed rule; details the costs and benefits of the rule;
analyzes alternatives; and presents the measures we would use to
minimize the burden on small entities. As indicated elsewhere in this
proposed rule, we are proposing to implement a variety of changes to
our regulations, payments, or payment policies to ensure that our
payment systems reflect changes in medical practice and the relative
value of services, and to implement statutory provisions. We provide
information for each of the policy changes in the relevant sections of
this proposed rule. We are unaware of any relevant Federal rules that
duplicate, overlap, or conflict with this proposed rule. The relevant
sections of this proposed rule contain a description of significant
alternatives if applicable.

C. Relative Value Unit (RVU) Impacts

1. Resource-Based Work, PE, and Malpractice RVUs
Section 1848(c)(2)(B)(ii)(II) of the Act requires that increases or
decreases in RVUs may not cause the amount of expenditures for the year
to differ by more than $20 million from what expenditures would have
been in the absence of these changes. If this threshold is exceeded, we
make adjustments to preserve budget neutrality.
Our estimates of changes in Medicare revenues for PFS services
compare payment rates for CY 2013 with proposed payment rates for CY
2014 using CY 2012 Medicare utilization as the basis for the
comparison. The payment impacts reflect averages for each specialty
based on Medicare utilization. The payment impact for an individual
physician could vary from the average and would depend on the mix of
services the physician furnishes. The average change in total revenues
would be less than the impact displayed here because physicians furnish
services to both Medicare and non-Medicare patients and specialties may
receive substantial Medicare revenues for services that are not paid
under the PFS. For instance, independent laboratories receive
approximately 83 percent of their Medicare revenues from clinical
laboratory services that are not paid under the PFS.
We note that these impacts do not include the effect of the January
2014 conversion factor changes under current law. The annual update to
the PFS conversion factor is calculated based on a statutory formula
that measures actual versus allowed or ``target'' expenditures, and
applies a sustainable growth rate (SGR) calculation intended to control
growth in aggregate Medicare expenditures for physicians' services.
This update methodology is typically referred to as the ``SGR''
methodology, although the SGR is only one component of the formula.
Medicare PFS payments for services are not withheld if the percentage
increase in actual expenditures exceeds the SGR. Rather, the PFS
update, as specified in section 1848(d)(4) of the Act, is adjusted to
eventually bring actual expenditures back in line with targets. If
actual expenditures exceed allowed expenditures, the update is reduced.
If actual expenditures are less than allowed expenditures, the update
is increased. By law, we are required to apply these updates in
accordance with sections 1848(d) and (f) of the Act, and any negative
updates can only be averted by an Act of the Congress. While the
Congress has provided temporary relief from negative updates for every
year since 2003, a long-term solution is critical. We are committed to
working with the Congress to reform Medicare physician payments to
provide predictable payments that incentivize quality and efficiency in
a fiscally responsible way. We provide our most recent estimate of the
SGR and physician update for CY 2014 on our Web site at http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/SustainableGRatesConFact/index.html?redirect=/SustainableGRatesConFact/
.
Tables 71 and 72 show the payment impact on PFS services. To the
extent that there are year-to-year changes in the volume and mix of
services provided by physicians, the actual impact on total Medicare
revenues will be different from those shown in Tables 71 (CY 2014 PFS
Proposed Rule Estimated Impact on Total Allowed Charges by Specialty)
and 72 (CY 2014 PFS Proposed Rule Estimated Impact on Total Allowed
Charges by Specialty by Selected Proposal).
The following is an explanation of the information represented in
Table 71:
Column A (Specialty): The Medicare specialty code as
reflected in our physician/supplier enrollment files.

[[Page 43512]]

Column B (Allowed Charges): The aggregate estimated PFS
allowed charges for the specialty based on CY 2012 utilization and CY
2013 rates. That is, allowed charges are the PFS amounts for covered
services and include coinsurance and deductibles (which are the
financial responsibility of the beneficiary). These amounts have been
summed across all services furnished by physicians, practitioners, and
suppliers within a specialty to arrive at the total allowed charges for
the specialty.
Column C (Impact of Work and Malpractice (MP) RVU
Changes): This column shows the estimated CY 2014 impact on total
allowed charges of the changes in the work and malpractice RVUs,
including the impact of changes due to potentially misvalued codes.
Column D (Impact of PE RVU Changes): This column shows the
estimated CY 2014 impact on total allowed charges of the changes in the
PE RVUs.
Column E (Combined Impact): This column shows the
estimated CY 2014 combined impact on total allowed charges of all the
changes in the previous columns.

Table 71--CY 2014 PFS Proposed Rule Estimated Impact on Total Allowed Charges by Specialty *
----------------------------------------------------------------------------------------------------------------
Impact of work
Allowed and MP RVU Impact of PE Combined
Specialty charges (mil) changes RVU changes impact
(percent) (percent) (percent)
(A) (B) (C) (D) (E)
----------------------------------------------------------------------------------------------------------------
TOTAL........................................... $86,995 2 -2 0
01--ALLERGY/IMMUNOLOGY.......................... 213 1 -4 -3
02--ANESTHESIOLOGY.............................. 1,862 4 -1 3
03--CARDIAC SURGERY............................. 355 3 -1 2
04--CARDIOLOGY.................................. 6,425 2 0 2
05--COLON AND RECTAL SURGERY.................... 158 2 -2 0
06--CRITICAL CARE............................... 273 3 -1 2
07--DERMATOLOGY................................. 3,113 2 -4 -2
08--EMERGENCY MEDICINE.......................... 2,929 3 0 3
09--ENDOCRINOLOGY............................... 447 2 -2 0
10--FAMILY PRACTICE............................. 6,358 2 -1 1
11--GASTROENTEROLOGY............................ 1,901 3 -2 1
12--GENERAL PRACTICE............................ 528 2 -2 0
13--GENERAL SURGERY............................. 2,236 3 -2 1
14--GERIATRICS.................................. 231 3 -1 2
15--HAND SURGERY................................ 151 2 -2 0
16--HEMATOLOGY/ONCOLOGY......................... 1,890 2 -3 -1
17--INFECTIOUS DISEASE.......................... 635 3 -1 2
18--INTERNAL MEDICINE........................... 11,416 3 -2 1
19--INTERVENTIONAL PAIN MGMT.................... 640 2 -3 -1
20--INTERVENTIONAL RADIOLOGY.................... 219 2 -6 -4
21--MULTISPECIALTY CLINIC/OTHER PHY............. 79 2 -2 0
22--NEPHROLOGY.................................. 2,123 3 -2 1
23--NEUROLOGY................................... 1,498 2 -4 -2
24--NEUROSURGERY................................ 712 2 -1 1
25--NUCLEAR MEDICINE............................ 51 2 -1 1
27--OBSTETRICS/GYNECOLOGY....................... 688 2 -2 0
28--OPHTHALMOLOGY............................... 5,592 2 -2 0
29--ORTHOPEDIC SURGERY.......................... 3,683 2 -2 0
30--OTOLARNGOLOGY............................... 1,128 2 -4 -2
31--PATHOLOGY................................... 1,134 3 -8 -5
32--PEDIATRICS.................................. 63 3 -3 0
33--PHYSICAL MEDICINE........................... 999 3 -3 0
34--PLASTIC SURGERY............................. 367 2 -2 0
35--PSYCHIATRY.................................. 1,165 3 -1 2
36--PULMONARY DISEASE........................... 1,775 3 -2 1
37--RADIATION ONCOLOGY.......................... 1,783 1 -6 -5
38--RADIOLOGY................................... 4,635 2 -3 -1
39--RHEUMATOLOGY................................ 551 2 -5 -3
40--THORACIC SURGERY............................ 332 3 -1 2
41--UROLOGY..................................... 1,858 2 -4 -2
42--VASCULAR SURGERY............................ 925 2 -4 -2
43--AUDIOLOGIST................................. 56 2 -1 1
44--CHIROPRACTOR................................ 722 3 -1 2
45--CLINICAL PSYCHOLOGIST....................... 579 4 -1 3
46--CLINICAL SOCIAL WORKER...................... 408 4 -1 3
47--DIAGNOSTIC TESTING FACILITY................. 779 0 -7 -7
48--INDEPENDENT LABORATORY **................... 812 1 -27 -26
49--NURSE ANES/ANES ASST........................ 1,055 4 0 4
50--NURSE PRACTITIONER.......................... 1,937 3 -2 1
51--OPTOMETRY................................... 1,106 2 -2 0
52--ORAL/MAXILLOFACIAL SURGERY.................. 44 2 -4 -2
53--PHYSICAL/OCCUPATIONAL THERAPY............... 2,797 2 -1 1
54--PHYSICIAN ASSISTANT......................... 1,405 3 -2 1
55--PODIATRY.................................... 1,975 2 -2 0
56--PORTABLE X-RAY SUPPLIER..................... 110 1 -2 -1

[[Page 43513]]

57--RADIATION THERAPY CENTERS................... 62 0 -13 -13
98--OTHER....................................... 25 3 -2 1
----------------------------------------------------------------------------------------------------------------
* Table 71 shows only the payment impact on PFS services. These impacts use a constant conversion factor and
thus do not include the effects of the January 2014 conversion factor change required under current law.
** PFS Payments only, which account for ~17% of Independent Laboratory payments from Medicare.

Table 72 shows the estimated impact of selected policy proposals on
total allowed charges, by specialty. The following is an explanation of
the information represented in Table 72:
Column A (Specialty): The Medicare specialty code as
reflected in our physician/supplier enrollment files.
Column B (Allowed Charges): The aggregate estimated PFS
allowed charges for the specialty based on CY 2012 utilization and CY
2013 rates. That is, allowed charges are the PFS amounts for covered
services and include coinsurance and deductibles (which are the
financial responsibility of the beneficiary). These amounts have been
summed across all services furnished by physicians, practitioners, and
suppliers within a specialty to arrive at the total allowed charges for
the specialty.
Column C (Impact of 2012 Claims data, 90 Percent Equipment
Utilization Assumption, Ultrasound Changes, and Other Minor Changes):
This column shows the estimated CY 2014 impact on total allowed charges
of the changes in the RVUs due to the 90 percent equipment utilization
assumption discussed in section II.A.2.f. of this proposed rule,
ultrasound changes discussed in section II.A.5, the use of CY 2012
claims data to model payment rates, and all other proposals that result
in minimal redistribution of payments under the PFS.
Column D (Impact of OPPS/ASC cap): This column shows the
estimated CY 2014 impact on total allowed charges of the changes in the
RVUs resulting from our proposed policy discussed in section II.A.4. of
this proposed rule.
Column E (Impact of MEI Revision): This column shows the
estimated CY 2014 combined impact on total allowed charges of the
changes in the RVUs resulting from our proposed policy to adjust the
RVUs to match the proposed revised MEI weights.
Column F (Cumulative Impact): This column shows the
estimated CY 2014 combined impact on total allowed charges of all the
proposed changes in the previous columns.

Table 72--CY 2014 PFS Proposed Rule Estimated Impact on Total Allowed Charges by Specialty by Selected Proposal*
----------------------------------------------------------------------------------------------------------------
Impact of 2012
claims data,
90%
utilization Total
Allowed assumption, Impact of OPD/ Impact of MEI (cumulative)
Specialty charges (mil) ultrasound ASC cap revision impact
changes, and (percent) (percent) (percent)
other minor
changes
(percent)
(A) (B) (C) (D) (E) (F)
----------------------------------------------------------------------------------------------------------------
TOTAL........................... $86,995 0% 0% 0% 0%
01--ALLERGY/IMMUNOLOGY.......... 213 -1 0 -2 -3
02--ANESTHESIOLOGY.............. 1,862 0 0 3 3
03--CARDIAC SURGERY............. 355 0 0 2 2
04--CARDIOLOGY.................. 6,425 2 0 0 2
05--COLON AND RECTAL SURGERY.... 158 0 0 0 0
06--CRITICAL CARE............... 273 0 0 2 2
07--DERMATOLOGY................. 3,113 0 0 -2 -2
08--EMERGENCY MEDICINE.......... 2,929 0 0 3 3
09--ENDOCRINOLOGY............... 447 -1 1 0 0
10--FAMILY PRACTICE............. 6,358 0 1 0 1
11--GASTROENTEROLOGY............ 1,901 0 0 1 1
12--GENERAL PRACTICE............ 528 0 0 0 0
13--GENERAL SURGERY............. 2,236 0 0 1 1
14--GERIATRICS.................. 231 0 1 1 2
15--HAND SURGERY................ 151 -1 1 0 0
16--HEMATOLOGY/ONCOLOGY......... 1,890 -1 1 -1 -1
17--INFECTIOUS DISEASE.......... 635 0 0 2 2
18--INTERNAL MEDICINE........... 11,416 0 1 0 1
19--INTERVENTIONAL PAIN MGMT.... 640 -1 0 0 -1
20--INTERVENTIONAL RADIOLOGY.... 219 -1 -2 -1 -4
21--MULTISPECIALTY CLINIC/OTHER 79 -1 0 1 0
PHY............................

[[Page 43514]]

22--NEPHROLOGY.................. 2,123 0 0 1 1
23--NEUROLOGY................... 1,498 0 -1 -1 -2
24--NEUROSURGERY................ 712 0 0 1 1
25--NUCLEAR MEDICINE............ 51 0 1 0 1
27--OBSTETRICS/GYNECOLOGY....... 688 0 0 0 0
28--OPHTHALMOLOGY............... 5,592 0 1 -1 0
29--ORTHOPEDIC SURGERY.......... 3,683 -1 1 0 0
30--OTOLARNGOLOGY............... 1,128 -1 0 -1 -2
31--PATHOLOGY................... 1,134 1 -6 0 -5
32--PEDIATRICS.................. 63 0 0 0 0
33--PHYSICAL MEDICINE........... 999 -1 1 0 0
34--PLASTIC SURGERY............. 367 0 1 -1 0
35--PSYCHIATRY.................. 1,165 0 0 2 2
36--PULMONARY DISEASE........... 1,775 0 1 0 1
37--RADIATION ONCOLOGY.......... 1,783 1 -4 -2 -5
38--RADIOLOGY................... 4,635 -1 0 0 -1
39--RHEUMATOLOGY................ 551 -3 1 -1 -3
40--THORACIC SURGERY............ 332 0 0 2 2
41--UROLOGY..................... 1,858 -1 0 -1 -2
42--VASCULAR SURGERY............ 925 1 -3 0 -2
43--AUDIOLOGIST................. 56 0 1 0 1
44--CHIROPRACTOR................ 722 1 1 0 2
45--CLINICAL PSYCHOLOGIST....... 579 0 0 3 3
46--CLINICAL SOCIAL WORKER...... 408 0 0 3 3
47--DIAGNOSTIC TESTING FACILITY. 779 -4 0 -3 -7
48--INDEPENDENT LABORATORY**.... 812 1 -25 -2 -26
49--NURSE ANES/ANES ASST........ 1,055 0 0 4 4
50--NURSE PRACTITIONER.......... 1,937 0 1 0 1
51--OPTOMETRY................... 1,106 0 1 -1 0
52--ORAL/MAXILLOFACIAL SURGERY.. 44 0 -1 -1 -2
53--PHYSICAL/OCCUPATIONAL 2,797 0 1 0 1
THERAPY........................
54--PHYSICIAN ASSISTANT......... 1,405 0 1 0 1
55--PODIATRY.................... 1,975 -1 1 0 0
56--PORTABLE X-RAY SUPPLIER..... 110 1 1 -3 -1
57--RADIATION THERAPY CENTERS... 62 0 -8 -5 -13
98--OTHER....................... 25 0 1 0 1
----------------------------------------------------------------------------------------------------------------
* Table 72 shows only the payment impact on PFS services. These impacts use a constant conversion factor and
thus do not include the effects of the January 2014 conversion factor change required under current law.
** PFS Payments only, which account for ~17% of Independent Laboratory payments.

2. CY 2014 PFS Impact Discussion
a. Changes in RVUs
The most widespread specialty impacts of the RVU changes are
generally related to two major factors. The first factor, as discussed
in section II.A.4. of this proposed rule, is our proposal to cap the
payments for certain nonfacility services at the facility rate plus the
lower of the OPPS or ASC payment. The second factor, as discussed in
section II.D., is our proposal to revise the Medicare Economic Index
(MEI) and adjust the RVUs to match the new weights for work, PE, and
MP.
In addition, a number of other changes contribute to the impacts
shown in Table 71. These include a statutory change that requires us to
use a 90 percent equipment utilization rate rather than the previously
used 75 percent for expensive diagnostic imaging equipment as discussed
in section II.A.2.f of this proposed rule, proposals to update direct
practice expense inputs, as discussed in section II.A.5. of this
proposed rule and proposals to adjust time for some services, as
discussed in section II.B.3.c. of this proposed rule.
Table 72 shows the same information as provided in Table 71, but
rather than isolating the policy impact on physician work, practice
expense, and malpractice separately, Table 72 shows the impact of
varied proposed policies on total RVUs.
b. Combined Impact
Column E of Table 71 and column F of Table 72 display the estimated
CY 2014 combined impact on total allowed charges by specialty of all
the proposed RVU changes. These impacts range from an increase of 3
percent for clinical social workers, clinical psychologists, nurse
anesthetists, and emergency medicine, to a decrease of 26 percent for
independent laboratories. Again, these impacts are estimated prior to
the application of the negative CY 2014

[[Page 43515]]

conversion factor (CF) update applicable under the current statute.
Table 73 (Impact of Proposed Rule on CY 2014 Payment for Selected
Procedures (Based on the March 2013 Preliminary Physician Update))
shows the estimated impact on total payments for selected high volume
procedures of all of the changes discussed previously. We have included
CY 2014 payment rates with and without the effect of the CY 2014
negative PFS CF update for comparison purposes. We selected these
procedures from among the most commonly furnished by a broad spectrum
of physician specialties. The change in both facility rates and the
nonfacility rates are shown. For an explanation of facility and
nonfacility PE, we refer readers to Addendum A of this proposed rule.
BILLING CODE 4120-01-P

[[Page 43516]]

[GRAPHIC] [TIFF OMITTED] TP19JY13.105

[[Page 43517]]

[GRAPHIC] [TIFF OMITTED] TP19JY13.104

[[Page 43518]]

[GRAPHIC] [TIFF OMITTED] TP19JY13.106

BILLING CODE 4120-01-C

[[Page 43519]]

D. Effect of Proposed Changes to Medicare Telehealth Services Under the
PFS

As discussed in section II.E.3 of this proposed rule, we are
proposing to refine our definition of rural as it applies to HPSAs
eligible for telehealth services as well as add transitional care
management services to the list of Medicare telehealth services. While
we expect these changes to increase access to care in rural areas,
based on recent utilization of current Medicare telehealth services,
including services similar to transitional care management, we estimate
no significant impact on PFS expenditures from the proposed additions.

E. Geographic Practice Cost Indices (GPCIs)

Based upon statutory requirements we are proposing to update the
GPCIs for each Medicare payment locality. The proposed GPCIs
incorporate the use of updated data and cost share weights as discussed
in II.E. The Act requires that updated GPCIs be phased in over two
years. Addendum D shows the estimated effects of the revised GPCIs on
area GAFs for the transition year (CY 2014) and the fully implemented
year (CY 2015). The GAFs reflect the use of the updated underlying GPCI
data, and the proposed revised cost share weights. The GAFs are a
weighted composite of each area's work, PE and malpractice expense
GPCIs using the national GPCI cost share weights. While we do not
actually use the GAFs in computing the fee schedule payment for a
specific service, they are useful in comparing overall areas costs and
payments. The actual geographic adjustment to payment for any actual
service will be different from the GAF to the extent that the
proportions of work, PE and malpractice expense RVUs for the service
differ from those of the GAF.
The most significant changes occur in 22 payment localities where
the fully implemented (CY 2015) GAF moves up by more than 1 percent (11
payment localities) or down by more than 2 percent (11 payment
localities). The impacts on the proposed GPCIs are primarily attributed
to the expiration of the 1.000 work GPCI floor. The use of updated
underlying GPCI data and cost share weights has a minimal impact on
locality GAFs. The total impact of the GPCI revisions is shown in the
2015 GPCI values of Addendum E.
We note that the proposed CY 2014 physician work GPCIs and
summarized geographic adjustment factors (GAFs) published in Addenda D
and E reflect the elimination of the 1.0 work GPCI floor provided in
section 1848 (e)(1)(E) of the Act, which is set to expire prior to the
implementation of the CY 2014 PFS.

F. Other Provisions of the Proposed Regulation

1. Rebasing and Revising Medicare Economic Index
The preliminary estimate of the proposed changes to the MEI for CY
2014 is a 0.1 percent decrease. This is based on an estimated 0.8
percent increase for CY 2014 under the current MEI compared to a 0.7
percent increase for CY 2014 under the proposed revised MEI.''
2. Coverage of Items and Services Furnished in FDA-Approved
Investigational Device Exemption (IDE) Clinical Trials
We are proposing a transparent centralized review process that
would be more efficient by reducing the burden for stakeholders. Once
the IDE coverage process is centralized, there will be a single entity
making the IDE coverage decision. This also eliminates duplicative
reviews by Medicare local contractors and the numerous applications
sent to contractors by stakeholders requesting IDE coverage. We believe
that a centralized review process will not significantly reduce the
number of IDE devices currently covered. Therefore, this rule will not
result in an extra burden to the public.
3. Ultrasound Screening for Abdominal Aortic Aneurysms
As discussed in section III.B. of this proposed rule, section
1861(s)(2)(AA) of the Act, with implementing regulations at Sec.
410.19, authorizes Medicare coverage of ultrasound screening for
abdominal aortic aneurysms (``AAA screening''). We are proposing to
modify Sec. 410.19 to allow coverage of one-time AAA screening without
receiving a referral as part of the IPPE, for beneficiaries that meet
certain other eligibility criteria (a family history of AAA or, for men
aged 65-75, a history of smoking). Approximately 45 percent of men aged
65-75 have a history of smoking. It is unknown how many individuals
have a family history of AAA or how many beneficiaries will avail
themselves of this benefit. Therefore, the impact of this change is
unknown for CY 2014.
4. Modification to Medicare Coverage of Colorectal Cancer Screening
As discussed in section III.C. of this proposed rule, sections
1861(s)(2)(R) and 1861(pp)(1) of the Act, and implementing regulations
at 42 CFR 410.37 authorize Medicare coverage of screening FOBT. We are
proposing to modify Sec. 410.37(b) to allow attending physicians,
physician assistants, nurse practitioners, and clinical nurse
specialists to furnish orders for screening FOBTs. While there may be
an increase in utilization, particularly in rural areas, it is unknown
how many individuals will avail themselves of this benefit. Therefore,
the impact of this change is unknown for CY 2014.
5. Ambulance Fee Schedule
As discussed in section III.D. of this proposed rule, section
604(a) through (c) of the ATRA require the extension of certain add-on
payments for ground ambulance services and the extension of certain
rural area designations for purposes of air ambulance payment. In
addition, as discussed in section III.D. of this proposed rule, section
637 of the ATRA (which added section 1834(l)(15) of the Act) specifies
that the fee schedule amount otherwise applicable under the preceding
provisions of section 1834(l) of the Act shall be reduced by 10 percent
for ambulance services furnished on or after October 1, 2013,
consisting of non-emergency basic life support (BLS) services involving
transport of an individual with end-stage renal disease for renal
dialysis services (as described in section 1881(b)(14)(B) of the Act)
furnished other than on an emergency basis by a provider of services or
a renal dialysis facility. The ambulance extender provisions and the
mandated 10 percent rate decrease discussed above are enacted through
legislation that is self-implementing. We are proposing to amend the
regulation text at Sec. 414.610 only to conform the regulations to
these self-implementing statutory requirements. As a result, we are not
making any policy proposals associated with these legislative
provisions and there is no associated regulatory impact.
6. Clinical Laboratory Fee Schedule
We are proposing to add language to the Code of Federal Regulations
to codify authority provided by statute and to establish a process
under which we will systematically reexamine the payment amounts
established under the CLFS to determine if changes in technology for
the delivery of that service warrant an adjustment to the payment
amount. We are also proposing a definition for the term technological
changes. Adjustments made under the new process could both increase fee
schedule amounts and provide for reductions in existing amounts. We
cannot estimate a net impact at this time.

[[Page 43520]]

7. Liability for Overpayments to or on Behalf of Individuals Including
Payments to Providers or Other Persons
As discussed in section III.M. of this proposed rule, we are
proposing to change the timing of the triggering event for the
``without fault'' and ``against equity and good conscience''
presumptions. As a result, there would be an estimated savings of $0.5
billion over 10 years.
8. Physician Compare Web Site
There will be no impact for the Physician Compare Web site because
we are not collecting any information for the Physician Compare Web
site.
9. Physician Payment, Efficiency, and Quality Improvements--Physician
Quality Reporting System (PQRS)
In the CY 2013 PFS final rule with comment period, we provided
estimates related to the impact of the requirements we finalized for
the PQRS for 2014. Since we are making additional proposals for 2014,
this section modifies the impact statement provided for 2014 in the CY
2013 PFS final rule with comment period. Please note that we will base
our estimates on information found in the 2011 Physician Quality
Reporting System and eRx Reporting Experience and Trends (hereinafter
``the PQRS Reporting Experience''). This report contains the latest
data we have gathered on PQRS participation. The PQRS Reporting
Experience is available at http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/PQRS/index.html?redirect=/
PQRS/. According to the 2011 Reporting Experience Report, over 1
million professionals were eligible to participate in the PQRS. A total
of $261,733,236 in PQRS incentives was paid by CMS for the 2011 program
year, which encompassed 26,515 practices that included 266,521 eligible
professionals (or approximately 27 percent of the professionals
eligible to participate). The average incentive earned for PQRS in 2011
per each individually-participating eligible professional was $1,059.
As we noted in our impact statement last year, we expect that, due
to the implementation of payment adjustments beginning in 2015,
participation in the PQRS would rise incrementally to approximately
300,000 eligible professionals and 400,000 eligible professionals in
2013 and 2014, respectively. We believe our estimate of 400,000
eligible professionals participating in PQRS in 2014 is accurate.
With respect to the estimate amount of incentives earned, for 2014,
eligible professionals can earn a 0.5 percent incentive (that is, a
bonus payment equal to 0.5 percent of the total allowed Part B charges
for covered professional services under the PFS furnished by the
eligible professional during the reporting period) for satisfactory
reporting, a reduction of 1.0 percent from 2011. Based on information
drawn from the 2011 Reporting Experience and our participation
estimate, we believe that, out of the 400,000 eligible professionals we
expect to participate in the PQRS in 2014, the PQRS will distribute
2014 incentives to approximately (27 percent of 1 million eligible
professionals) 270,000 eligible professionals. At $1,059 per eligible
professional, the PQRS would distribute approximately $286 million in
incentive payments in 2014. We believe these incentive payments will
help offset the cost eligible professionals may undertake for
participating in the PQRS for the applicable year.
We note that the total burden associated with participating in the
PQRS is the time and effort associated with indicating intent to
participate in the PQRS, if applicable, and submitting PQRS quality
measures data. When establishing these burden estimates, we assume the
following:
The proposals for reporting for the PQRS for the 2014
incentive and 2016 payment adjustment would be established as proposed
in this CY 2014 Medicare PFS proposed rule.
For an eligible professional or group practice using the
claims, registry, or EHR-based reporting mechanisms, we assume that the
eligible professional or group practice would attempt to report PQRS
quality measures data with the intention of earning the 2014 PQRS
incentive. Therefore, an eligible professionals or group practice would
report on 9 measures.
With respect to labor costs, we believe that a billing
clerk will handle the administrative duties associated with
participating, while a computer analyst will handle duties related to
reporting PQRS quality measures. According to the Bureau of Labor
Statistics, the mean hourly wage for a billing clerk is approximately
$16/hour whereas the mean hourly wage for a computer analyst is
approximately $40/hour.
For an eligible professional who wishes to participate in the PQRS
as an individual, the eligible professional need not indicate his/her
intent to participate. The eligible professional may simply begin
reporting quality measures data. Therefore, these burden estimates for
individual eligible professionals participating in the PQRS are based
on the reporting mechanism the individual eligible professional
chooses. However, we believe a new eligible professional or group
practice would spend 5 hours--which includes 2 hours to review the PQRS
measures list, review the various reporting options, and select a
reporting option and measures on which to report and 3 hours to review
the measure specifications and develop a mechanism for incorporating
reporting of the selected measures into their office work flows.
Therefore, we believe that the initial administrative costs associated
with participating in the PQRS would be approximately $80 ($16/hour x 5
hours).
With respect to an eligible professional who participates in the
PQRS via claims, the eligible professional must gather the required
information, select the appropriate quality data codes (QDCs), and
include the appropriate QDCs on the claims they submit for payment. The
PQRS collects QDCs as additional (optional) line items on the existing
HIPAA transaction 837-P and/or CMS Form 1500 (OCN: 0938-0999). Based on
our experience with Physician Voluntary Reporting Program (PVRP), we
continue to estimate that the time needed to perform all the steps
necessary to report each measure via claims will range from 0.25
minutes to 12 minutes, depending on the complexity of the measure.
Therefore, the time spent reporting 9 measures would range from 2.25
minutes to 108 minutes. Using an average labor cost of $40/hour, we
estimate that time cost of reporting for an eligible professional via
claims would range from $1.50 (2.25 minutes or 0.0375 hours x $40/hour)
to $72.00 (108 minutes or 1.8 hours x $40/hour) per reported case. With
respect to how many cases an eligible professional would report when
using the claims-based reporting mechanism, we proposed that an
eligible professional would need to report on 50 percent of the
eligible professional's applicable cases. The actual number of cases on
which an eligible professional would report would vary depending on the
number of the eligible professional's applicable cases. However, in
prior years, when the reporting threshold was 80 percent, we found that
the median number of reporting cases for each measure was 9. Since we
are proposing to reduce the reporting threshold to 50 percent, we
estimate that the average number of reporting cases for each measure
would be reduced to 6. Based on these estimates, we estimate that the

[[Page 43521]]

total cost of reporting for an eligible professional choosing the
claims-based reporting mechanism would range from ($1.50/per reported
case x 6 reported cases) $9.00 to ($72.00/reported case x 6 reported
cases) $432.
With respect to an eligible professional or group practice who
participates in the PQRS via a qualified registry, direct EHR product,
EHR data submission vendor product, or qualified clinical data
registry, we believe there would be little to no burden associated for
an eligible professional or group practice to report PQRS quality
measures data to CMS, because the selected reporting mechanism submits
the quality measures data for the eligible professional. While we note
that there may be start-up costs associated with purchasing a qualified
registry, direct EHR product, EHR data submission vendor, or qualified
clinical data registry, we believe that an eligible professional or
group practice would not purchase a qualified registry, direct EHR
product, EHR data submission vendor product, or qualified clinical data
registry solely for the purpose of reporting PQRS quality measures.
Therefore, we have not included the cost of purchasing a qualified
registry, direct EHR, EHR data submission vendor product, or qualified
clinical data registry in our burden estimates.
Unlike eligible professionals who choose to report individually, we
note that eligible professionals choosing to participate as part of a
group practice under the GPRO must indicate their intent to participate
in the PQRS as a group practice. The total burden for group practices
who submit PQRS quality measures data via the proposed GPRO web-
interface would be the time and effort associated with submitting this
data. To submit quality measures data for the PQRS, a group practice
would need to (1) be selected to participate in the PQRS GPRO and (2)
report quality measures data. With respect to the administrative duties
for being selected to participate in the PQRS as a GPRO, we believe it
would take approximately 6 hours--including 2 hours to decide to
participate in the PQRS as a GPRO, 2 hours to self-nominate, and 2
hours to undergo the vetting process with CMS officials--for a group
practice to be selected to participate in the PQRS GPRO for the
applicable year. Therefore, we estimate that the cost of undergoing the
GPRO selection process would be ($16/hour x 6 hours) $96. With respect
to reporting, the total reporting burden is the time and effort
associated with the group practice submitting the quality measures data
(that is, completed the data collection interface). Based on burden
estimates for the PGP demonstration, which uses the same data
submission methods, we estimate the burden associated with a group
practice completing the data collection interface would be
approximately 79 hours. Therefore, we estimate that the report cost for
a group practice to submit PQRS quality measures data for the proposed
reporting options in an applicable year would be ($40/hour x 79 hours)
$3,160.
Aside from the burden of eligible professionals and group practices
participating in the PQRS, we believe that vendors of registries,
qualified clinical data registries, direct EHR products, and EHR data
submission vendor products incur costs associated with participating in
the PQRS. Please note that we have proposed requirements for a new
reporting mechanism in this CY 2014 PFS proposed rule--the qualified
clinical data registry. For purpose of these burden estimates, we
believe that, at least in its initial stage, vendors of a qualified
clinical data registry would have burden estimates similar to
traditional registries, as we believe many of the vendors seeking to
become qualified as a clinical data registry in the PQRS will be
existing qualified registries.
With respect to qualified registries and qualified clinical data
registries, the total burden for qualified registries who submit PQRS
Quality Measures Data would be the time and effort associated with
submitting this data. To submit quality measures data for the proposed
program years for PQRS, a registry would need to (1) become qualified
for the applicable year and (2) report quality measures data on behalf
of its eligible professionals. With respect to administrative duties
related to the qualification process for both traditional registries
and clinical data registries, we estimate that it will take a total of
10 hours--including 1 hour to complete the self-nomination statement, 2
hours to interview with CMS, 2 hours to calculate numerators,
denominators, and measure results for each measure the registry wishes
to report using a CMS-provided measure flow, and 5 hours to complete an
XML submission--to become qualified to report PQRS quality measures
data. Therefore, we estimate that it would cost a traditional registry
and clinical data registry ($16.00/hour x 10 hours) $160 to become
qualified to submit PQRS quality measures data on behalf of its
eligible professionals.
With respect to the reporting of quality measures data, we believe
the burden associated with reporting is the time and effort associated
with the registry calculating quality measures results from the data
submitted to the registry by its eligible professionals, submitting
numerator and denominator data on quality measures, and calculating
these measure results. We believe, however, that registries already
perform these functions for its eligible professionals irrespective of
participating in the PQRS. Therefore, we believe there would be little
to no additional burden associated with reporting PQRS quality measures
data. Whether there is any additional reporting burden will vary with
each registry, depending on the registry's level of savvy with
submitting quality measures data for the PQRS.
With respect to EHR products, the total burden for direct EHR
products and EHR data submission vendors who submit PQRS Quality
Measures Data would be the time and effort associated with submitting
this data. To submit quality measures data for the proposed program
years under the PQRS, a direct EHR product or EHR data submission
vendor would need to report quality measures data on behalf of its
eligible professionals. Please note that we are not proposing to
continue to require direct EHR products and EHR data submission vendors
to become qualified to submit PQRS quality measures data.
In addition to the GPRO web interface, please note that we have
proposed a new reporting mechanism that would be available to group
practices comprised of 25+ eligible professionals: the certified survey
vendor. With respect to using a certified survey vendor, we believe
there would be little to no burden associated for a group practice to
report the CG CAHPS survey data to CMS, because the selected reporting
mechanism submitted the quality measures data for the group practice.
While there may be start-up costs associated with purchasing a
certified survey vendor, we believe that a group practice would not
purchase a certified survey vendor solely for the purpose of reporting
the CG CAHPS survey for the PQRS. Therefore, we have not included the
cost of purchasing a certified survey vendor in our burden estimates.

[[Page 43522]]

Table 74--Estimated Costs for Reporting PQRS Quality Measures Data per Eligible Professional
----------------------------------------------------------------------------------------------------------------
Estimated Estimated Number of
hours cases measures Hourly rate Total cost
----------------------------------------------------------------------------------------------------------------
Individual Eligible Professional 5.0 1 N/A $16 $80
(EP): Preparation..............
Individual EP: Claims........... 1.8 6 9 40 3,888
Individual EP: Registry......... N/A 1 N/A N/A Minimal
Individual EP: EHR.............. N/A 1 N/A N/A Minimal
Group Practice: Self-Nomination. 6.0 1 N/A 16 96
Group Practice: Reporting....... 79 1 N/A 40 3,160
----------------------------------------------------------------------------------------------------------------

Table 75--Estimated Costs per Vendor To Participate in the PQRS
----------------------------------------------------------------------------------------------------------------
Estimated
hours Hourly rate Total cost
----------------------------------------------------------------------------------------------------------------
Registry: Self-Nomination....................................... 10 $16 $160
----------------------------------------------------------------------------------------------------------------

10. Medicare EHR Incentive Program
Please note that the requirements for meeting the clinical quality
measures (CQM) component of achieving meaningful use for the EHR
Incentive Program in 2014 were established in a standalone final rule
published on September 4, 2012 (77 FR 53968). The proposals contained
in this CY 2014 PFS proposed rule merely propose alternative methods to
report CQMs to meet the CQM component of achieving meaningful use for
the EHR Incentive Program in 2014. We believe any impacts these
proposals would have are absorbed in the impacts discussion published
in the EHR Incentive Program final rule published on September 4, 2012.
11. Medicare Shared Savings Program
Please note that the requirements for participating in the Medicare
Shared Saving Program and the impacts of these requirements were
established in the final rule for the Medicare Shared Savings Program
that appeared in the Federal Register on November 2, 2011 (76 FR
67962). The proposals for the Medicare Shared Savings Program set forth
in the CY 2014 MPFS proposed rule expand the incorporation of reporting
requirements and incentive payments related to PQRS under section 1848
to include reporting requirements related to the payment adjustment.
Since ACO participants and ACO provider/suppliers will not have to
report PQRS separately to avoid the payment adjustment, this reduces
the quality reporting burden for ACO participants participating in the
Shared Savings Program. There is no impact for the additional proposals
related to requirements for setting benchmarks or for scoring the CAHPS
measure modules.
12. Physician Value-Based Payment Modifier and the Physician Feedback
Reporting Program
The changes to the Physician Feedback Program in section III.K. of
this proposed rule would not impact CY 2014 physician payments under
the Physician Fee Schedule. We anticipate that as we approach
implementation of the value modifier, physicians will increasingly
participate in the Physician Quality Reporting System to determine and
understand how the value modifier could affect their payments.
13. Existing Standards for E-Prescribing Under Medicare Part D and
Identification
This section of the proposed rule imposes no new requirements
because use of the official Part D e-prescreening standards; NCPDP
SCRIPT 10.6, Formulary and Benefit 3.0 are voluntary, and as such, it
will not have a significant economic impact on a substantial number of
small entities, small rural hospitals or state, local, or tribal
governments or on the private sector.
14. Chiropractic Services Demonstration
As discussed in section III.M. of this proposed rule, we are
continuing the recoupment of the $50 million in expenditures from this
demonstration in order to satisfy the BN requirement in section
651(f)(1)(B) of the MMA. We initiated this recoupment in CY 2010 and
this will be the fifth and final year. As discussed in the CY 2010 PFS
final rule with comment period, we finalized a policy to recoup $10
million each year through adjustments to payments under the PFS for
chiropractic CPT codes in CYs 2010 through 2014. For each year of this
recoupment, we have provided OACT's projected chiropractic expenditures
based on previous year's data. While OACT's projections have included
the statutory reductions to physician payments, the statute was amended
in each year to avoid these reductions. As a result, Medicare
expenditures for chiropractic services during the recoupment were
higher than the OACT projections. Chiropractic services expenditures
during the recoupment period have been as follows: $540 million in
2010; $520 million in 2011; and $580 million in 2012. In total, CMS
recouped $32.8 million over the years of 2010, 2011 and 2012. OACT now
projects chiropractic expenditures to be approximately $580 million in
2013. A 2 percent recoupment percentage for chiropractic services would
result in approximately $11.6 million in 2013. For the years 2010
through 2013, CMS would have recouped approximately $44.4 million of
the $50 million required for budget neutrality.
CMS plans to recoup the remaining funds, approximately $5.6
million, and will reduce chiropractic CPT codes (CPT codes 98940,
98941, and 98942) by the appropriate percentage, which by our
preliminary estimates is one percent if the approximately 25 percent
reduction in physician payments takes effect in 2014. If the statute is
amended to avoid the physician payment reduction, we will reduce the
recoupment percentage as appropriate to ensure the recoupment does not
exceed $50 million. For instance, if the statute is amended to provide
for a zero percent PFS update, we would reduce the recoupment
percentage to approximately 0.7 percent.

G. Alternatives Considered

This proposed rule contains a range of policies, including some
provisions related to specific statutory provisions. The preceding
preamble provides descriptions of the statutory provisions that are
addressed, identifies those

[[Page 43523]]

policies when discretion has been exercised, presents rationale for our
final policies and, where relevant, alternatives that were considered.

H. Impact on Beneficiaries

There are a number of changes in this proposed rule that would have
an effect on beneficiaries. In general, we believe that many of the
proposed changes, including the refinements of the PQRS with its focus
on measuring, submitting, and analyzing quality data; establishing the
basis for the value-based payment modifier to adjust physician payment
beginning in CY 2015; improved accuracy in payment through revisions to
the inputs used to calculate payments under the PFS and the capping
certain nonfacility services at the facility rate plus the lower of the
OPPS or ASC rate; and revisions to payment for Part B drugs will have a
positive impact and improve the quality and value of care provided to
Medicare beneficiaries.
Most of the aforementioned proposed policy changes could result in
a change in beneficiary liability as relates to coinsurance (which is
20 percent of the fee schedule amount if applicable for the particular
provision after the beneficiary has met the deductible). To illustrate
this point, as shown in Table 73, the CY 2013 national payment amount
in the nonfacility setting for CPT code 99203 (Office/outpatient visit,
new) is $108.05, which means that in CY 2013 a beneficiary would be
responsible for 20 percent of this amount, or $21.61. Based on this
proposed rule, using the current (CY 2013) CF of 34.0376, adjusted to
35.6652 to include budget neutrality, the CY 2014 national payment
amount in the nonfacility setting for CPT code 99203, as shown in Table
73, is $113.15, which means that, in CY 2014, the proposed beneficiary
coinsurance for this service would be $22.63.

I. Accounting Statement

As required by OMB Circular A-4 (available at http://www.whitehouse.gov/omb/circulars/a004/a-4.pdf), in Table 76 (Accounting
Statement), we have prepared an accounting statement showing the
estimated expenditures associated with this proposed rule. This
estimate includes the CY 2014 incurred benefit impact associated with
the estimated CY 2014 PFS conversion factor update based on the FY 2014
President's Budget baseline.

Table 76--Accounting Statement: Classification of Estimated Expenditures
------------------------------------------------------------------------
Category Transfers
------------------------------------------------------------------------
CY 2014 Annualized Monetized Estimated decrease in expenditures of
Transfers. $19.6 billion for PFS conversion factor
update.
From Whom To Whom?........... Federal Government to physicians, other
practitioners and providers and
suppliers who receive payment under
Medicare.
CY 2014 Annualized Monetized Estimated increase in payment of $286
Transfers. million.
From Whom To Whom?........... Federal Government to eligible
professionals who satisfactorily
participate in the Physician Quality
Reporting System (PQRS).
CY 2014 Annualized Monetized Estimated decrease in expenditures of $50
Transfers. million for liability for overpayments
to or on behalf of individuals including
payments to providers or other persons.
From Whom To Whom?........... Federal Government to physicians, other
practitioners and providers and
suppliers who receive payment under
Medicare.
------------------------------------------------------------------------

Table 77--Accounting Statement: Classification of Estimated Costs,
Transfer, and Savings
------------------------------------------------------------------------
Category Transfer
------------------------------------------------------------------------
CY 2014 Annualized Monetized Transfers of $29 million.
beneficiary cost coinsurance.
From Whom to Whom? Beneficiaries to Federal
Government.
------------------------------------------------------------------------
Category Cost
------------------------------------------------------------------------
CY 2014 Annualized Monetized Cost to $66.6 million.
eligible professionals of Participating in
the PQRS Program
------------------------------------------------------------------------

J. Conclusion

The analysis in the previous sections, together with the remainder
of this preamble, provides an initial ``Regulatory Flexibility
Analysis.'' The previous analysis, together with the preceding portion
of this preamble, provides a Regulatory Impact Analysis.
In accordance with the provisions of Executive Order 12866, this
regulation was reviewed by the Office of Management and Budget.

List of Subjects

42 CFR Part 405

Administrative practice and procedure, Health facilities, Health
professions, Kidney diseases, Medical devices, Medicare, Reporting and
recordkeeping requirements, Rural areas, X-rays.

42 CFR Part 410

Health facilities, Health professions, Kidney diseases,
Laboratories, Medicare, Reporting and recordkeeping requirements, Rural
areas, X-rays.

42 CFR Part 411

Kidney diseases, Medicare, Reporting and recordkeeping
requirements.

42 CFR Part 414

Administrative practice and procedure, Health facilities, Health
professions, Kidney diseases, Medicare, Reporting and recordkeeping
requirements.

42 CFR Part 423

Administrative practice and procedure, Emergency medical services,
Health facilities, Health maintenance organizations (HMO), Health
professionals, Medicare, Penalties, Privacy, Reporting and
recordkeeping requirements.

42 CFR Part 425

Administrative practice and procedure, Health facilities, Health
professions, Medicare, Reporting and recordkeeping requirements.
For the reasons set forth in the preamble, the Centers for Medicare
& Medicaid Services propose to amend 42 CFR chapters IV as set forth
below:

PART 405--FEDERAL HEALTH INSURANCE FOR THE AGED AND DISABLED

0
1. The authority citation for part 405 continues to read as follows:

Authority: Secs. 205(a), 1102, 1861, 1862(a), 1862(m), 1869,
1871, 1874, 1881, and 1886(k) of the Social Security Act (42 U.S.C.
405(a), 1302, 1395x, 1395y(a), 1395y(m), 1395ff, 1395hh, 1395kk,
1395rr and 1395ww(k)), and sec. 353 of the Public Health Service Act
(42 U.S.C. 263a).

0
2. Section 405.201 is amended by adding paragraph (a)(3) and revising
paragraph (b) to read as follows:

[[Page 43524]]

Sec. 405.201 Scope of subpart and definitions.

(a) * * *
(3) CMS identifies criteria for coverage of items and services
furnished in IDE studies.
(b) Definitions. As used in this subpart--
Category A (Experimental) device refers to a device for which
``absolute risk'' of the device type has not been established (that is,
initial questions of safety and effectiveness have not been resolved)
and the FDA is unsure whether the device type can be safe and
effective.
Category B (Nonexperimental/investigational) device refers to a
device for which the incremental risk is the primary risk in question
(that is, initial questions of safety and effectiveness of that device
type have been resolved), or it is known that the device type can be
safe and effective because, for example, other manufacturers have
obtained FDA approval for that device type.
ClinicalTrials.gov refers to the National Institutes of Health's
National Library of Medicine's online registry and results database of
publicly and privately supported clinical studies of human participants
conducted around the world.
Contractors refers to Medicare Administrative Contractors and other
entities that contract with CMS to review and adjudicate claims for
Medicare items and services.
IDE stands for investigational device exemption. An FDA-approved
IDE application permits a device, which would otherwise be subject to
marketing approval or clearance, to be shipped lawfully for the purpose
of conducting a clinical study in accordance with 21 U.S.C. 360j(g) and
21 CFR parts 812 and 813.
Pivotal studies or trials refer to clinical investigations designed
to collect definitive evidence of the safety and effectiveness of a
device for a specified intended use, typically in a statistically
justified number of subjects. It may or may not be preceded by an early
and/or a traditional feasibility study.
Routine care items and services refer to items and services that
are otherwise generally available to Medicare beneficiaries (that is,
there exists a benefit category, it is not statutorily excluded, and
there is not a national noncoverage decision) that are furnished in
either the experimental or the control arms of a clinical trial and
that would be otherwise furnished even if the beneficiary were not
enrolled in a clinical trial.
Superiority studies or trials refers to studies or trials that are
intended to demonstrate at some prespecified level of confidence that
the effect of an investigational treatment is superior to that of an
active control by more than a prespecified margin.
0
3. Section 405.207 is amended by revising paragraph (b)(2) to read as
follows:

Sec. 405.207 Services related to a non-covered device.

* * * * *
(b) * * *
(2) Routine care items and services related to experimental/
investigational (Category A) devices as defined in Sec. 405.201(b);
and furnished in conjunction with an FDA-approved clinical trial that
meet the IDE study standards in Sec. 405.212.
* * * * *
0
4. Section 405.211 is revised to read as follows:

Sec. 405.211 Coverage of items and services in FDA approved IDE
studies.

(a) Requirements. CMS review includes the following items and
supporting materials as needed:
(1) The FDA approval letter.
(2) IDE study protocol.
(3) IRB approval letter.
(4) ClinicalTrial.gov identifier.
(b) Coverage of routine care items and services for Category A
devices. Medicare may cover routine care items and services furnished
in any FDA-approved Category A IDE study if the criteria in Sec.
405.212(a)(1) through (13) are met. Medicare covers routine care items
and services furnished in any FDA-approved Category A IDE study if the
criteria in Sec. 405.212(a) and (b) are met.
(c) Coverage of Category B IDE devices and routine care. Medicare
may cover a Category B IDE device and routine care items and services
furnished in any FDA-approved Category B IDE study if the criteria in
Sec. 405.212(a)(1) through (13) are met. Medicare covers a Category B
IDE device and routine care items and services furnished in any FDA-
approved Category B IDE study if the criteria in Sec. 405.212(a) and
(c) are met.
(d) Coverage of Category A routine services and Category B IDE
devices and routine care that do not wholly fall under Sec. 405.212
(b) or (c). If an IDE device is furnished in an FDA-approved IDE study
that does not wholly fall under Sec. 405.212(b) or (c), CMS considers
whether the study's attainment of the criteria in Sec. 405.212 (a) are
sufficient to mitigate the failure to meet Sec. 405.212(b) or (c).
(e) Notification. All CMS-approved IDE studies will be posted on
the CMS coverage Web site and published in the Federal Register.
0
5. Section 405.212 is added to read as follows:

Sec. 405.212 IDE study criteria.

(a) All category A and B IDE studies must conform to the following
criteria for Medicare coverage under Sec. 405.211:
(1) The principal purpose of the study is to test whether the item
or service meaningfully improves health outcomes of patients who are
represented by the Medicare-enrolled subjects.
(2) The rationale for the study is well supported by available
scientific and medical information, or it is intended to clarify or
establish the health outcomes of interventions already in common
clinical use.
(3) The study results are not anticipated to unjustifiably
duplicate existing knowledge.
(4) The study design is methodologically appropriate and the
anticipated number of enrolled subjects is adequate to answer the
research question(s) being asked in the study.
(5) The study is sponsored by an organization or individual capable
of completing it successfully.
(6) The study is in compliance with all applicable Federal
regulations concerning the protection of human subjects found at 45 CFR
part 46.
(7) All aspects of the study are conducted according to appropriate
standards of scientific integrity set by the International Committee of
Medical Journal Editors.
(8) The study has a written protocol that clearly demonstrates
adherence to the standards listed here as Medicare requirements.
(9) Where appropriate, the clinical research study is not designed
to exclusively test toxicity or disease pathophysiology in healthy
individuals. Trials of all medical technologies measuring therapeutic
outcomes as one of the objectives may be exempt from this standard only
if the disease or condition being studied is life threatening as
defined in 21 CFR 312.81(a) and the patient has no other viable
treatment options.
(10) The study is registered on the ClinicalTrials.gov Web site
and/or the Registry of Patient Registries (RoPR) by the principal
sponsor/investigator prior to the enrollment of the first study
subject.
(11) The study protocol specifies the method and timing of public
release of results on all pre-specified outcomes, including release of
negative outcomes. The release should be hastened if the study is
terminated early. The results must be made public within 24 months

[[Page 43525]]

of the end of data collection. If a report is planned to be published
in a peer reviewed journal, then that initial release may be an
abstract that meets the requirements of the International Committee of
Medical Journal Editors. However a full report of the outcomes must be
made public no later than three (3) years after the end of data
collection.
(12) The study protocol explicitly discusses subpopulations
affected by the item or service under investigation, particularly
traditionally underrepresented groups in clinical studies, how the
inclusion and exclusion criteria effect enrollment of these
populations, and a plan for the retention and reporting of said
populations in the study. If the inclusion and exclusion criteria are
expected to have a negative effect on the recruitment or retention of
underrepresented populations, the protocol must discuss why these
criteria are necessary.
(13) The study protocol explicitly discusses how the results are or
are not expected to be generalizable to subsections of the Medicare
population to infer whether Medicare patients may benefit from the
intervention. Separate discussions in the protocol may be necessary for
populations eligible for Medicare due to age, disability or Medicaid
eligibility.
(b) Medicare covers routine care items and services in an FDA-
approved Category A IDE study that meets the requirements in paragraph
(a) of this section and the study is the following:
(1) A pivotal study.
(2) A superiority study design.
(c) Medicare covers the IDE device and routine care items and
services in an FDA-approved Category B IDE study that meets the
requirements in paragraph (a) of this section and the study is the
following:
(1) A pivotal study.
(2) A superiority study design.
0
6. Section 405.350 is amended by revising paragraph (c) to read as
follows:

Sec. 405.350 Individual's liability for payments made to providers
and other persons for items and services furnished the individual.

* * * * *
(c) For purposes of paragraph (a)(2) of this section, a provider of
services or other person shall, in the absence of evidence to the
contrary, be deemed to be without fault if the determination of the
carrier, the intermediary, or the Centers for Medicare & Medicaid
Services that more than the correct amount was paid was made subsequent
to the fifth year following the year in which notice was sent to such
individual that such amount had been paid.
0
7. Section 405.355 is amended by revising paragraph (b) to read as
follows:

Sec. 405.355 Waiver of adjustment or recovery.

* * * * *
(b) Adjustment or recovery of an incorrect payment (or only such
part of an incorrect payment as may be determined to be inconsistent
with the purposes of Title XVIII of the Act) against an individual who
is without fault shall be deemed to be against equity and good
conscience if the incorrect payment was made for items and services
that are not payable under section 1862(a)(1) or (a)(9) of the Act and
if the determination that such payment was incorrect was made
subsequent to the fifth year following the year in which notice of such
payment was sent to such individual.
0
8. Section 405.2413 is amended by--
0
A. Redesignating paragraphs (a)(4) and (5) as paragraphs (a)(5) and
(6), respectively.
0
B. Adding new paragraph (a)(4).
0
C. Revising newly redesignated paragraph (a)(5).
The revision and addition reads as follows:

Sec. 405.2413 Services and supplies incident to a physician's
services.

(a) * * *
(4) Services and supplies must be furnished in accordance with
applicable State law;
(5) Furnished under the direct supervision of a physician; and
* * * * *
0
9. Section 405.2415 is amended by--
0
A. Redesignating paragraphs (a)(4) and (5) as paragraphs (a)(5) and
(6), respectively.
0
B. Adding new paragraph (a)(4).
0
C. Revising newly redesignated paragraph (a)(5).
0
D. Revising paragraph (b).
The revision and addition reads as follows:

Sec. 405.2415 Services and supplies incident to nurse practitioner
and physician assistant services.

(a) * * *
(4) Services and supplies must be furnished in accordance with
applicable State law;
(5) Furnished under the direct supervision of a nurse practitioner,
physician assistant, nurse midwife, specialized nurse practitioner or a
physician; and
* * * * *
(b) The direct supervision requirement is met in the case of a
nurse practitioner, physician assistant, nurse midwife, or specialized
nurse practitioner only if such a person is permitted to supervise such
services under the written policies governing the rural health clinic.
* * * * *
0
10. Section 405.2452 is amended by--
0
A. Redesignating paragraphs (a)(4) and (5) as paragraphs (a)(5) and
(6), respectively.
0
B. Adding new paragraph (a)(4).
0
C. Revising newly redesignated paragraph (a)(5).
0
D. Revising paragraph (b).
The revision and addition reads as follows:

Sec. 405.2452 Services and supplies incident to clinical psychologist
and clinical social worker services.

(a) * * *
(4) Services and supplies must be furnished in accordance with
applicable State law;
(5) Furnished under the direct supervision of a clinical
psychologist, clinical social worker or physician; and
* * * * *
(b) The direct supervision requirement in paragraph (a)(5) of this
section is met only if the clinical psychologist or clinical social
worker is permitted to supervise such services under the written
policies governing the Federally qualified health center.

PART 410--SUPPLEMENTARY MEDICAL INSURANCE (SMI) BENEFITS

0
11. The authority citation for part 410 continues to read as follows:

Authority: Secs. 1102, 1834, 1871, 1881, and 1893 of the Social
Security Act (42 U.S.C. 1302. 1395m, 1395hh, and 1395ddd).

Sec. 410.19 [Amended]

0
12. In Sec. 410.19(a) amend the definition of ``eligible beneficiary''
by removing paragraph (1) and redesignating paragraphs (2) and (3) as
paragraphs (1) and (2), respectively.
0
13. Section 410.26 is amended by--
0
A. Revising paragraph (a)(1).
0
B. Redesignating paragraph (b)(7) and (8) as paragraph (b)(8) and (9),
respectively.
0
C. Adding new paragraph (b)(7).
The revision and addition reads as follows:

Sec. 410.26 Services and supplies incident to a physician's
professional services: Conditions.

(a) * * *
(1)Auxiliary personnel means any individual who is acting under the
supervision of a physician (or other practitioner), regardless of
whether the

[[Page 43526]]

individual is an employee, leased employee, or independent contractor
of the physician (or other practitioner) or of the same entity that
employs or contracts with the physician (or other practitioner) and
meets any applicable requirements to provide the services, including
licensure, imposed by the State in which the services are being
furnished.
* * * * *
(b) * * *
(7) Services and supplies must be furnished in accordance with
applicable State law.
* * * * *
0
14. Section 410.37 is amended by revising paragraph (b) to read as
follows:

Sec. 410.37 Colorectal cancer screening tests: Conditions for and
limitations on coverage.

* * * * *
(b) Condition for coverage of screening fecal-occult blood tests.
Medicare Part B pays for a screening fecal-occult blood test if it is
ordered in writing by the beneficiary's attending physician, physician
assistant, nurse practitioner, or clinical nurse specialist.
* * * * *
0
15. Section 410.59 is amended by--
0
A. Adding paragraph (e)(1)(iv).
0
B. Revising paragraph (e)(2)(iv).
0
C. Adding paragraph (e)(2)(v).
The revision and additions reads as follows:

Sec. 410.59 Outpatient occupational therapy services: Conditions.

* * * * *
(e) * * *
(1) * * *
(iv) Outpatient occupational therapy services furnished by a CAH
directly or under arrangements shall be counted towards the annual
limitation on incurred expenses as if such services were paid under
section 1834(k)(1)(b) of the Act.
(2)* * *
(iv) Outpatient occupational therapy services furnished by a nurse
practitioner, clinical nurse specialist, or physician assistant or
incident to their services; and
(v) Outpatient occupational therapy services furnished by a CAH
directly or under arrangements.
* * * * *
0
16. Section 410.60 is amended by--
0
A. Adding paragraph (e)(1)(iv).
0
B. Revising paragraph (e)(2)(v).
0
C. Adding paragraph (e)(2)(vi)