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Benchmark of the Week

Readers of the 2020 proposed Medicare physician fee schedule (PFS) are probably trying to figure out how the new E/M rules will affect their reimbursement. But CMS has already looked at last year's volume and mix of services provided by each provider specialty and assessed the effect of the proposed fee schedule on them.

Practices are seeing a downward trend in revenue for cerumen-removal services even as the total number of claims was buoyed in recent years with the arrival of CPT code 69209 (Removal impacted cerumen using irrigation/lavage, unilateral).

The recent discussion of ways to hold down drug pricing is needed, as you can see by the latest quarterly average sales price (ASP) update issued by CMS. The ASP update shows the upper limit on prices to which providers will be allowed to add a surcharge of 6% in the 3rd quarter of 2019.

Practices that run diagnostic tests and independent labs fared pretty well with a range of panels associated with millions of dollars in revenue in recent years. But a few tests, including vitamin D and hemoglobin assays, continue to perplex the billing department.

MedPAC may be right that the use of nurse practitioners (NPs) and physician assistants (PAs) under incident-to billing is masking the size of their contribution to care. It’s clear that even when billing under their own specialty codes, these top mid-levels are billing more than before, according to 2017 Medicare claims data, the most recent available. Overall denial rates are not great, but when you put them to work on the right service they do very well.

The regulatory burden linked to prior authorizations is getting worse, and it’s not only causing administrative headaches. It’s also leading to patients veering from the recommended course of treatment.
Modifier 22 (Increased procedural services) doesn't get claimed a lot. But on some of procedures for which it’s most often used — the ones for which you can easily see how extra work would be required — it has low denial rates. And there are some codes with 22 for which you have to wonder what the billers were thinking.
Providers report several million claims for hip, foot and shoulder X-rays every year but those services don’t pay out the most.
As mentioned in our patient records story, there’s been a slow, steady climb in U.S. patients’ willingness to access their medical records. But the climb has been slower for some groups than others.

Practices that opt to partake in the Primary Care First delivery model that’s launching in 2020 will greet a hybrid payment model that combines two revenue sources: per-encounter fees and quarterly, population-based payments (see story, p. 1).


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