New year brings big, small changes to practice administration

Three federal regulations create new opportunities and hurdles for physicians, including new reimbursements, Medicare annual wellness visits and a potential uptick in office visits to document over-the-counter drugs for health plans.

A plethora of new federal regulations will affect internal medicine this year. Health care reform has had a wide impact on every aspect of primary care medicine, and many agencies within the federal government also have a tremendous influence on practice management.

Primary care incentive program


The Patient Protection and Affordable Care Act (ACA) provides a 10% bonus in addition to the fee schedule payment for select primary care services furnished by primary care physicians in calendar years 2011-2015. To qualify for the bonus, a physician must be self-designated in a primary care specialty and must provide predominantly primary care services.

Beginning in 2011, Medicare will pay an additional 10% for designated primary care visits. ACP was a driving force behind Congress' creation of this program, referred to as the Primary Care Incentive Payment Program (PCIP).

The law defines primary care services as those that fall within the Current Procedural Terminology (CPT) codes below. These designated services are important because they are the services on which the 10% bonus payment will be paid, integral to the calculation as to which physicians qualify to receive the bonus:

  • office/outpatient visits, CPT 99201-99215;
  • nursing facility services, CPT 99304-99318;
  • domiciliary, rest home, or custodial care services, CPT 99324-99340; and
  • home services, CPT 99341-99350.

A detailed discussion of the program, including how internists can find out if they qualify, can be viewed online.

Annual wellness visit

In a move to expand the preventive care focus of Medicare coverage, the Affordable Care Act extends the preventive focus of Medicare coverage by implementing the Annual Wellness Visit (AWV).

By design, the annual wellness visit will supplement the Initial Preventive Physical Examination (IPPE, also called the “Welcome to Medicare” exam) by adding subsequent-year visits that will allow the physician and patient to develop a personalized prevention plan. It is designed to include both age-appropriate preventive services and services that may be appropriate because of the beneficiary's individual health concerns. The benefit provides for six required elements of care, as determined by CMS.

The AWV has specific codes for its billing. The Healthcare Common Procedure Coding System (HCPCS) codes are:

  • G0438: Annual wellness visit, including personalized prevention plan services, first visit, and
  • G0439: Annual wellness visit, including personalized prevention plan services, subsequent visit.

The payment values are equivalent to that of the Level 4 new patient office visit (CPT 99204) and the Level 4 established patient office visit (CPT 99214), respectively.

A more specific discussion of the annual wellness visit benefit is online.

Q codes for flu vaccines

CMS has created specific HCPCS codes and payment rates for its billing purposes for the 2010-2011 influenza season. For dates of service during the beginning of the flu season (Oct. 1, 2010 thru Dec. 31, 2010), internists should continue to use CPT 90658 for flu vaccines; however, code 90658 should not be billed in conjunction with Q codes.

For services beginning on Jan. 1, 2011, CPT code 90658 is no longer payable by Medicare. Instead, physicians should choose from among these codes: Q2035 (Afluria), Q2036 (FluLaval), Q2037 (Fluvirin), Q2038 (Fluzone), and Q2039 (not otherwise specified flu vaccine).

For more information, please see the CMS quick-reference guide.

Medical savings accounts

Since 2003, health flexible spending arrangements (health FSAs) and health reimbursement arrangements (HRAs) have been used to reimburse for the cost of over-the-counter (OTC) drugs. In 2011, patients must obtain a prescription to have their OTC items' costs reimbursed. The one drug exception is insulin, which remains reimbursable even without a prescription.

This new IRS rule does not apply to non-drug items, such as crutches, bandages, or blood glucose testing supplies, which can still be reimbursed without a prescription. These types of items are still considered medical care as defined by Internal Revenue Code Section 213(d)(1) if they are used for “the diagnosis, cure, mitigation, treatment or prevention of disease, or for the purpose of affecting any structure or function of the body.”

ACP anticipates that a significant, unintended consequence of the new rule will be that physicians will be challenged to schedule and document many more office visits to accommodate patients who plan to seek reimbursement for OTC drugs. ACP is concerned about this increased administrative burden and remains focused on ensuring that physicians can continue to provide vital quality care to their patients.

For additional information on the provision, please reference this Internal Revenue Service document.

Physicians exempt from the ‘Red Flags' rule

The Federal Trade Commission's “Red Flags” rule, written to protect against medical identity theft, now exempts physicians from its scope.

The Fair and Accurate Credit Transactions Act of 2003 directed financial regulatory agencies, including the Federal Trade Commission (FTC), to create rules requiring “creditors” and “financial institutions” to identify, detect and respond to patterns, practices or specific activities that could indicate identity theft. The FTC defined “creditor” to include physicians who allow patients to defer payments while insurance claims are filed and processed.

Advocacy efforts on the part of ACP, other medical societies and other involved parties successfully convinced the FTC to delay its enforcement of the rule. This allowed time to pursue relief from Congress. Congress acted at the request of ACP and others and passed a law in December 2010 that modified the law's definition of “creditor,” thereby exempting physicians from that definition. The Red Flags rule took effect Jan. 1, but will not apply to physicians and their practices.