Beginning in November 2010, the AASM sent out regular updates to members related to the 2011 Medicare Physician Fee Schedule (MPFS) Final Rule. To avoid confusion and help clarify payment changes, we have developed an overview of the MPFS Final Rule including a timeline of events, national payment information, instructions for finding local payment information and a glossary of key terms.
Timeline of Events
- Nov. 2, 2010 – Display Copy of the MPFS was published.
- Nov. 10, 2010 – AASM President Dr. Patrick Strollo sent a message to members encouraging them to contact elected representatives, local media, and patients regarding the negative effects of proposed cuts to the MPFS.
- Nov. 18, 2010 – Senate voted to approve The Physician Payment and Therapy Relief Act of 2010 (HR 5712), which postponed the proposed cuts to the conversion factor from Dec. 1, 2010 to Jan. 1, 2011. This postponement was approved by the House of Representatives on Nov. 29, 2010.
- Dec. 8, 2010 – Senate approved Medicare and Medicaid Extenders Act of 2010 (HR 4994) which delayed scheduled cuts resulting from the Sustainable Growth Rate (SGR) through Jan. 1, 2012. The bill was approved by the House of Representatives on Dec. 9, 2010 and signed into law by President Obama on Dec. 15, 2010.
- Dec. 29, 2010 – CMS published an Emergency Update to the CY 2011 Medicare Physician Fee Schedule Database. The new conversion factor rate of $33.9764 effective Jan. 1, 2011 was announced.
National Payment
Total payment for a given service is calculated using four main components: physician work relative value units (RVUs), practice expense RVUs, professional liability insurance RVUs and the conversion factor. The total RVUs (physician work RVUs + practice expense RVUs + professional liability insurance RVUs) are multiplied by the conversion factor to find the total national payment for the service.
Total National Payment
The following table details national payment for the sleep medicine testing codes. Also included is the change in payment from the 2010 rates. This payment reflects full service payment including both the technical and professional components of the service.
|
Code |
Total RVU |
Total Payment |
Change in Payment from 2010 Rate |
|
95800 |
6.05 |
$205.52 |
NA |
|
95801 |
2.85 |
$96.81 |
NA |
|
95803 |
4.78 |
$162.38 |
+$36.63 |
|
95805 |
12.08 |
$410.36 |
+$15.82 |
|
95806 |
5.36 |
$182.08 |
-$21.46 |
|
95807 |
13.83 |
$469.81 |
-$8.06 |
|
95808 |
19.12 |
$649.51 |
-$17.15 |
|
95810 |
20.43 |
$694.01 |
-$72.20 |
|
95811 |
22.05 |
$749.04 |
-$96.82 |
Total National Professional Component Payment
A number of our members bill for the professional component of a given service independently. For national payment of the professional component of the sleep medicine testing codes, please see the table below. As with the table above, this table also includes the change in payment from the 2010 rates.
|
Code |
Physician Work RVU |
Physician Work Payment |
Change in Payment from 2010 Rate |
|
95800 |
1.05 |
$35.67 |
NA |
|
95801 |
1.00 |
$33.97 |
NA |
|
95803 |
.90 |
$30.57 |
-$6.30 |
|
95805 |
1.20 |
$40.76 |
-$28.56 |
|
95806 |
1.25 |
$42.46 |
-$18.74 |
|
95807 |
1.28 |
$43.48 |
-$17.72 |
|
95808 |
1.74 |
$59.11 |
-$38.59 |
|
95810 |
2.50 |
$84.93 |
-$44.85 |
|
95811 |
2.60 |
$88.32 |
-$51.42 |
How to Find Local Payment
The payment rates quoted in the tables above are national rates. Payments for all services vary based on locality. In order to find payment specific to your state, please use the Medicare Physician Fee Schedule Lookup feature on the CMS website: https://www.cms.gov/apps/physician-fee-schedule/overview.aspx.
The search feature allows you to find pricing information for a single code or a list of codes. By indicating your specific locality on the search form you can easily find payment information.
Glossary of Terms
The following terms are regularly used in AASM updates about payment information as well as on the CMS website.
Conversion Factor (CF) – The conversion factor is the number that, when multiplied by the RVUs assigned for a service, determines the payment for that service.
RVU – The RVU or relative value unit is the unit of measure assigned to aspects of the service performed. A relative value unit is assigned for the physician work, the practice expense and the malpractice insurance for each service payable by Medicare. These relative value units are multiplied by the conversion factor to determine payment for each service.
Physician Work RVU – The physician work RVU is the unit of measure assigned to the physician’s portion of the service performed.
Practice Expense RVU – The practice expense RVU is the unit of measure assigned to the technical component of the service performed.
Professional Liability Insurance (PLI) RVU – Also known as malpractice, professional liability insurance RVU is the unit of measure used to indicate the portion of reimbursement estimated to cover malpractice insurance for the particular service. This unit is proportional to the amount of risk in the service.
