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  • December 31, 2013

Physician Payment Cut Averted for 3 Months
On Dec. 26, 2013, President Obama signed into law the Pathway for SGR Reform Act of 2013. This law prevents the significant Sustainable Growth Rate (SGR) payment cuts that would have gone into effect on Jan. 1, 2014. The new law provides a 0.5% update for services provided under the Physician Fee Schedule (PFS) for three months. The new payment rate will be in effect from Jan. 1, 2014 through March 31, 2014. Based on this update, the 2014 conversion factor is set at $35.8228.

Section 1102 of the new law provides an extension of the Medicare Physician Work Geographic Adjustment FloorThe existing 1.0 floor on the physician work geographic practice cost index (GPCI) is extended through March 31, 2014. As with the physician payment update, this extension will be reflected in the revised 2014 MPFS.

The Pathway for SGR Reform Act of 2013 provides a temporary fix while Congress continues its work on SGR repeal legislation. However, the bill does not provide relief from the sequestration cuts to payments for physician-administered drugs, including chemotherapy under Medicare Part B. Click Here to contact your legislators and ask them to cosponsor H.R. 1416, which would remove the sequestration cuts on physician-administered Part B drugs.

Clinical Trial Claims
Effective January 1, 2014, it will be mandatory to report a clinical trial number on claims for items and services provided in clinical trials that are qualified for coverage as specified in the “Medicare National Coverage Determination (NCD) Manual,” Section 310.1.

MLN Matters® Number: MM8401 provides the following instruction:

The clinical trial number to be reported is the same number that has been reported voluntarily since the implementation of CR 5790, dated January 18, 2008. That is the number assigned by the National Library of Medicine (NLM) website when a new study appears in the NLM Clinical Trials database.

For professional claims, the 8-digit clinical trial number preceded by the 2 alpha characters of CT must be placed in Field 19 of the paper claim Form CMS-1500 (e.g., CT12345678) or the electronic equivalent 837P in Loop 2300 REF02(REF01=P4) when a clinical trial claim includes:

  • ICD-9 code of V70.7/ICD-10 code Z00.6 (in either the primary or secondary positions) and
  • Modifier Q0 and/or Q1, as appropriate (outpatient claims only).

Medicare Part B clinical trial/registry/study claims with dates of service on and after January 1, 2014, not containing an 8-digit clinical trial number will be returned as unprocessable to the provider for inclusion of the trial number.

Coverage Under the New Health Insurance Marketplaces
Coverage under the new Health Insurance Marketplaces begins January 1, 2014. Many of the new enrollees will not yet have received their insurance card. CMS is the HHS department responsible for overseeing the new Marketplaces and they have provided the following information on verifying insurance coverage under these new plans:

If the marketplace in your state is run by the Federal government, it is best to call their plan’s customer service line, a list of all plans and their customer service numbers can be found in this database. Here is a fact sheet for using the database.   If you cannot find the number, call the Marketplace Call Center (1-800-318-2596).

If your state has its own health insurance exchange, contact your state. To find the website for your state exchange, select the name of your state in the box at the left hand side of the website.