Change in 2014 Medicaid Enhanced Fees for PCPs

TNAAP has just learned the 2014 Medicaid Enhanced Fees for Primary Care Providers have been revised. The new rates are being applied due to changes implemented by CMS. These rates were published on the TennCare website on Monday, March 24, 2014. There is approximately a $2-$4 decrease in the fees from 2013 to 2014 for most Evaluation and Management (E/M) codes. The 2014 fees went into effect January 1, 2014. All TennCare MCOs are currently loading the 2014 fees. Providers will begin to see a decrease in payment for these E/M codes and MCOs will begin reprocessing overpayments or underpayments made based on the 2013 fees as soon as they have the new fees loaded in their systems.

The rate for the Medicaid payment increase is calculated using the Medicare Conversion Factor (CF) in effect for 2013 ($34.0230) and 2014 ($35.8228) or for calendar year 2009 ($36.0666), whichever is higher, multiplied by the current (i.e., 2014) Relative Value Units (RVUs) and adjusted for geographic locality. For both 2013 and 2014, the 2009 CF is higher so that is what is used for determining the rate for the Medicaid payment increase. So for 2014, the Medicaid payment increase rate is calculated using the 2009 CF ($36.0666) and the 2014 RVUs.

For the 2014 Medicare Physician Fee Schedule the practice expense (PE) portion of the Relative Value Units (RVUs) for most E/M codes was decreased in 2014. The decrease in the practice expense for these codes resulted in total RVU decreases, which resulted in payment amount decreases.

This is due to PE refinements that CMS made to adjust the RVUs to match revised Medical Economic Index (MEI) cost shares. This refinement generally resulted in increases of payments for codes for which work is a higher proportion of their total relative values and decreases in payments for codes for which PE is a higher proportion of their total relative values.

For example, the non-facility PE RVUs for CPT code 99213 decreased from 1.09 to 1.00 from 2013 to 2014 which decreased the total RVUs from 2.13 to 2.04 from 2013 to 2014. When the geographic adjustment for Tennessee is applied to CPT code 99213, the total rate decreases from $70.63 to $68.70 from 2013 to 2014, a difference of $1.93.

Please see the following link for the 2013 and 2014 Enhanced Rates:

http://www.tn.gov/tenncare/pro-enhancedrates.shtml

These rate changes may not be implemented for commercial payers or for providers not eligible for the enhanced rates depending on individual contracts and conversion factors used by payers.

TNAAP will provide any updates as they become available. If you have questions, please contact Janet Smith at janet.smith@tnaap.org.

The Tennessee Chapter of the American Academy of Pediatrics (TNAAP) is not affiliated with any other organization, vendor or company. The information contained herein is intended for educational purposes only, and any other use (including, without limitation, reprint, transmission or dissemination in whole or in part) is strictly prohibited. Although reasonable attempts have been made to provide accurate and complete information, neither the publisher nor any person associated with TNAAP warrant or guarantee the information contained herein is correct or applicable for any particular situation. TNAAP will not undertake to update any information provided herein. In all cases, the practitioner or provider is responsible for use of this educational material, and any information provided should not be a substitution for the professional judgment of the practitioner or provider.

*CPT codes, nomenclature and other data are copyright 2013 American Medical Association. All rights reserved. No fee schedules, basic units, relative values or related listings are included in CPT. The AMA assumes no liability for the data contained herein.