Last month, the Centers for Medicare & Medicaid Services published the proposed rules for revisions to payment policies under the physician fee schedule for calendar year 2005. It includes 242 pages of “proposed” changes. CMS is accepting comments on these proposed rules through Sept. 24, 2004.
The reason for the changes is quite simple: CMS wants to “improve” the payment for your services. Unfortunately, CMS’s definition of improvement does not necessarily mean an increase, as we’re well aware that many changes are implemented to decrease payments. In fact, CMS estimates that Medicare payments to urologists will decrease 13% in 2005. This decrease is fueled by an estimated 38% decrease in payment for luteinizing hormone-releasing hormone agonists.
According to Medicare statistics, urologists received approximately 37% of their 2004 total revenues from drugs and 60% from physician fee schedule services.
Some of the most common procedures are changing very slightly, if at all.
Office visits, both in the office and in the hospital, have increased slightly.
Cystoscopy will pay $206.54, an increase of $0.16, in the office. In the hospital, cystoscopy will pay $110.66, an increase of $2.01.
Prostatic needle biopsies will pay $222.08 in the office, a decrease of $2.09.
Radical prostatectomy has slightly increased to $21.45.<b style=’mso-bidi-font-weight:normal’> </b>However, this is the first time in years that this hospital procedure has not decreased.
Chemotherapeutic injections (96400), the code most commonly used for injections of LHRH agonists, have decreased to $51.14 from $64.07. This decrease is less than we originally anticipated. However, the future is unclear.
The CPT editorial committee, a work group at the American Medical Association, is studying all chemotherapeutic injections with the possibility that codes will be changed and new codes added. CMS is studying the payment for these services. Changes could be made prior to implementation of the 2005 fee schedule.
The good news is that CMS will now pay practice expenses for inserting a ureteral stent in the office, for a total payment of $333.36.
Note that all payments listed above are national averages and will not directly compare with the payment in your state.
Also, on Jan. 1, 2005, Medicare will eliminate the current limiting criteria and routinely pay for “low-osmolar contrast media” on the basis of average sales price (ASP) plus 6% in accordance with the new standard methodology for drug pricing. The payment will also be reduced by 8% to account for low-osmolar contrast media currently paid for in the practice expense of each applicable CPT code.
Some LHRH questions answered The proposed rules clarify some issues in the LHRH drug payments and leave some issues unanswered. First, manufactures will determine the ASP. Then, CMS will average all manufacturers’ ASPs that are charged under a single “J” code according to their respective volumes to determine an ASP for that HCPC (or “J”) code.
For example, the ASP for leuprolide acetate (Lupron, Eligard) will be averaged to develop a single ASP for the J9217. The proposed rules anticipate that all states will pay using the lowest ASP for J9217 or J9202 (goserelin acetate [Zoladex]). The price published was $234.28—higher than many anticipated. However, the proposed rules state that these are “discussion prices” and that actual pricing will be set using third-quarter ASP data from the manufacturers.
The 106% payment will be based on the ASP calculations, not on the price you pay. CMS is aware that some urologists are paying more than this, while others pay less.
When deciding how to treat patients with LHRH drugs in the future, keep in mind good patient care. Most urologists desire to continue to treat their patients in their office, without disruption, and are looking for a way to avoid high inventory cost and the risk of nonpayment.
The bottom line is continue to get the best price you can for the drug that you think is most appropriate for your patients, be sure your contract price is at the ASP or below, and be aware that the payment for the next quarter may decrease. Be prepared to adjust your purchasing contract accordingly.
In summary, the changes for 2005 are relatively minor with the exception of the decrease in payments for drugs. In 2006, we face another 5% decrease in the conversion factor unless CMS changes the fee schedule formula or there is an act of Congress that changes the decrease to an increase. Fortunately, this is exactly what has happened for the last several years.
Urologist Ray Painter, MD, is president of Physician Reimbursement Systems, Inc., in Denver and is also publisher of Urology Coding and Reimbursement Sourcebook
Disclaimer:
The information in this column is designed to be authoritative, and every effort has been made to ensure its accuracy at the time it was written. However, readers are encouraged to check with their individual carrier or private payers for updates and to confirm that this information conforms to their specific rules.
