Medicare payments to urologists down again in 2013 final rule

SGR-mandated cuts, revenue reallocations to primary care put squeeze on urologists

Within less than a week last month, President Obama was re-elected and the 2013 Medicare physician fee schedule final rule was released. For urologists, the overall impact of these two events is twofold: Obamacare will remain, and we’ll need to watch and lobby Congress, once again, for a fix or delay of the sustainable growth rate (SGR), a problem not addressed by Obamacare. The final rule, published on Nov. 1, lists relative value changes, process changes for some services, and the conversion factor. It continues the implementation of Obamacare.

In this article, we will cover a few issues gleaned from the 1,362-page final rule that could affect your urology practice.

 

Focus on primary care

The focus on primary care continues. Many issues included in the Patient Protection and Affordable Care Act (ACA) are designed to address the designated payment problem for primary care and preventive health care services. The final rule addresses fundamental changes outlined in the ACA for payment modeling, such as accountable care organizations (ACOs) and the medical home concept. (For a description of these new models and links to more information, see, “New payment models outlined in the final rule,” right.)

These types of projects are shaping health care differently throughout the country. Each urology practice will need to examine referral sources and the local market carefully and plan for changes that are occurring. State reform will play an integral role in health care reform overall, but the sheer number of patients coming into Medicare will place CMS in a central role. In general, urology practices across the country will need to continue to develop EHR use, work on their ability to share and analyze data, and develop treatment patterns and protocols to participate with the changing models.

IPAB’s actions uncertain

There is no mention of the Independent Payment Advisory Board (IPAB) in the final rule.

The timeline included in the ACA requires that Medicare’s chief actuary submit a report by April 30, 2013 stating whether per capita spending will exceed the target growth rate. If spending is projected to exceed the target, the IPAB submits a spending control proposal to Congress by Jan. 15, 2014. (If spending is projected to meet the target, the spending control plan is considered advisory, and Congress has the option of accepting the advice or rejecting the plan in whole or in part.) The Department of Health and Human Services must implement IPAB proposals if spending is projected to exceed the target unless they are overridden by a supermajority of Congress.

At this time, there is a question as to whether spending targets will be met. Separately, there is significant support for revising or repealing this portion of the ACA; however, the law does include language protecting the IPAB, so bipartisan support will be required to make a change. Stay tuned on this issue.

In addition to the continued development of health care reform initiatives initiated by the ACA, the final rule for 2013 brings a few other changes that will affect urology practices next year. We are facing the SGR-dictated drop in the conversion factor. CMS has calculated a –26.4% update to the conversion factor or a conversion factor of $25.0008 to replace the current conversion factor of $34.0376.

Interestingly, the conversion factor update for 2012 was a positive 0.6%, which in conjunction with the Medical Economic Index update of 0.8% did affect the cumulative update upwards from the –27.2% update projected last year. Once again, Congress must act to change this number and fix the SGR for the long term. The AUA and American Medical Association continue to lobby Congress for a permanent fix in the SGR or at least a temporary stay.

Changes in RVUs, codes

The relative value units (RVUs) in the final rule for 2013 include a few changes. First, this is the final year of the phase-in of practice expense (PE) changes. This final-year phase-in impacts urology payments overall. The projected change for urology as a specialty due to RVU changes is slightly over –1%. The RVU impact for urology is based solely on changes to the PE RVUs. Each urology practice will feel this slightly differently depending on the services they provide.

Medicare will also expand the Multiple Procedure Payment Reduction (MPPR) policy in radiology. The expansion will include application of a 50% reduction for same-day services in radiology and other imaging services. Multiple service reductions will also apply to same-day physical therapy services at 25% of the technical component (TC).

A new code, 52287 (Cystourethroscopy, with injection[s] for chemodenervation of the bladder), has been added and valued for 2013. This code will be used most frequently for injection of onabotulinumtoxinA (Botox). The injected drug will be billed separately in the office setting.

Other code adjustments to values of individual codes will impact urologists, including a reduction of 52% to the –TC of code 88305 (Surgical pathology, gross and microscopic examination) and a reduction in code 77418 for intensity-modulated radiation therapy of roughly 20% based on decreased time per service.

Taking into account RVU changes other than the change in PE values, changes to MPPR, and the addition or deletion of new codes, Medicare has projected a 1% increase for urology.

Medicare has also adjusted payments for Transitional Care Management, with a focus on shifting revenue to primary care. To fund this increase for primary care, CMS has adjusted payments for multiple specialties; urology is expected to see a 1% decrease overall relative to this reallocation.

Putting all of these effects together—the 1% decrease from PE changes, the 1% increase due to MPPR and other RVU changes, and the 1% decrease to shift money to transitional care—urology is expected to see slightly more than a 1% decrease in reimbursement through Medicare, provided the SGR is delayed and the conversion factor remains at $34.0376.

The ACA has also required CMS to change its focus on review of existing RVUs. Until 2011, work RVUs and PE RVUs were on a separate 5-year review cycle. CMS, in reaction to the ACA and the changing health care system, has now placed review of RVUs on a rolling cycle and will review designated codes each year. Codes can be nominated for review based on any of the following criteria:

codes and families of codes for which there has been the fastest growth

codes or families with substantial change in practice expense

recently established codes for new technologies or services

multiple codes that are billed in conjunction with furnishing a single service

codes with low relative values, particularly those that are often billed multiple times for a single treatment

codes that have not been subject to review since the implementation of the Resource Based Relative Value Scale (Harvard Valued Codes)

other codes determined appropriate by the HHS secretary.

For the 2013 final rule, 13 codes in the urinary system and male genital system were reviewed for work value changes. The Relative Value Update Committee (RUC) recommended no change for codes 50590, 52234, 52235, and 53850. CMS accepted the recommendations, and the values remain unchanged. The RUC recommended increases in work values for codes 52224, 52354, and 52355. CMS accepted the recommendations of the RUC for an increase but not to the degree recommended for codes 52354 and 52355. The RUC recommended decreases in the work values for codes 52214, 52240, 52351, 52352, and 52353. CMS accepted these recommendations, with 52240 and 52352 decreased more than the RUC recommended.

The final code was the new code 52287, for which there was no increase or decrease. The value was accepted as recommended by the RUC. Expect code values to continue to come up for review, the newest wrinkle in the program. The one change that will become most evident in this regard is the potential for these reviews to result in new single codes for combined procedures.

G codes for physical medicine

Another significant change affecting some urology practices will be the requirement to use G codes with billing of physical medicine services. These changes will affect those groups providing pelvic floor exercises. CMS is finalizing reporting requirements; however, initially it appears that a G code and modifier from the lists provided in the table below will be required at the beginning of the treatment (when the plan of care is established), reporting of a G code and modifier every 10th day of treatment or on the 30th calendar day and/or at the end of the treatment session as described in the plan of care, whichever comes first.

As an example, for a patient prescribed 1 month of pelvic floor rehabilitation at one session per week, Medicare would expect that code G8990 and a modifier would be reported with the first treatment and code G8993 and the modifier would be reported with the final treatment. If a different patient’s plan of care requires two treatment sessions per week for 6 weeks, code G8990 and a modifier would be reported with the first treatment; G8991 and a modifier would be reported with the second session in week 5; and code G8993 and the modifier would be reported with the final treatment. The secondary functional limitation codes would be used for those patients with more than one limitation being treated concurrently.

As the reporting requirements for these types of services are finalized, we will keep you posted. Note that the caps for physical medicine services remain in effect, and modifier –KX for those services provided above the physical medicine cap are being carefully reviewed for supporting documentation. We encourage all practices providing these services to contact Physician Reimbursement Systems with information (info@prsnetwork.com) developed for your area and to provide feedback on actual effect on payments as they occur so we can continue to share this with other urologists.

Expansion of telemedicine

Telemedicine services are being expanded. The ability to be paid for these services is dependent upon both the originating request and site (must be a health professional shortage area) and the provider. Each site must be capable of and/or licensed to provide telecommunication services in the state they practice. Payments are based upon the site in which the patient is located. Practices interested in provision of telecommunication services will need to analyze requirements for their state of residence and originating request sites.

Finally, we report that the geographic practice cost index with a floor of 1 for areas other than Alaska, Montana, North Dakota, Nevada, South Dakota, and Wyoming will be removed unless action is taken by Congress to retain this floor. This will effectively drop payments for those in rural and other lower income areas for 2013.

As has been the case over the past several years, the release of the final rule has not been a source of joy for most urologists. We all hope and lobby for a change in the SGR, which is the single biggest threat to Medicare payments under the current system. With the budget deficit, increasing Medicare beneficiaries, and rising costs, expect this trend of decreases to continue. Prepare your practice for decreases in amount per service, changes in marketplace structure, and increasing payment for services under capitation or packaged pricing models. Fee-for-service health care is under assault.