Overhauling the nation’s health care system is on the mind of every physician, if not every American. As the debate over health care reform rages, one thing is certain: Regardless of what happens in Washington, changes will occur in 2010 that will directly affect your practice. For urologists, most of the news is not good.
This article provides a brief historical perspective on how changes to the Medicare payment system have affected urologists, then focuses on what you can expect in 2010.
As you know, there have been a number of changes in the payment system over the past several years, and if the proposed Medicare payment rules as published in July are adopted in November,next year will be no exception. Some of the more impactful changes in the payment system relative to urology have involved drugs administered in the office, office-based surgery, and minimally invasive services such as transurethral microwave thermotherapy (TUMT) and transurethral needle ablation (TUNA). Although some of these changes have been positive for urology, others have not. It certainly seems that any time the Centers for Medicare & Medicaid Services identifies an area of profit, it quickly changes the reimbursement rules to take that profit away.
Although Medicare will identify and address areas that it determines are being overpaid, many payment changes are the result of methodology shifts that transfer payment from one specialty to another. This year’s proposed changes are the result of a CMS calculation change. Thus, the negative impact of the change for urology and radiation oncology will have a positive impact on other specialties. The chances of these changes being phased in or eliminated are minimal.
As a result, many of your office-based surgeries and all minimally invasive prostate therapies will be reimbursed at a lower rate. For urology, CMS has estimated that the changes to the system in 2010 overall will result in a 7% decrease for the same services next year if the conversion factor remains unchanged. Those of you with intensity-modulated radiation therapy centers will feel an even larger impact from these changes—some key services will decline an estimated 38%.
Dollars redirected to primary care
CMS identifies “overpaid” services in many ways, with significant increases in frequency and negative audits being two of the most common. Areas that Medicare is going to address next year include consultations, urodynamics, and in-office imaging. These changes will result in an overall decrease in urology reimbursement of between 8% and 10%, even if the Medicare sustainable growth rate impact on the conversion factor is delayed or corrected.
Consultations have been identified by the Office of Inspector General as a significant source of overpayment through audits. The elimination of consultations and a redistribution of values will get rid of this overpayment problem and allow CMS to redirect money to primary care.
The frequency of urodynamic testing has increased significantly over the last few years. Although the decrease in urodynamics payments will only be about 17% according to the proposed rules, the big shoe has yet to drop: We anticipate that a new Current Procedural Terminology code will be assigned an even lower reimbursement.
Imaging has increased steadily at the same time, as more and more physicians, including urologists, have added the technology to their practices. CMS began reducing payments for imaging services 3 years ago, but has not seen the anticipated decrease in services and is proposing more drastic measures for 2010.
Clinical pathology services billed through a urology office increased dramatically over a short period of time. Medicare addressed this issue by increasing restrictions as to where services can be provided and by instituting the anti-markup provision.
Payment for TUMT, TUNA, and laser prostate procedures was reduced 40% over a 4-year period after a significant increase in these services. To accomplish this, CMS reduced the practice expense value through a change in methodology that allowed the organization to more quickly address changes in the costs of disposables and equipment to the physician office.
All of these reductions are examples of CMS policy implemented without major health care reform. All have impacted the bottom line for physician practices. Many of the services targeted for payment reduction have been reported less frequently after the payment reduction.
The assessment of the drop in price relative to the drop in number of services may not be one-to-one in cause and effect. In fact, in the case of TUMT and TUNA, there were clinical issues that contributed to a decrease in the services provided. However, if you look at the cause and effect from CMS’s perspective, clinical issues may be ignored because the agency’s goal is to provide more benefits to more people for less money as an increasing number of Americans reach Medicare age. As long as physicians are willing to work for the rates CMS pays, do not be surprised to see cuts increase.
If current trends continue, we can expect decreasing payments for the services we order and the technical component for services we provide. There will be a continued increase in payment for evaluation and management services, more incentive pay for transparency, and hopefully more payment for managing care.
If you see a new technology that can be incorporated into your practice that makes sense clinically and financially, plan for decreased reimbursement for that service in 18 to 24 months, basing investment on reasonable expectation.
As we travel around the country discussing billing and payments with different practices, we see many areas in which the billing process can be improved. In order to survive and thrive in the future, we must band together to share data and improve our billing and collecting effectiveness. Urologists will have to change the way they view their time, their services, and their practice. Fortunately, there is significant room for improvement in all practices, small or large.
Coding and Reimbursement Ray Painter, MD, Mark Painter
Urologist Ray Painter, MD, is president of Physician Reimbursement Systems, Inc., in Denver and is also publisher of Urology Coding and Reimbursement Sourcebook.
Mark Painter is CEO of PRSUrology SC in Denver.
How will health care reform affect your reimbursement? Ray Painter, MD and Mark Painter discuss changes to watch for in the years ahead.
See: http://urologytimes.com/reformeffects”>http://urologytimes.com/reformeffects
Learn how to communicate with your coder at: http://urologytimes.com/coders”>http://urologytimes.com/coders
