The Centers for Medicare and Medicaid Services (CMS) has provided some light reading with the publication of the Physician Fee Schedule (PFS), Hospital Outpatient Prospective Payment and Ambulatory Surgical Center Payment Systems, as well as Quality Reporting Programs final rules for calendar year 2020. The combined updates are captured in thousands of pages, covering a wide variety of changes, updates and comments. We would like to focus our attention on those changes that will impact vascular surgeons.
The PFS lists all clinical services and procedures along with their relative value units (RVU) for the fiscal year. Those RVUs are converted to dollar amounts using the annual Medicare conversion factor (CF). In2020, there will be a slight increase in the Medicare CF from $36.0391 to $36.0896. Changes to the CF are just one of the many things that affects reimbursement for vascular surgeons. For example, CMS’ massive repricing of over 1,300 supplies and 750 equipment items has affected our high-cost supplies, such as vein ablation catheters, atherectomy devices, vascular stents and intravascular ultrasound (IVUS) catheters. Because of this CMS initiative, our office-based labs (OBLs) will see decreases in reimbursement. These changes are being implemented over four years.
There are several changes in Current Procedural Terminology (CPT) codes affecting reimbursement for 2020.
The iliac branch endograft (IBE) changed from a category III code to a category I code on Jan. 1, 2020, bearing designated physician work RVUs (wRVUs). The appropriate CPT code will depend on if IBE is performed alone or in conjunction with an endovascular repair (EVAR) of an abdominal aortic aneurysm (AAA). When performed with select EVAR codes (34703, 34704, 34705, 34706), you would use the add-on code +34717. If performing a bilateral, then this code would be used twice. If performing an IBE as a standalone code, then use code 34718 (with a -50 modifier if bilateral). The wRVU value for 34717 is 9.00 with a total facility RVU value of 12.94. Remember, add-on codes are not subject to the multiple-procedure reduction (50% reduction). The standalone code, 34718, has a wRVU value of 24.00 and total facility RVU of 36.08 with a 90- day global period. These codes include the preoperative sizing, intraoperative catheter selection and imaging, and stent deployment in the ipsilateral common iliac, external iliac and internal iliac arteries.
Preoperative arterial and vein mapping for hemodialysis access will have a new code. Since 2005, G-code G0365 was used for the unilateral arm artery and vein mapping for patients who had never undergone creation of an arteriovenous access (graft or vein).
In 2020, this G-code will be replaced with two CPT codes. These new codes require assessment of both arterial inflow and venous outflow. If only assessing arteries or veins, then the new codes will not apply. CPT code 93985 is a duplex scan of arterial inflow and venous outflow for bilateral extremities while 93986 is a unilateral study.
These codes do not include physiologic studies and are also not limited to first-time evaluation for hemodialysis access creation and may be used for upper or lower extremities. The 2020 rates are more consistent with the resources used to deliver these services with an increase in wRVU from 0.25 for G0365, to 0.50 for 93986 and 0.80 for 93985.
The CPT codes for stab phlebectomy of varicose veins, 10–20 (37765) and more than 20 (37766), were identified in a high volume growth screen and slated for review. A robust, multidisciplinary survey including all providers performing these procedures was undertaken. The clinicians who completed these surveys reported a decrease of 25% in surgical time for 10–20 stab phlebectomies and 33% reduction to perform more than 20 stabs. As a result, the wRVU saw a reduction in values. CMS also changed the global period for the stab phlebectomy codes from 90 days to 10 days. This change in global period reduced the total clinic visits from two to one, further impacting the wRVUs. However, with the changes in global period, clinicians are now able to bill and be reimbursed for the second visit when performed.
IVUS was re-reviewed due to concerns over increased expenditures driven by increased non-facility utilization. The Society for Vascular Surgery (SVS) offered extensive comments to CMS detailing the appropriate use and medical benefit of IVUS. Subsequently, CMS has agreed to maintain the current values and did not implement their proposed 14% reduction for IVUS of the initial noncoronary vessel (CPT 37252) and 17% reduction for IVUS of each additional vessel (37253).
Several angiography codes were flagged by CMS for high utilization: abdominal aortography (75625), abdominal aortography plus bilateral iliofemoral lower extremity (75630), angiography, visceral, selective or superselective (75726), and the add-on code for each additional vessel studied with angiography (75774). Through our concerted efforts on the SVS Coding Committee, using the RUC surveys completed by the SVS membership, we were able to obtain increased reimbursement for all four. Abdominal aortography plus bilateral iliofemoral imaging will increase by 12% and abdominal aortography (75625) will see a 26% increase over 2019. Visceral angiography will see a 91% increase in wRVU value, while 75774 will see a 180% increase.
Finally, there will be significant changes for exploration-without-repair codes for 2020. The previous codes for exploration not followed by surgical repair—with or without lysis of artery—have been condensed into three new codes. Previously carotid artery (35701), femoral artery (35721), popliteal artery (35741) and other (35761), they are now: 35701 for the neck (e.g., carotid, subclavian), 35702 for the upper extremity (e.g., axillary, brachial, radial, ulnar) and 35703 for the lower extremity (e.g., common femoral, deep femoral, superficial femoral, popliteal, tibial, peroneal). The new codes will be valued at 7.50, 7.12 and 7.50 wRVUs, respectively.
There are several changes on the horizon that will affect reimbursement in the future.
Evaluation and Management (E/M) reimbursement is a recurring topic of discussion at CMS and within the healthcare community. Significant changes are slated for 2021. CMS has stated that they do not intend to apply any E/M increases to the post-op visits included in the 10- or 90-day global packages. SVS, along with our surgical colleagues, will continue to work diligently to avoid the implementation of this inappropriate proposal.
These issues loom large for 2020. RUC surveys sent to SVS members are essential to efforts for appropriate reimbursement but often only a minority is completed. We would ask all members to take them seriously.
Francesco Aiello, MD, is associate professor of surgery in the division of vascular and endovascular surgery at the University of Massachusetts Medical School in Worcester, Massachusetts. Matthew Sideman, MD, is a practicing vascular surgeon in San Antonio, Texas.