The Centers for Medicare and Medicaid Services (CMS) is addressing 211 codes the agency believes may have resource inputs that are misvalued in its 2014 Medicare Physician Fee Schedule (PFS) Proposed Rule.
The proposal calls for capping non-facility (office) Practice Expense (PE) Relative Value Units for these codes so they would not exceed facility payments under the Hospital Outpatient Prospective Payment System (OPPS) or Ambulatory Surgical Center (ASC) payment rates, even though vascular surgeons incur full PE in their offices.
CMS has ignored fundamental differences between the resource-based Physician Fee Schedule used for Medicare physician payment, which captures actual costs for each individual service, and the Ambulatory Payment Classifications used for OPPS and ASC rates that bundle high- and low-margin services into a single classification. These differences render service-by-service comparisons inappropriate and inaccurate. Also, ASC rates are at least 40 percent less than OPPS rates.
Under the CMS proposal, services provided less than five percent of the time in the hospital setting are supposedly exempt from the cap. However, many of these services are being capped at the OPPS rates even though they are rarely or never performed in that setting. Even more unreasonable, CMS has chosen to apply the ASC rates to 112 codes, including 13 vascular codes, even though only eight of these services are provided in an ASC at least five percent of the time. In addition, CMS is using the 2013 OPPS/ASC payment rates instead of the corrections and adjustments made to these by CMS for 2014.
The vascular codes that are reduced in the Proposed Rule include:
· CPT Code 36147 – access av dial grft for eval, -40%
· CPT Code 36566 – insert tunneled cv cath, -76%
· CPT Code 37220 – iliac revasc, -24%
· CPT Code 37224 – fem/popl revasc with tia, -37%
· CPT Code 37225 – fem/popl revasc with ather, -56%
· CPT Code 37226 – fem/popl revasc with stent, -47%
· CPT Code 37227 – fem/popl revasc stent & ather, -24%
· CPT Code 37228 – tib/per revasc with tia, -56%
· CPT Code 37229 – tib/per revasc with ather, -55%
· CPT Code 37230 – tib/per revasc with stent, -40%
· CPT Code 37231 – tib/per revasc with stent & ather, -13%
· CPT Code 37234 – revsc opn/prq tib/pero stent, -42%
· CPT Code 37235 – tib/per revasc stent and ather, -41%
· CPT Code 93922 – Upr/l xtremity art 2 levels, -18%
· CPT Code 93924 – Lwr xtr vasc stdy bilat, -31%
SVS has responded to this issue by:
1. Submitting comments to CMS on the Proposed Rule on September 6 opposing the non-facility cap. These comments can be found on VascularWeb.org
2. Meeting with CMS officials on September 10 in opposition to the cap
3. Seeking a legal opinion with other specialty societies (pathologists, interventional radiologists, radiation oncologists, among others) on whether CMS has the legislative authority to cap office reimbursement
4. Emailing grassroots letters from SVS members to their House members, asking them to oppose the cap by sending letters to CMS. As a result, more than 100 letters were sent to House members on this issue
5. Signing onto a letter to CMS with 40 other health care groups in opposition. This letter can be found on VascularWeb.org
6. Leading a coalition of physician associations in opposition to office reimbursement cuts by asking members of Congress, particularly those who are MDs, to contact CMS in opposition to cuts. As a result, 16 members of the House GOP Doctor’s Caucus submitted a letter to CMS on October 17; this letter can be found on VascularWeb.org
7. Raising PAC funds to attend events with targeted members of Congress. As a result of a discussion with Rep. Roe at an event, SVS staff secured his sponsorship of the above letter. SVS members can still contribute to the PAC by completing a donation form on VascularWeb.org
CMS was scheduled to issue its 2014 Medicare PFS Final Rule at the beginning of November; however, because of the government shutdown, the Final Rule will likely be released on November 27.