The Proposed Fee Schedule Rule Contains Some Important Developments for Anesthesia
The first thing that most of us look for when CMS publishes the Proposed and then the Final Medicare Fee Schedule Rules is the payment update. CMS chose to say nothing about payment rates for 2015 in the Proposed Rule that appeared on July 3rd, however, because the Fee Schedule update and Sustainable Growth Rate (SGR) “calculations are determined under a prescribed statutory formula that cannot be changed by CMS.” (CMS Fact Sheet on Proposed policy and payment changes to the Medicare Physician Fee Schedule for Calendar Year 2015.) Instead, the current conversion factors will remain unchanged through March 2015, pursuant to the Protecting Access to Medicare Act (PAMA) of 2014. Before Congress passed PAMA, CMS had estimated the update 2015 at -20.9 percent. That is still a reasonable approximation—unless, as everyone hopes, the SGR is repealed or at least suspended again by legislation.
The Proposed Rule nevertheless consists of 608 pages and covers numerous topics. We focus in this Alert on some of the proposals of particular interest to anesthesiologists and pain physicians.
Anesthesia for Endoscopic Procedures
Anesthesiologists who have continued to provide care for patients undergoing screening colonoscopies and upper GI endoscopies through all the coverage policy turmoil of the last 15 or more years are being vindicated. CMS has now gone on record acknowledging that a number of published studies “suggest that the prevailing standard of care for endoscopies in general and screening colonoscopies in particular is undergoing a transition, and that anesthesia separately provided by an anesthesia professional is becoming the prevalent practice.” (Proposed Rule pp. 186-187.) The Agency’s own analysis revealed that 53 percent of screening colonoscopies for which Medicare claims were submitted in 2013 generated a separate anesthesia claim.
Because of the change in the standard of care, CMS is revising the definition of “screening colonoscopy” to bring anesthesia furnished in conjunction with the service within the scope of the provision that Medicare Part B waives beneficiaries’ deductible and coinsurance and pays 100 percent of the Fee Schedule amount established for certain colorectal cancer screening tests. The purpose of the revision is to encourage more patients to undergo a screening colonoscopy, which is consistent with the intent of the statutory provision to waive Medicare cost-sharing for certain recommended preventive services.
By proposing to pay 100 percent of the fee for an anesthetic for a screening colonoscopy under the regulation to be revised (42 C.F.R. §410.160(b)(7)) and waive the patient’s share in every instance, CMS has admitted that anesthesia provided by an anesthesia professional is just as “medically necessary” as the sedation that is currently bundled into the gastroenterologist’s fee. If the service is important enough to be treated like other screening procedures for which the copayment and deductible are waived, logically the anesthesiologist must be paid by Medicare too.
There are a number of Local Coverage Decisions (LCDs) in which various Medicare contractors have predetermined that anesthesia for routine screening colonoscopies is not medically necessary. These LCDs are inconsistent with the proposed change, with the public policy of encouraging preventive care and indeed with CMS’ acknowledgement of the current standard of care. Any such LCDs may need to be modified accordingly. It will be up to anesthesiology leadership, local or national, to persuade the carrier medical directors to update their policies. Commercial payers may also be educated on the changed standard of care.
Although the revision of the definition of “screening colonoscopy” to include the separate anesthesia service is only at the proposal stage, CMS’ recognition that the majority of screening colonoscopies are done under anesthesia should be of permanent value regardless of the fate of the definition at the Final Rule stage.
Payment Rates for Interventional Pain Procedures
The Final Fee Schedule Rule published last November and effective on January 1, 2014 reduced the relative value units (RVUs) for the four interlaminar epidural injections identified by CPT® codes 62310, 62311, 62318 and 62319. CMS was bombarded with thousands of comment letters criticizing the decision to use values lower than those recommended by the AMA-Specialty Society Relative Value Update Committee (RUC). In response, the Agency has announced its intention to re-examine the “interim final” values assigned to the four injections in last year’s Final Rule.
Beginning January 1, 2015 and continuing until the re-examination is completed and its results implemented, CMS will revert to the higher 2013 RVUs and “will use the CY 2013 work RVUs, work times, and direct PE inputs to establish payment rates for CY 2015.”
The reason for the temporary reinstatement of the RVUs that were in place last year is the Agency’s finding that that fluoroscopic guidance is both typically used and typically reported separately in conjunction with the epidural injection services. As CMS stated,
[W]e believe it would be appropriate for the injection and imaging guidance codes to be bundled and the inputs for image guidance to be included in the valuation of the epidural injection codes as it is for transforaminal and paravertebral codes. We do not believe the epidural injection codes can be appropriately valued without considering the typical use of image guidance. We also believe this will help assure relativity with other injection codes that include the image guidance. To determine how to appropriately value resources for the combined codes, we believe more information is needed. Accordingly, we propose to include CPT codes 62310, 62311, 62318 and 62319 on the potentially misvalued code list so that we can obtain information to support their valuation with the image guidance included.
The re-valuation of the epidural codes is an instance of CMS giving with one hand and taking away with the other. While increasing the RVUs to their previous levels, the Agency also proposes to prohibit the billing of image guidance codes in conjunction with the four epidural injections.
PQRS - Measure #30
CMS proposes to remove 73 measures from the PQRS lineup, including:
- Measure #30 (Perioperative Care: Timing of Prophylactic Antibiotic—Administering Physician),
- Measure #23 (Venous Thromboembolism [VTE] Prophylaxis),
- Measure #109 (Osteoarthritis (OA): Function and Pain Assessment),
- Measure #142 (Osteoarthritis (OA): Assessment for Use of Anti-Inflammatory or Analgesic Over-the-Counter (OTC) Medications.
- Measure #248 (Substance Use Disorders: Screening for Depression Among Patients with Substance Abuse or Dependence)
The rationale for the removal of Measures #30 and #23 is that “eligible professionals consistently [meet] performance on this measure with performance rates close to 100% suggesting there is no gap in care.” The most common other rationale for removal is “the measure steward indicating they will no longer maintain this measure.” (Proposed Rule, Table 24, pp. 338-357).
The deletion of the measures listed above makes it more difficult for anesthesiologists and pain physicians to satisfy the requirement that they report on at least nine measures. If they report only one to eight measures, they may be subject to the Measure Applicability Validation (MAV) process by which CMS will determine if they could have reported more. The Anesthesia Quality Institute’s (AQI’s) National Anesthesia Clinical Outcomes Registry (NACOR), which was designated a Qualified Clinical Data Registry (QCDR) earlier this year, will likely become even more attractive as a method of participating in PQRS, given that it has defined 11 quality measures that supplement the official PQRS measures, if the proposed deletions are finalized. (See our Alert Reporting PQRS Measures: Anesthesiology's Own Quality Clinical Data Registry (QCDR) dated June 16, 2014.)
The criteria for satisfactory reporting by individual eligible professionals are generally similar to the criteria in effect for the 2014 PQRS incentive (report on at least nine measures from three different domains for at least 50 percent of patients; measures with a 0 percent performance rate would not be counted). One proposed innovation would be a requirement that eligible professionals who see at least one Medicare patient in a face-to-face encounter and choose to report PQRS quality measures via claims and registry would be required to report on at least two measures in a newly-proposed set of PQRS cross-cutting measures (Proposed Rule Table 21, pp. 308-314). The cross-cutting measures include such familiar items as:
- Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention: Percentage of patients aged 18 years and older who were screened for tobacco use one or more times within 24 months AND who received cessation counseling intervention if identified as a tobacco user.
- Pain Assessment and Follow-Up: Percentage of visits for patients aged 18 years and older with documentation of a pain assessment using a standardized tool(s) on each visit AND documentation of a follow-up plan when pain is present.
- Care Plan: Percentage of patients aged 65 years and older who have a care plan or surrogate decision maker documented in the medical record or documentation in the medical record that a care plan was discussed but the patient did not wish or was not able to name a surrogate decision maker or provide a care plan.
Other Proposals
The Proposed Rule would also:
- Increase the amount of information about physicians and practices on the Physician Compare website, including information pertaining to quality measure performance,
- Continue implementation of the value-based payment modifier (VBM) by applying the 2017 VBM to solo practitioners and all physician and nonphysician eligible professionals (EPs) in groups with two or more EPs. (The maximum amount of payment risk under the VBM would increase from 2 percent in 2016 to 4 percent in 2017),
- Transition all 10- and 90-day global period codes to 0-day global periods starting in CY 2017,
- Add procedures to the telehealth list,
- Create a process for added transparency in developing payment rates,
- Implement separate payment for chronic care management services,
- Solicit information on the use of locum tenens physicians, with a view toward tightening up the rules on supplementing the workforce or replacing departed group members, and
- Delete the exception in the Physician Payment Sunshine Act (Open Payments Program) for reporting of indirect payments by industry to physicians serving as faculty for accredited and/or certified continuing medical education.
CMS is now receiving public comments on the Proposed Rule; the comment period will close on September 2, 2014. The Final Rule is expected to be posted around the 1st of November. We will continue to study the proposals so that we will be able to describe the implications of the Final Rule quickly when it is published. In the meantime, please let us know if you would like further information on any of the topics noted above.