PROPOSED PAYMENTS FOR PAIN: Anesthesiologists May Not Like What They See

Anesthesia providers are facing the real possibility of a reduction in reimbursement for acute pain services in the coming year. However, the end of the story has yet to be written.

As a follow-up to our recent articles on the proposed Medicare Physician Fee Schedule (MPFS) for 2020 and our trend analysis of acute pain services, we would like to provide additional details on pain codes and their payment. As noted in our treatment of the 2020 MPFS, little is expected to change for anesthesia practices next year, with the notable exception of the acute pain component. We observed generally that some postoperative pain codes—particularly those associated with the somatic nerves—may pay less next year than they do this year. Today, we will be providing you with specific details on the full array of acute pain codes and their expected reimbursement.

A View to a Killjoy

Nothing spoils the spirit and lessens the laughter like a report of reduced income. It's not only a buzzkill; it makes you want to kill Buzz! However, we ask that you refrain from killing the messenger on this occasion, and instead soberly consider the projected pain payments that are currently scheduled for 2020. Keep in mind that these numbers have not been finalized and are subject to change.

Further below, we provide a chart that contains relative value unit (RVU) data extracted from Addendum B of the proposed 2020 MPFS. These RVUs reflect a combination of three components that seek to place a specified value on a particular medical service: work value, practice expense and malpractice cost. Naturally, the total RVU rate for a service in the non-facility setting, such as a physician's office, will be higher since the calculation will include a higher practice expense value, due to overhead costs.

To avoid any confusion, one more thing should be noted before we proceed. The RVUs we will be discussing in connection with acute pain services should not be confused with the "base unit values" suggested for these services as found in the Relative Value Guide (RVG). While those could be used to bill certain payers, this alert is strictly focused on the values and payments applicable to the Medicare fee schedule.

Our chart additionally provides a comparison of the 2019 RVUs with those proposed for 2020. Since the vast majority of postoperative pain procedures are performed in the facility setting (e.g., hospital inpatient, hospital outpatient, ambulatory surgery center), we have listed the expected differential in payment from 2019 to 2020 in the far-right column for that category.

On Closer Inspection

As you can see from a brief scan of this chart, the majority of the codes contained therein are scheduled for a decrease in payment value for the new year. However, it may be worth taking a closer look at these proposed changes. Indeed, there are several things we should note in connection with the above numbers, such as the following:

1. The recommended RVUs for 2020 will be multiplied by the proposed 2020 conversion factor (CF) of $36.09, reflecting a slight increase from this year's CF of $36.04. The result of this calculation renders the expected payment for the given service in the coming year. Take for example CPT 64447, femoral nerve block, single. This year, that service pays $68.93 in the facility setting. Next year, it will pay $54.49.
   
   That $14 differential may not seem all that significant at first glance. It certainly won't break the bank. However, as Rocky said to Adrian when discussing the money stolen out of his locker over the years, "it adds up." Let us suppose that an anesthesia provider places an average of 35 such blocks in a year for Medicare beneficiaries; that works out to a loss of $500 annually tied to this code alone.
   
2. Keep in mind that the above example was based on a 0.40-unit reduction in the RVU for that single code. If you aggregate the RVU changes for all the somatic nerve block codes (CPT 64400 – 64489), taken together, there is an overall reduction of 10.09 RVUs proposed for this code set. So, depending on the type and number of blocks you place for separate payment relative to Medicare patients, you may incur a reduction in income reaching into the thousands of dollars.
   
3. The good news is that, while the somatic nerve blocks will generally pay less next year, most of the epidural block and catheter codes will pay a bit more. The exceptions are 62322 and 62326—the two lumbar-related codes (without imaging), block and continuous catheter, respectively. If you use imaging, the postoperative lumbar epidurals will actually pay a little more next year.
   
4. Based on a review of the peripheral nerve blocks submitted on behalf of our clients, many of you are primarily making use of four block/catheter services:
   
   • 64415 – Interscalene (brachial plexus), single
   • 64446 – Sciatic, continuous
   • 64447 – Femoral, single
   • 64486-64489 – TAP (depending on single or continuous, unilateral or bilateral)
   
   While there are minimal to moderate reductions in three of these categories, the TAP category actually contains an overall increase in the proposed RVUs for 2020.
   
5. Many of you utilize ultrasonic guidance (USG) in the placement of these blocks. There was no change in RVUs proposed for next year in relation to 76942—the CPT code reflecting USG for needle placement. The rate will remain the same at 0.91 in both the facility and non-facility setting. However, as we previously reported, the proposed 2020 MPFS discusses the possibility of bundling USG into some of these acute pain services, beginning in 2021; but that's another year and another battle.
   
6. Remember that the RVUs listed in the above chart are based on a national standard. They do not necessarily reflect the actual RVUs directly applicable to your practice. Recall that these national RVUs are adjusted for geographic locality in order to more accurately reflect the market forces found within your particular city or region. Again, your numbers may vary from those found in the above chart.

Seeing the Silver Lining

We're often reminded that every cloud has a pot of gold . . . hmm . . . I could be mixing my metaphors a bit. Nevertheless, while much of what we've reported today is unwelcome news, there are still a few things that may provide a modicum of consolation and hope.

First, remember that these proposed acute pain RVU reductions could be rescinded. The American Society for Anesthesiologists (ASA) has been fighting vociferously for such an outcome, and many of you have added your voice to this effort. You still have until the 27th of this month to submit your concerns to CMS. Nothing will be finalized until this November, at which time we will provide you with another update. Second, as stated previously, some of your postoperative epidural and TAP services are scheduled to actually increase in value in the new year. Third, you can begin now to determine how to best respond to these potential RVU changes from a clinical, financial and strategic perspective.

So, while our first look at these proposals may leave us in a haze of disappointment, all is not lost. There is hope yet on the horizon; and, in time, the clouds will clear.

If you would like to receive an estimate of the change in reimbursement you or your group may encounter in 2020 as a result of the anticipated changes in RVU rates for your acute pain services, please do not hesitate to contact your account representative.