2014 billing update

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RexMorganMD

RexMorganMD

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Anyone have any info on the 2014 Medicare reimbursement for ultrasound, stim and other procedures we suspect to be on the chopping block? I heard through the grapevine stim will be decimated to $880 and the L code is gone.
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RexMorganMD said:
Anyone have any info on the 2014 Medicare reimbursement for ultrasound, stim and other procedures we suspect to be on the chopping block? I heard through the grapevine stim will be decimated to $880 and the L code is gone.
Click to expand...

I heard this was supposed to be released this week.
 
Stim info should come out soon. It was supposed to come out first week of Nov but the govt shutdown pushed things back. I predict a decrease by 30-50% and a doing away with the L code. I also predict it'll be paid based on leads or just off of a professional fee.
 
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I was told this was all finalized Wed and should be on the Medicare website, but I couldn't find it.

Per what I'm told, for in-office stim the L code is gone and a one lead trial pays $1,281.65 and a second lead an additional $640.

Could be wrong. Someone who can navigate the CMS site can confirm.

http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched/index.html

If correct, and subtracting the cost of a lead, a 3 level lumbar rf pays more than stim now.
 
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emd123 said:
I was told this was all finalized Wed and should be on the Medicare website, but I couldn't find it.

Per what I'm told, for in-office stim the L code is gone and a one lead trial pays $1,281.65 and a second lead an additional $640.

Could be wrong. Someone who can navigate the CMS site can confirm.

http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched/index.html

If correct, and subtracting the cost of a lead, a 3 level lumbar rf pays more than stim now.
Click to expand...

WOW!,

Stim goes from being the best paying pain procedure to one of the worst in a stroke of the pen by CMS.

Anybody know the difference in reimbursement for stim trials done in office vs a facility? Unless the companies just start providing free leads for in-0ffice trials, it may pay better to just do stim trials at your local ASC
 
I think this is the link that has the info (page 433 of 1369), but I haven't been able to make heads or tails of the info to confirm an actual dollar amount on the 63650 (or the killing of the L8680):

http://www.ofr.gov/OFRUpload/OFRData/2013-28696_PI.pdf

Will have to put it to rest until Monday, next week, I suppose.
 
emd123 said:
I think this is the link that has the info (page 433 of 1369), but I haven't been able to make heads or tails of the info to confirm an actual dollar amount on the 63650 (or the killing of the L8680):

http://www.ofr.gov/OFRUpload/OFRData/2013-28696_PI.pdf

Will have to put it to rest until Monday, next week, I suppose.
Click to expand...
HI-

I just read pg 433.

This cant be correct. It says current is 10. And recommended is 15. Doesn't that suggest an increase?
 
PinchandBurn said:
HI-

I just read pg 433.

This cant be correct. It says current is 10. And recommended is 15. Doesn't that suggest an increase?
Click to expand...

You're forgetting about the L code, which is separate, under DME. I really hope it's wrong, too, because if correct it means approximately a 90% cut in a 2 lead stim trial, after leads are paid for.

Per my (very solid yet not confirmed) source, there will be an increase in the 63650 reimbursement (as above), but with the elimination of L8680, ie, L-code now paying $0 per contact.

It will be determined this week for sure, one way or the other, since it is somewhere in the CMS website.
 
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I think it might be a bigger hit than I first thought and I hate to say it but I agree with your source. It might end up being a total net gain of somewhere around $1500 or so. Up until very recently, I expected that we'd net about $3500. Bad day for stim.
 
Pain Applicant1 said:
I think it might be a bigger hit than I first thought and I hate to say it but I agree with your source. It might end up being a total net gain of somewhere around $1500 or so. Up until very recently, I expected that we'd net about $3500. Bad day for stim.
Click to expand...
Wow.


Yes, it seems for those that were doing this in office it's going to take a huge it.

I practice in the hospital, where I could only bill by lead number anyways. I wonder what impact it will have on me...............................
 
Looks like office based stim is dead - I think the ASC based trials will pay more but not nearly as much as office based stim did. Any word on U/S or vertebro/kypho? Pain reimbursement really took a $hit....
 
My biller and I are trying to find it the L code is eliminated for all payers or if it is just for medicare (like the consult codes, 99244, etc. from several years ago). Does anyone know the answer?
 
RexMorganMD said:
Looks like office based stim is dead - I think the ASC based trials will pay more but not nearly as much as office based stim did. Any word on U/S or vertebro/kypho? Pain reimbursement really took a $hit....
Click to expand...


I dont have the exact numbers but I can tell you that in office kypho got quacked about 50-60%.......
 
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PinchandBurn said:
Wow.


Yes, it seems for those that were doing this in office it's going to take a huge it.

I practice in the hospital, where I could only bill by lead number anyways. I wonder what impact it will have on me...............................
Click to expand...


You will see higher reimbursement.....
 
mille125 - do you have any documentation you can share related to this or is this just word of mouth?
 
Update: 2014 Medicare IPM cuts


Trigger

20552- $53.08
- 4.88% vs 2013

20553- $61.24
-5.26% vs 2013


ESI

62310-$105.13
-58.24%

62311-$103.43
-51.20%


TF

64483-$214.00
-7.91%

64484-$85.06
-6.37%


C facets

64490-$186.45
-7.74%

64491-$91.52
-6.27%

64492-$92.20
-5.90


L facets

64493-$168.41
-7.82%

64494-$84.04
-6.08%

64495-$84.38
-6.06%


C RF

64633-$418.48
+.57%

64634-$189.
+.72%


L Rf

64635-$412.70
+1%

64636-$171.48
+1%

Kypho

22524- $7111
-11%


Stim leads

L code- $0
-100%

Stim CPT code

63650-lead 1, $1,281
Subsequent leads, $641
(An increase in CPT, minus 90% overall if L-code included)
 
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thanks, got hospital numbers for comparison?
 
emd123 said:
Update: 2014 Medicare IPM cuts


Trigger

20552- $53.08
- 4.88% vs 2013

20553- $61.24
-5.26% vs 2013


ESI

62310-$105.13
-58.24%

62311-$103.43
-51.20%


TF

64483-$214.00
-7.91%

64484-$85.06
-6.37%


C facets

64490-$186.45
-7.74%

64491-$91.52
-6.27%

64492-$92.20
-5.90


L facets

64493-$168.41
-7.82%

64494-$84.04
-6.08%

64495-$84.38
-6.06%


C RF

64633-$418.48
+.57%

64634-$189.
+.72%


L Rf

64635-$412.70
+1%

64636-$171.48
+1%

Kypho

22524- $7111
-11%


Stim leads

L code- $0
-100%

Stim CPT code

63650-lead 1, $1,281
Subsequent leads, $641
(An increase in CPT, minus 90% overall if L-code included)
Click to expand...

Is this final emd?
 
what is the 76942 wRVU for 2014?
 
So the proposed rates posted in July were -2% for epidurals. Not really buying this -50% alarmist word of mouth friend of a friend info until I actually see a link or real data.
 
L codes are still around for commercials and won't be touched throughout 2014 but may get hit in 2015, no one knows just yet.

Also, L codes aren't gone, they're just gone for the office. ASCs can still bill the L code.
 
How can this equate? wRVU went from 1.58 down to 1.18 which equals a 0.40 drop or 25% decrease. But emd says 62310 went to $105.13 which is a 58.24% decrease. How can these two estimates be equal?? Was there another 25% cut in one of the other components making up the total RVU? Is this how that works?
 
Ducttape said:
Huh?

Read the CMS document. ESI down from 1.58 to 1.18 wRVU...
Click to expand...

Trying to figure out how that equates 51-58% cut? Maybe I'm naive but I'm not sure what that actually means in dollars. Can't figure the whole RVU formula thing out. And I'm not sure why they'd propose a 2% cut in July and then drop that giant hammer. Would love to see a dollar conversion chart.

Regarding US, the florida Medicare decided that it was unacceptable to use 76942 code for almost any reason. They recommended the unpaid 76999. That happened around May.

If anyone can help me figure out this whole wRVU thing, I'd love to learn.
 
Pain Applicant1 said:
L codes are still around for commercials and won't be touched throughout 2014 but may get hit in 2015, no one knows just yet.

Also, L codes aren't gone, they're just gone for the office. ASCs can still bill the L code.
Click to expand...
This is the part I'm wondering about. I bill consult consult codes all the time, and medicare doesn't pay them, but over half of my commercial payers still do.

Seems reasonable to still bill the L codes to private insurance companies during 2014. Maybe we can get paid on those for a year before it changes for private insurance companies.
 
For those not familiar with RVUs and are noting "I dont understand RVUs", here is a quick primer. RVUs are used to assign value to certain services provided as an alternate means of 'keeping score' for the work you have done instead of paying you based on collections, etc. It is used primarily for hosp/hosp system employed docs where the hosp really has control over the payor mix and who you see, the billing/coding, collections, etc. For each code you bill there is a universally set RVU (set by CMS I believe) and your employer keeps your tally. Your pay is often based a RVU multiplier, or if on salary, you may bonus or not depending on your quarterly or annual wRVU's. Make sense? So if I get paid 60 bucks an RVU and a procedure goes from 2 rvu's to 1 rvu i got a problem if i do that procedure all the time. It may be possible that the facility rvu didnt change much so the hosp might not care as much as i do about a given cut.
 
I should have been more clear. I understand RVUs but do not understand how they translate into an actual dollar value for a non employed doc.
 
i just reviewed all the documents on the ASIPP site, because i couldnt figure out how they could be saying only a 4% reduction to IPM.

when you look at the ASIPP documents, the overall monetary decrease for procedures does not look as intolerable/bad as the wRVU decrease does on paper.


for example, for LESI, 63611, office based payment rate is currently $211.96, and it will be reduced to $206.86. a 2.4% decrease. the faciliy based rate of $89.82 will actually increase to $92.02, an increase of 2.4%.

Facility fees for a lot of procedures, based on ASIPP, will actually go up considerably - a 14.3 % increase for epidurals (tho 2nd and additional levels for TF will go away completely).
 
Ducttape said:
i just reviewed all the documents on the ASIPP site, because i couldnt figure out how they could be saying only a 4% reduction to IPM.

when you look at the ASIPP documents, the overall monetary decrease for procedures does not look as intolerable/bad as the wRVU decrease does on paper.


for example, for LESI, 63611, office based payment rate is currently $211.96, and it will be reduced to $206.86. a 2.4% decrease. the faciliy based rate of $89.82 will actually increase to $92.02, an increase of 2.4%.

Facility fees for a lot of procedures, based on ASIPP, will actually go up considerably - a 14.3 % increase for epidurals (tho 2nd and additional levels for TF will go away completely).
Click to expand...

The 2014 documents on the ASIPP website are the proposed rates based on the CMS release in July. They have not updated their site to reflect the final release last week.
 
DOctorJay said:
mille125 - do you have any documentation you can share related to this or is this just word of mouth?
Click to expand...

On which part? Medicare has posted changes on in office kypho. Reimbursement has been slashed.
 
Pain Applicant1 said:
L codes are still around for commercials and won't be touched throughout 2014 but may get hit in 2015, no one knows just yet.

Also, L codes aren't gone, they're just gone for the office. ASCs can still bill the L code.
Click to expand...


Yes but what will the rate be? We cant expect private insurance to pay 10 to 20 times medicare for any period of time..
 
Ducttape said:
i just reviewed all the documents on the ASIPP site, because i couldnt figure out how they could be saying only a 4% reduction to IPM.

when you look at the ASIPP documents, the overall monetary decrease for procedures does not look as intolerable/bad as the wRVU decrease does on paper.


for example, for LESI, 63611, office based payment rate is currently $211.96, and it will be reduced to $206.86. a 2.4% decrease. the faciliy based rate of $89.82 will actually increase to $92.02, an increase of 2.4%.

Facility fees for a lot of procedures, based on ASIPP, will actually go up considerably - a 14.3 % increase for epidurals (tho 2nd and additional levels for TF will go away completely).
Click to expand...
That document is exactly why I have a hard time believing all of the 50% cut news. I'd be shocked if they proposed a 2% cut and then increased the cut by more than 20 times the original proposal. The RVU to real dollar conversion is what is confusing to me right now.
 
Ducttape said:
i just reviewed all the documents on the ASIPP site, because i couldnt figure out how they could be saying only a 4% reduction to IPM.
Click to expand...

Because they are factoring stim as an "increase" since 63650 does technically go up. They're not factoring the massive L code elimination tied to the 63650 because it's a DME or "L" code.

It all depends on how they weight each CPT code in coming up with the "total average cuts." RF stays the same, esi's are down 51 and 58%, and everything else is down 4-8%. Does that equal 4%? Absolutelyfrickinlutely not, it's massive.

But, if you include a stim CPT code "increase" for the 63650, which technically was increased by 188%, technically, you can make it look like it balances out, on paper, if you leave the L code out of the calculation.

Again, if the L code 100% cut isn't factored in, which it never would be because it is and always has been on the DME schedule, you have a "4%" cut on paper, but overall a massive cut in reality, especially if you've been doing significant numbers of in-office stim, or ESIs.

It's mind blowing. I can't tell you how relieved I'll be if I'm wrong.
 
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.
 
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Yo GabbaPentin said:
Trying to figure out how that equates 51-58% cut? Maybe I'm naive but I'm not sure what that actually means in dollars. Can't figure the whole RVU formula thing out. And I'm not sure why they'd propose a 2% cut in July and then drop that giant hammer. Would love to see a dollar conversion chart.

Regarding US, the florida Medicare decided that it was unacceptable to use 76942 code for almost any reason. They recommended the unpaid 76999. That happened around May.

If anyone can help me figure out this whole wRVU thing, I'd love to learn.
Click to expand...

I really, really hope it's wrong too, because I'm all "in office" and 70% Medicare. Unfortunately, the same source that nailed the stim cuts down to the penny over Thanksgiving weekend, has crunched the other numbers as well. Nobody, saw cuts this massive coming.

The CMS committee explains here, how and why they vehemently disagreed with the proposal of an only 2% proposed cut:

"For CPT code 62310, we disagree with the work RVU of 1.68 recommended by the AMA RUC because the reduction from the current work is not comparable to the 63 percent reduction in time being recommended by the AMA RUC. We, however, agree that the methodology used by the AMA RUC to develop a recommendation was appropriate. Using this methodology, we calculated the difference in the AMA RUC recommendations for CPT 62310 and 62318 and subtracted this from our CY 2014 interim work RVU for CPT 62318, which results in a work RVU of 1.18, which we are establishing as the CY 2014 interim final work RVU for CPT code 62310.
The AMA RUC recommended maintaining the current work RVU for CPT code 62311 of 1.54 even though its recommended intraservice time decreased 50 percent. We disagreed with this approach.To determine the CY 2014 interim final work RVU we subtracted the difference between the AMA RUC-recommended work RVUs of 62311 and 62319 from our CY 2014 interim final work RVU for CPT code 62319. We believe that the resultant work RVU of 1.17 is a better approximation of the work involved in CPT code 62311."

Work RVUs for C ESI drops 38% from 1.91 to 1.18
Work RVUs for L ESI drops 24% from 1.54 to 1.17

Then you multiply the new RVUs by the 2014 conversion factor. If that conversion factor is lower this year, that's where you get your 50+% cuts.

Again, I can't tell you how happy I'll be if I'm wrong.

Pages 328 and 356:

http://www.ofr.gov/OFRUpload/OFRData/2013-28696_PI.pdf
 
emd123 said:
I really, really hope it's wrong too, because I'm all "in office" and 70% Medicare. Unfortunately, the same source that nailed the stim cuts down to the penny over Thanksgiving weekend, has crunched the other numbers as well. Nobody, saw cuts this massive coming.

The CMS committee explains here, how and why they vehemently disagreed with the proposal of an only 2% proposed cut:

"For CPT code 62310, we disagree with the work RVU of 1.68 recommended by the AMA RUC because the reduction from the current work is not comparable to the 63 percent reduction in time being recommended by the AMA RUC. We, however, agree that the methodology used by the AMA RUC to develop a recommendation was appropriate. Using this methodology, we calculated the difference in the AMA RUC recommendations for CPT 62310 and 62318 and subtracted this from our CY 2014 interim work RVU for CPT 62318, which results in a work RVU of 1.18, which we are establishing as the CY 2014 interim final work RVU for CPT code 62310.
The AMA RUC recommended maintaining the current work RVU for CPT code 62311 of 1.54 even though its recommended intraservice time decreased 50 percent. We disagreed with this approach.To determine the CY 2014 interim final work RVU we subtracted the difference between the AMA RUC-recommended work RVUs of 62311 and 62319 from our CY 2014 interim final work RVU for CPT code 62319. We believe that the resultant work RVU of 1.17 is a better approximation of the work involved in CPT code 62311."

Work RVUs for C ESI drops 38% from 1.91 to 1.18
Work RVUs for L ESI drops 24% from 1.54 to 1.17

Then you multiply the new RVUs by the 2014 conversion factor. If that conversion factor is lower this year, that's where you get your 50+% cuts.

Again, I can't tell you how happy I'll be if I'm wrong.

Pages 328 and 356:

http://www.ofr.gov/OFRUpload/OFRData/2013-28696_PI.pdf
Click to expand...

"Nobody, saw cuts this massive coming"
after the sequester, and Obama raping medicare of 1 trillion dollars, you should have seen it coming.
to survive you need to phase your medicare patients down, otherwise you are a dead duck like the cardiologists....
 
.
 
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stim4u said:
"Nobody, saw cuts this massive coming"
after the sequester, and Obama raping medicare of 1 trillion dollars, you should have seen it coming.
to survive you need to phase your medicare patients down, otherwise you are a dead duck like the cardiologists....
Click to expand...

It is very cold today where I live...that damn Obama
 
Damn,

This might be game over.

Employed option is back on the table.
 
I thought those proposed rates were actually proposed by CMS back in July?

And where are the pain societies in all of this? They only place I've heard about all of this is on sdn.
 
Disciple said:
Damn,

This might be game over.

Employed option is back on the table.
Click to expand...

The thought actually crossed my mind. But the worry about hospital employment from finanical perspective, is that they are notorious for luring you with a great initial contract, then cutting you pay by 30% after 2 years after your family has settled in and purchased a house.

I do believe that office based procedures are practically dead as of 2014. CMS just guaranteed increased costs for the government by this move. Pain Physicians will move to performing procedures at hospitals and ASCs, which will cost CMS and other insurance companies 3X what they were paying for office-based procedures.

Who here does procedures in an ASC?

Could you please chime in regarding what are facility fees for common pain procedures?
What % owner of an ASC, do you to have in order for it to be advantageous to do your procedures there?
 
emd says Kypho 22524- $7111, decreased -11%. Millie says it's been "slashed". Which one of you is right?
 
bedrock said:
The thought actually crossed my mind. But the worry about hospital employment from finanical perspective, is that they are notorious for luring you with a great initial contract, then cutting you pay by 30% after 2 years after your family has settled in and purchased a house.

I do believe that office based procedures are practically dead as of 2014. CMS just guaranteed increased costs for the government by this move. Pain Physicians will move to performing procedures at hospitals and ASCs, which will cost CMS and other insurance companies 3X what they were paying for office-based procedures.

Who here does procedures in an ASC?

Could you please chime in regarding what are facility fees for common pain procedures?
What % owner of an ASC, do you to have in order for it to be advantageous to do your procedures there?
Click to expand...

I was thinking, not so much employed as a solo doc for one community hospital, but employed by a hospital system, one of the local medical foundations, etc., where they may have several doctors in the same specialty, and preferably, with a contract that does not prohibit you from concurrently working as an independent contractor elsewhere.

In saturated areas, ASCs don't provide much of a return annually. Unless you start your own. Not really a good option these days.

In my region, massive cuts for ASCs were last year's disaster.
 
clubdeac said:
emd says Kypho 22524- $7111, decreased -11%. Millie says it's been "slashed". Which one of you is right?
Click to expand...

I'm sticking by my source. Has been on the money so far, unfortunately.
 
mille125 said:
Yes but what will the rate be? We cant expect private insurance to pay 10 to 20 times medicare for any period of time..
Click to expand...

You can expect that for now, it takes time for them to catch up with Medicare. Think about TENS units, granted not the same price range but still an example. They shouldn't be touched for 2014 but of course no one knows for sure. My prediction is that they'll be adjusted for in 2015. As you know, you can and should continue to bill the L code out to commercials at your current rate. If they cut it, they cut it but they'll just reduce it in the adjustment and you'll find out on the next EOB. However, from what I know, and I was the first to mention the L code (several months ago) and caught a lot of slack for it (no apologies received just yet), commercials should remain steady for 2014. I could be wrong because anything could happen at any time but for now this is the way it's looking.
 
who was on the AMA RUC that gave them cannon fodder?
 
If this is true, it will seriously affect all our practices.
I just started 10 weeks ago and was kind of getting excited. Practice is growing and am doing about 30-35 procedures a week.
See about 20-22 patients a day including 6-8 procedures a day. Slightly heavy medicare population but right now, Ill take what I can get

AND NOW THIS ... And my biller has just confirmed.
 
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