2014 CMS

[emd123]

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


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

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[powermd]

Fantastic, they're going to slash US guidance as well…

 

[bedrock]

Fantastic, they're going to slash US guidance as well…

details?

 

[emd123]

Fantastic, they're going to slash US guidance as well…

Was about to by a machine. Guess I wont.

 

[clubdeac]

I just bought one. This is such bull****... when are we going to fight this ****! What other profession would put up with this kind of bull

 

[oreosandsake]

second link about page 89

In the case of CPT code 76942 (Ultrasonic guidance for needle placement (for example, biopsy, aspiration, injection, localization device), imaging supervision and interpretation), we agreed with the AMA RUC’s recommendation to replace the current equipment input of the “room, ultrasound, general” (EL015) with “ultrasound unit, portable” (EQ250). We note that this service is typically reported with other codes that describe the needle placement procedures and that the recommended change in equipment from a room to a portable device reflects a change in the typical kinds of procedures reported with this image guidance service. Given this change, we believe that it is appropriate to reconsider the procedure time assumption currently used in establishing the direct PE inputs for this code, which is 45 minutes. We reviewed the services reported with CPT code 76942 to identify the most common procedures furnished with this image guidance. The code most frequently reported with CPT code 76942 is CPT 20610 (Arthrocentesis, aspiration and/or injection; major joint or bursa (for example, shoulder, hip, knee joint, subacromial bursa). The assumed procedure time for this service is five minutes. The procedure time assumptions for the vast majority of other procedures frequently reported with CPT code 76942 range from 5 to 20 minutes. Therefore, in addition to proposing the recommended change in equipment inputs associated with the code, we proposed to change the procedure time assumption used in establishing direct PE inputs for the service from 45 to 10
minutes, based on our analysis of 30 needle placement procedures most frequently reported with CPT code 76942. We noted that this reduced the clinical labor and equipment minutes associated with the code from 58 to 23 minutes.

Comment: Several commenters noted that the AMA RUC is planning to conduct surveys and review the assumptions regarding the code and that CMS will be in a better position to make more accurate determinations if it waits for that data from the AMA RUC. One commenter stated that CMS should not make a change in the direct PE input database based on information in the Medicare claims data without input from the medical specialty societies whose members furnish and report the ultrasound guidance as described with CPT code 76942 and that a recommendation from the AMA RUC may provide better data than the information contained on Medicare claims.

Response: We appreciate the partnership of the AMA RUC in the misvalued code initiative, but as a general principle, we do not believe that we should refrain from making appropriate changes to code values solely because the AMA RUC is planning to review a service in the future. In some cases, we believe that we should examine claims information and other sources of data and make proposals regarding the appropriate inputs used to develop the amount Medicare pays for PFS services. We believe that notice and comment rulemaking itself provides a means for the public, including medical specialty societies and the AMA RUC, to respond substantively to proposed changes in resource inputs for particular services. Furthermore, in cases like this one, we do not believe that the information reflected in the Medicare claims data is subjective or open to differing interpretations.

Comment: Several commenters, including the AMA RUC, pointed out that CPT code 76942 includes supervision and interpretation, which represents both time and work that is

CMS-1600-FC 91

separate from the surgical code and that the additional time included in the direct PE inputs may reflect time in addition to the base procedure.

Response: We appreciate the response of the AMA RUC and others in pointing out concerns with our assumptions. We note that the proposed clinical labor service period of 23 minutes includes the 10 minutes of intra-service time in addition to 2 minutes for preparing the room, equipment, and supplies, 3 minutes for preparing and positioning the patient, 3 minutes for cleaning the room, and 5 minutes for processing images, completing data sheet, and presenting images and data to the interpreting physician. We did not receive information from any commenters suggesting that the time allocated for these tasks was inadequate. Therefore, we are finalizing our adjustment to the clinical labor minutes associated with this code, as proposed.

 

[powermd]

In a different section they comment on the cost of the US machines and, I believe, plan to use the lowball "portable" unit cost of about $8K, because there is one portable machine being sold for that. That sure seems fair, after all the $8K machine permits identical quality work as our $50K Logiq.

 

[clubdeac]

And for the US novices like myself it takes a lot longer than 5-10mintues to do an US guided nerve block. This is such crap!

 

[emd123]

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


"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."

Pages 328 and 356:

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

Table of rvu's:

http://www.cms.gov/Medicare/Medicar...d/Downloads/CMS-1600-F-CY2014-PFS-Addenda.zip

 

[clubdeac]

emd I can't take reading this ****. So is this final? How likely is it these changes are accurate? Is there anything we can do to stop this massive attack on our specialty or do we just bend over and take it? And most importantly who in the dept of HHS or CMS etc decided ESIs weren't worth **** or that a CESI was technically no more difficult or risky than an ILESI? Specifically what body of people within CMS are unilaterally and arbitrarily determining the value of my livelihood?!

 

[bedrock]

This thread is very depressing. How the hell can they cut so many things at once? SCS, ESI, ultrasound?

The cervical epidural is the most concerning to me. It is 10x riskier than a lumbar epidural and for me, takes twice as long to perform because I'm so careful doing CESI, even though I've done a thousand of them.

Makes me so mad I'm ready to joint an out of network practice that does all their stuff at an ASC, so they can charge $3000 for an epidural. I've never agreed with that approach, but if CMS decides to only pay me $50 to do a cervical epidural(right next to someones spinal cord), it may be time to fight the man......and prepare for the soon to come day when I'll just be charging cash.

 

[bedrock]

MODERATOR-

This thread really needs to be moved to the private forum, thanks

 

[lord_jeebus]

Wow, CESI is less than twice the RVUs for 69210: remove impacted cerumen requiring instrumentation, unilateral (0.61 RVU)

 

[Aether2000]

These changes are inevitable given the massive increase in utilization of these codes by non-pain management physicians and noctors. The orthopedic surgeons and neurosurgeons do these in their offices now on anyone that walks in, the NPs and PAs supervised by untrained internal medicine physicians have opened several "pain clinics" that are really injections for drugs practices in our state, and FPs are doing facet injections under US guidance. The fact is that indeed it takes only a few minutes to perform ultrasound injections and yes, US machines may be too expensive for some practices. The overutilization of injection procedures is driving the CMS to find cost cuts that are a "SGR equivalent" for the specialty, making for no increases in the net cost of injection procedures. Doctors in this country cannot police themselves due to lack of any relevant body with which to penalize outliers, so the government and insurance will do it for us. Ironically, in European countries, access to fluoroscopy is frequently limited to hospitals due to reimbursement issues and the person using the fluoroscope is controlled by scope of practice controls placed by the government that filter down to the hospitals who therefore control who can access fluoroscopy. In the US model of healthcare, the wild wild west, physicians have not been hitherto subjected to similar constraints as seen in Europe. Couple this with the very high financial rewards for a busy injection practice/SCS practice, there is simply no incentive to reduce the number of injections, tighten the criteria for injections or spinal cord stimulation, or reduce costs by using non-injection alternatives. The NPs/CRNAs/PAs doctor wannabes (really are $$$$ wannabes) are jumping on the band wagon since there is no oversight authority to stop these dangerous untrained uneducated *****s from thinking they can do exactly what pain physicians that have trained for years can do.
So, the collapse of the specialty begins, much as I predicted 5 years ago. Hopefully the patients will not suffer too much from reduction of care but in my opinion, they may actually benefit from the reduction in overused injections causing serious long term side effects.

 

[emd123]

emd I can't take reading this ****. So is this final? How likely is it these changes are accurate? Is there anything we can do to stop this massive attack on our specialty or do we just bend over and take it? And most importantly who in the dept of HHS or CMS etc decided ESIs weren't worth **** or that a CESI was technically no more difficult or risky than an ILESI? Specifically what body of people within CMS are unilaterally and arbitrarily determining the value of my livelihood?!

As someone who is trying to build a practice the right way, in a highly competitive market, I know, my brain is about to explode, too. Like Dorothy, I just wanna wake up and be back in Kansas again.

But we should all try to chill out (although that may be impossible) until ASIPP can convert all this to concrete dollar amounts, hopefully soon. I don't know how to make sense of any CMS's codes and RVU formulas. I'm hoping ASIPP will tell us "it's not as bad as it looks" at first glance, or with some codes increasing and others decreasing, "it's a wash." It's unfortunate they dropped this on everyone the last day before a holiday weekend, so everyone is guessing, and assuming the worst.

I did find the 63650 (stim) RVUs, but what it means, I have no idea. I also can't find the facet, RF, or current L codes, anywhere. The stim RVUs are in addendum C in the zip file below, if anyone knows how to convert the RVUs to dollar amounts:

"63650

work RVU-7.15
Non-facility PE RVU- 29.92
Facility PE RVU- 4.17
Malpractice RVU- 0.61"

http://www.cms.gov/Medicare/Medicar.../Downloads/CMS-1600-F-CY2014-PFS-Addenda.zip3

 

[powermd]

Are these proposed cuts for 2015, or finalized cuts for 2014??

 

[emd123]

Are these proposed cuts for 2015, or finalized cuts for 2014??

"CY 2014 Physician Fee Schedule Final Rule with Comment Period"


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

 

[emd123]

2014 CMS, overall funding, per specialty:

Pathology - down 6%
Interventional Pain- down 4%
Rheumatology-down 4%
Allergy/immuno- down 3%
Derm, GI, heme/Onc, ortho, ENT, rads, vascular, all- down 2%. Many others, down 1%

Chiropractic- UP 12% overall,
Clinical psych/social work- UP 8%
Psychiatry- up 6%
Nurse Anesthesia- UP 3%


Source, your very own US Government, Medicare, pages 1285-1286

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

 

[deleted472101]

We need to lobby more

 

[Ducttape]

Algos, I would have to temper the thought that injections will be reduced, but patient requests for pain management will go up due to social mores and the aging population...

Ultimately this may lead to increased med management and by extension increased opioid use...

 

[Aether2000]

and their unrealistic expectations of being pain free.

 

[emd123]

Algos, I would have to temper the thought that injections will be reduced, but patient requests for pain management will go up due to social mores and the aging population...

Ultimately this may lead to increased med management and by extension increased opioid use...

And here's another thing. If CMS is thinking that people are over utilizing procedures because they "pay too much," and that this is the reason they are cutting reimbursement, to decrease costs, then this could back fire. To the extent that procedure over utilization is financially motivated, is the extent to which cuts could paradoxically trigger more procedures, if people determine they need to increase volume to make up the difference. Of course some people over utilize procedures, but is more of the increase in national procedure volume simply due to the aging "in-pain" population increasing, ie, baby boomers entering old age?

With millions of baby boomers entering the 65 and over Medicare age group in the next 10 years, there will necessarily be an increase in not only procedures performed, but surgeries, office visits and meds, no matter what anyone does.

I think cuts will worsen over utilization, and that this approach will backfire.

 

[SSdoc33]

And here's another thing. If CMS is thinking that people are over utilizing procedures because they "pay too much," and that this is the reason they are cutting reimbursement, to decrease costs, then this could back fire. To the extent that procedure over utilization is financially motivated, is the extent to which cuts could paradoxically trigger more procedures, if people determine they need to increase volume to make up the difference. Of course some people over utilize procedures, but is more of the increase in national procedure volume simply due to the aging "in-pain" population increasing, ie, baby boomers entering old age?

With millions of baby boomers entering the 65 and over Medicare age group in the next 10 years, there will necessarily be an increase in not only procedures performed, but surgeries, office visits and meds, no matter what anyone does.

I think cuts will worsen over utilization, and that this approach will backfire.

it will have a net zero effect. interventionalists will perform more procedures to roughly offset the difference of decreased reimbursements. utilization will go up, reimbursement will go down. we will be working harder for the same amount of money. ****ty.

 

[clubdeac]

We need to lobby strongly for two things: 1) Interventional pain procedures be limited to those individuals with appropriate/proper training i.e. a pain fellowship with a ABMS certification in Pain Medicine unless you have been practicing pain for X number of years (grandfather clause) and 2) Appropriate reimbursement commensurate with skill level, risk and efficacy of procedure. This is just becoming ridiculous

 

[PinchandBurn]

We need to lobby strongly for two things: 1) Interventional pain procedures be limited to those individuals with appropriate/proper training i.e. a pain fellowship with a ABMS certification in Pain Medicine unless you have been practicing pain for X number of years (grandfather clause) and 2) Appropriate reimbursement commensurate with skill level, risk and efficacy of procedure. This is just becoming ridiculous

100 % agreed !

 

[spondy14]

Do they give actual RVU's? The more I read, it almost sounds like it won't take effect until 2015?

 

[jj337]

We need to lobby strongly for two things: 1) Interventional pain procedures be limited to those individuals with appropriate/proper training i.e. a pain fellowship with a ABMS certification in Pain Medicine unless you have been practicing pain for X number of years (grandfather clause) and 2) Appropriate reimbursement commensurate with skill level, risk and efficacy of procedure. This is just becoming ridiculous

100 % agreed !

I was at ASRA last weekend and this point was brought up. The main thing against being able to limit a given type of treatment to a certain specialty is the new rules in the ACA (Obamacare). Apparently, there is a "no bias" clause which allows anyone to practice any type of medicine as long as they show "proficiency". This would indicate that, along with PCP's and other physicians performing pain and other procedures outside their scope of practice, mid-levels will be allowed to perform more procedures (including GI, pain, and surgery). Credentialing will still be an issue but will not be if it is in a stand alone clinic. Maybe someone else can add to what was said but there was a speech devoted to this topic and the speaker was quite clear. I am definitely not an expert and would appreciate any help on the subject.

 

[jsaul]

That's nice...CMS cuts reiumbursement for these procedures. But what about the fusion industrial complex?????
It is getting out of hand the number of fusions being done in the lumbar spine and now the SI joint.

the equipment reps are now even paying the 20 percent that medicare only patients have to entice them to get surgeries. This is true. it happened to one of my patients. She was thinking about getting SI joint fusion after a surgeon convinced her. But once the rep said he would pay the 20 percent that she would owe then her mind was made up. She had medicare only. I heard of this happening in my area with lumbar fusions as well

 

[Pain Applicant1]

the equipment reps are now even paying the 20 percent that medicare only patients have to entice them to get surgeries. This is true. it happened to one of my patients. She was thinking about getting SI joint fusion after a surgeon convinced her. But once the rep said he would pay the 20 percent that she would owe then her mind was made up. She had medicare only. I heard of this happening in my area with lumbar fusions as well

That's illegal and you can and should report it. It's insurance fraud and you can earn 15% of what Medicare takes back. If you don't report it, IM me with the rep's name and I'll happily get on the phone with CMS.