The annual publication of the draft Medicare physician fee schedule (MPFS) is an event, but this year’s draft has drawn substantial criticism from across the board, despite the promise of more coverage of telehealth. The Medical Imaging & Technology Association (MITA) and a coalition of surgeons have blasted the draft as a hazard to patient access to both evaluation and management (E/M) services and surgical procedures, both of which present substantial headwinds for the medical device industry.

The U.S. Centers for Medicare and Medicaid Services (CMS) posted the draft MPFS the first week of August, adding a number of HCPCS codes to the existing set of telehealth codes that are eligible for reimbursement. In addition, the draft highlights several nominations for potentially misvalued CPT codes, including CPT code 22867, which is for insertion of interlaminar/interspinous stabilization/distraction devices without fusion.

The submitters of this nomination argued that the physician work relative value assigned to CPT 22867 undervalues the procedure relative to the CPT code for laminectomy (63047), given that the surgical steps are similar. However, they also argued that there is additional intensity and complexity involved in the work described in 22867 relative to CPT 63047, but there are also some concerns regarding the related malpractice relative value units (RVUs). The agency is taking the proposal under consideration and seeks feedback from stakeholders.

Changes to E/M portend a ‘profoundly negative impact’

MITA said in an Aug. 7 statement that the MPFS draft’s changes to rates paid for E/M services “will have a profoundly negative impact on specialty physicians” and other health care professionals that provide imaging services. MITA said it and other organizations opposed the cuts, and offered the suggestion that CMS temporarily waive the budget neutrality requirements that ordinarily apply to any changes in the rate-setting framework.

The American College of Radiology (ACR) posted an analysis of the MPFS, explaining that the proposed conversion factor of $32.26 represents a budget neutrality factor in excess of 10% over the existing conversion factor of $36.09. The overall effect would be an 11% decrease in rates, with interventional radiology sustaining a hit of 9%. Radiation oncology and radiotherapy centers would see a cut of 6%, ACR said, adding that it would be in touch with members of the House and Senate regarding the proposal.

The Aug. 3 CMS press release for the draft said that the draft includes a series of proposal regarding practice expense, including the third year of a market-based supply and equipment pricing update. The proposed change to the conversion factor drew the ire of the Surgical Care Coalition, which blasted the proposal in an Aug. 4 statement.

The coalition, which lists the Society of Thoracic Surgeons (STS) among its members, said the proposal would reduce payments to nearly all surgical specialties, some by 9% (cardiac surgery). STS has been intimately involved in Medicare coverage proposals for transcatheter aortic valve replacement (TAVR) devices, and collaborates with the American College of Cardiology on the registry for TAVR devices.

STS said a survey conducted earlier this year indicated that one in three private surgical practices voiced concerns about their ability to stay in business, thanks to the drop in procedures stemming from the COVID-19 pandemic. The combination of the pandemic and the cuts to Medicare rates will “likely force surgeons to take fewer Medicare patients, leading to longer wait times and reduced access,” the coalition said.

The draft floats several changes to a number of RVUs, including CPT code 93306, for complete transthoracic echocardiography with Doppler ultrasound. One submitter claimed that the RVUs for this code are overstated, recommending that the CMS drop the work RVU from 1.50 to 1.46. Ventricular assist device interrogation under CPT 93750 may be trimmed from 0.96 to 0.85, the latter figure the result of a crosswalk from CPT 78598. The CMS said the proposed change to 93750 reflects survey data that suggest the amount of time needed to interrogate VAD devices is less than 24 minutes, a decrease of six minutes from the current presumed work time.

Hip, knee arthroplasty may also take a hit

For orthopedic devices, the draft proposes adoption of a work RVU of 19.60 for CPT code 27130, and a work RVU of 19.60 for CPT code 27447. These codes address total hip and total knee arthroplasty (THA and TKA), respectively, and CMS noted that it had arrived at an interim work RVU of 20.72 for both codes for calendar year 2014.

The agency undertook another examination of RVUs for these codes a year later, which resulted in an impasse due to lack of sufficient data to propose any changes. These codes were proposed as misvalued for the 2019 calendar year, however.

The CMS said a number of services associated with both procedures, such as inpatient and outpatient follow-up, were overestimated, and the agency noted that it seeks feedback on pre-procedure optimization activities that could improve outcomes. CMS announced it would remove TKA from the inpatient-only list in 2018, while the same announcement regarding THA was issued the following year.

There are several codes related to implanted interstitial glucose monitors that are under consideration, specifically the category III CPT codes 0446T through 0448T, each of which is currently priced by Medicare administrative contractors. The CMS proposes to affix a work RVU to these codes of 1.14 (0446T), 1.34 (0447T) and 1.91 (0448T), along with a price of $1,500 for the sensor. The proposal to price the smart transmitter at $1,000 is based on the use of similar equipment in heart failure monitoring systems, the draft said.

The agency said its proposal to eliminate several national coverage determinations is girded by the perception that coverage is more aptly determined by Medicare administrative contractors, and floated several NCDs for this approach. Among these is the 2008 NCD for magnetic resonance spectroscopy and a 1978 NCD for histocompatibility testing. Also on this list is the 2008 NCD for FDG-PET evaluation for inflammation and infection: CMS said the value added by the procedure is not well supported by the literature in several of the covered applications.

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