More Doctor Revenue Cuts

CMS says it's finalized its' decision, now will Congress intervene to halt the cuts? They'd better.

Yet for cardiac electrophysiologists, we will have our procedural revenue drastically cut by a little-known change to our Medicare procedural reimbursements from electrophysiology procedures. This is because catheter ablation procedures will no longer be exempt from needing a "51-modifier" added to procedure billing codes. (I apologize for adding this Medicare mumbo jumbo to my blog, but some EP docs might be interested...) Because I am not a billing nerd, here's the content of a letter e-mailed to all EP physicians from the Heart Rhythm Society explaining the issues:

November 2, 2007

Dear Heart Rhythm Society Member:

The Heart Rhythm Society (HRS) is writing this letter to make you aware of a change in CPT coding that will take effect on January 1, 2008, which will ultimately result in a change in reimbursement for electrophysiological studies and ablation procedures from Medicare and eventually all private insurance third-party payers. The following paragraphs will explain the rationale behind the decision to comply with the change and the consequences of not doing so.

As many of you are aware, within CPT, modifier 51 (Multiple Procedures) is designed to trigger multiple procedure payment reductions when a physician performs separate procedures on the same patient during the same session. These separate procedures are not incidental to the primary procedure and are separately payable. The payer reimburses the highest-ranked procedure at 100 percent and any additional procedures at 50 percent. The vast majority of surgical procedure codes within CPT are subject to the multiple procedure payment reduction rule. Procedure codes that are modifier 51 exempt are not subject to the multiple procedure payment reduction rule and are paid at full rate.

In 2006, the American Medical Association (AMA) CPT Editorial Panel convened a work-group to conduct a review of certain codes. The work-group was instructed to develop recommendations for the 2008 cycle that would eliminate redundancy, inconsistency, and variable interpretations identified for a select group of modifiers and address issues related to modifier 51. More specifically, the work-group was to determine the appropriateness of codes designated as modifier 51 exempt (Appendix E of the CPT book) and develop a set of criteria to use in determining future applications for exempt status.

The work-group felt that the two primary criterion for inclusion of a procedure in Appendix E was that the current RUC values were consistent with exemption from multiple procedure reductions, and the values already had reduced pre- and post-service work and practice expenses, if the procedure was determined to be typically adjunctive or performed with another procedure(s). The work-group's recommendations for 2008 included removal of 151 of the 181 codes currently on the exemption list. It was discovered that many of the services, including certain EP study and ablation procedures, did not meet the new inclusion requirements for retention.

For over a decade, all of the codes in the Intracardiac Electrophysiologic Procedures/Studies subsection (93600-93662) of CPT, with the exception of add-on codes 93609, 93613, 93621, 93622, 93623, and 93662, have been modifier 51 exempt. In the 2008 edition of CPT, the modifier 51 exempt symbol "x" has been omitted from EP study codes 93619, 93620, 93624, 93640, 93641, 93642 and 93660, and ablation procedures 93650, 93651 and 93652. This change eliminates the long-standing exemption status and will result in payment decreases by 50% when multiple procedures are performed by the same physician during the same patient encounter.

From a payment perspective, the rationale is that some of the work for a given procedure is not repeated when two or more procedures are performed simultaneously. Medicare payment rates for EP studies and ablation procedures are based on each service being provided independently. The intra-service work is only a portion of the total work value, while the other portion represents pre- and post-service work. For these procedures, the pre- and post-service work components overlap when multiple procedures are performed on the same patient on the same date of service.

HRS in consultation with the American College of Cardiology (ACC) assessed the impact of this change, and after very careful consideration decided to not object to removal of the codes from the exemption list. While the negative financial impact of removing the codes from exempt status was understood, it was determined that there was greater financial risk in challenging this decision. To maintain exempt status would have required development of rationale to meet the new inclusion criteria. The AMA and the Centers for Medicare & Medicaid Services (CMS) indicated that if all of the inclusion criterion were not met according to the CPT Editorial Panel, then the family of codes (93600-93662) would be sent back to the AMA Relative Value Update Committee (RUC) for complete re-valuation so that CMS payment policy and the modifier 51 exempt status of the codes are congruent. Considering this, HRS and ACC thought it would be counter-productive to the best interest of the EP profession to challenge this decision.

HRS will continue to work diligently with the AMA and CMS to ensure that EP services remain appropriately reimbursed in this politically challenging economic environment.

Well it looks like we're gonna take it in the shorts. Who's next?

-Wes