Dr. Christopher Merifield represented ISIS members at the AMA Relative Value Update Committee (RUC) on April 25-27, 2013. RUC is an advisory body to CMS, and reviews medical procedures and provides Relative Value Unit (RVU) recommendations to CMS. Historically, CMS has accepted 95% or more of the RUC Value recommendations.

Additionally, a RUC workgroup continues to develop screens that are designed to identify codes which may be potentially "misvalued” based on assumptions about trends such as utilization growth; the RUC workgroup determines whether their current value is appropriate.

ISIS remains actively involved with both CPT and RUC processes of the AMA. Our representatives are present at every meeting to provide input and justification for proper values of interventional spine codes.

The Centers for Medicare & Medicaid Services (CMS) issued a final rule on the requirements for manufacturers of drugs, biological and medical devices to publically report payments and other transfers of value made to physicians and teaching hospitals.  Additionally, any ownership or investment interests physicians or their family members have in the manufacturers must be disclosed to CMS.

Data collection will begin Aug. 1, 2013 and CMS will start publishing the data by Sept. 30, 2014.  According to CMS, manufacturers, group purchasing organizations, teaching hospitals and physicians will have an opportunity to review and correct reported information before it is made public. 

ISIS submitted a comment letter to the Centers for Medicare and Medicaid Services (CMS) during public comment period on the Final Rule of the Medicare Physician Fee Schedule.  CMS announced that it is finalizing the proposal to reimburse CRNAs at the same rate as physicians for chronic pain procedures, which they are allowed to perform in their state.  ISIS strongly disagrees with this decision.  To view the letter click here.

On November 27, Centers for Medicare and Medicaid Services published a list of topics which "may have the potential to be subjects for further evaluation using literature reviews, claims based analyses, or as subjects for analysis in a National Coverage Determination (NCD)”.  Among other topics, CMS named epidural and transforaminal injections and implantable central nervous system stimulators for intractable pain. 

Although, at this point, no indication has been made by CMS about any immediate plans to review the spine interventional procedures they listed – ISIS is committed to continue its work with Medicare representatives to advocate for appropriate access to these procedures for our patients.

To review the full list of procedures, which may be subject to review please click here. 

Unless Congress acts to stop physician payment cuts; as of January 1, 2013 the Medicare payments to physicians will drop by 26.5%.   

Demand that Congress act before January 1 and contact your representative and senators TODAY!!  Use the American Medical Association (AMA) resources to send them an email by clicking here and call their offices through the grassroots hotline at 1-800-833-6354.  Tell your representatives to stop the looming payment cut and repeal the flawed Sustainable Growth Rate (SGR) formula.

On November 1, 2012, the Centers for Medicare and Medicaid Services (CMS) published a Final Rule on Medicare Physician Fee Schedule for 2013. Contained in the rule are several issues of great importance to ISIS members:

CRNAs to be paid the same as Physicians for Chronic Pain Services

In a move decried by all physician organizations, CMS reaffirmed their decision to pay CRNAs on the same level as physicians for any chronic pain management services, that they are allowed to perform by their State. ISIS submitted a letter strongly opposing the proposal (click here to review ISIS letter) and encouraged members to submit comments to CMS through provided website links and information. This decision will go into effect as of January 2013.

Members are encouraged to contact their House and Senate representatives to ask them to oppose the CMS decision and take legislative action to rescind the new rule.

Reimbursement for Fluoroscopy Guidance Code (CPT 77003)

Previously, CMS requested a review of code 77003 (Fluoroscopic guidance and localization of needle or catheter tip for spine or paraspinous diagnostic or therapeutic injection procedures (epidural or subarachnoid) due to the fact that the code was flagged as one with high expenditure. ISIS twice conducted a survey of physician work, in which multiple other physician organizations participated. The results were presented to the AMA Relative Value Update Committee (RUC) and the RUC made a recommendation to CMS that the current value should be maintained.In the rule, CMS decided to accept the RUC recommended value but on interim basis only, and is asking for another review of this code, this time along with CPT codes 77002 and 77001 (non-spine fluoroscopy guidance codes).

Reimbursement for Electrode Implantation to be Reviewed

CMS requested a review of work and practice expense values for 63650 (Percutaneous implantation of neurostimulator electrode array, epidural); ISIS submitted public comments to CMS, indicating that the review of physician work values for this code is not necessary, as it was recently reviewed; and only practice expense inputs should be assigned, since they currently do not exist in non-facility setting. In the final rule CMS appears to be agreeable to the plan that RUC will review the practice expense only, for non-facility setting. ISIS will be participating in the preparation and presentation of the proper inputs to assure fair reimbursement.

Dr. Claire Tibiletti and Dr. Andrew Yu represented ISIS at the AMA House of Delegates Advocacy Meeting, November 10-13, 2012.  Multiple policy issues were discussed, including the delay or elimination of ICD-10 requirement, drug shortages, uniform approach for assessing patients for controlled substances for chronic pain and harm reduction strategies for opioid overdose. The House also established principles for physician employment to protect physicians who enter into employment agreements.  To view the principles document please visit: http://www.ama-assn.org/resources/doc/hod/ama-principles-for-physician-employment.pdf

ISIS joined more than 100 state and specialty medical societies in sending a letter to Congress outlining the principles for repealing the flawed physician payment, sustainable growth formula (SGR) and a successful transition to a Medicare program that would function well.

Physicians face a steep Medicare fees cut of 27 percent in January 2013. This situation is unacceptable – it creates tremendous hardships and instability, stifles innovation and erodes access for Medicare patients. The formula must be repealed so that the medical community can work toward implementing the outlined principles and work on developing a productive environment. To view the letter click here.

On October 2, 2012, the Office of Inspector General for the Department of Health and Human Services released an outline of planned efforts and investigations for year 2013. A summary of some of the topics included in the 2012 plan, which ISIS members may find of interest, is provided below. To review the full Work Plan you may visit: https://oig.hhs.gov/reports-and-publications/archives/workplan/2013/Work-Plan-2013.pdfn

Additionally, on October 24, 2012 the OIG will launch a webcast – which will remain on their website for viewing at any time. A roughly 30 minute program on emerging trends in combating fraud, waste and abuse and priorities for 2013. To obtain more information on the program please visit: https://oig.hhs.gov/newsroom/outlook/

Summary of selected topics in the 2013 OIG Work Plan:

• Electrodiagnostic Testing—Questionable Billing

Review of Medicare claims data to identify questionable billing for electrodiagnostic testing and determine the extent to which Medicare utilization rates differ by provider specialty, diagnosis, and geographic area for these services.

• Diagnostic Radiology—Medical Necessity of High-Cost Tests

Review Medicare payments for high-cost diagnostic radiology tests to determine whether they were medically necessary and the extent to which the same diagnostic tests are ordered for a beneficiary by primary care physicians and physician specialists for the same treatment

• Physicians—Error Rate for Incident-To Services Performed by Nonphysicians

Review physician billing for "incident-to” services to determine whether payment for such services had a higher error rate than that for non-incident-to services. The OIG will also assess Medicare’s ability to monitor services billed as "incident-to.” Medicare Part B pays for certain services billed by physicians that are performed by nonphysicians incident to a physician office visit.

A 2009 OIG review found that when Medicare allowed physicians’ billings for more than 24 hours of services in a day, half of the services were not performed by a physician. Uqualified nonphysicians performed 21 percent of the services that physicians did not personally perform. Incident-to services are a program vulnerability in that they do not appear in claims data and can be identified only by reviewing the medical record. They may also be vulnerable to overutilization and expose beneficiaries to care that does not meet professional standards of quality.

• Physicians - Place-of-Service Coding Errors

Review physicians’ coding on Medicare Part B claims for services performed in ambulatory surgical centers and hospital outpatient departments to determine whether they properly coded the places of service. Federal regulations provide for different levels of payments to physicians depending on where services are performed. Medicare pays a physician a higher amount when a service is performed in a nonfacility setting, such as a physician’s office, than it does when the service is performed in a hospital outpatient department or, with certain exceptions, in an ambulatory surgical center.

• Evaluation and Management Services—Potentially Inappropriate Payments Determine the extent to which CMS made potentially inappropriate payments for E/M services in 2010 and the consistency of E/M medical review determinations.

Review multiple E/M services for the same providers and beneficiaries to identify electronic health records (EHR) documentation practices associated with potentially improper payments. Medicare contractors have noted an increased frequency of medical records with identical documentation across services.

• Off-Label Use of Medicare Part B Drugs

Review off-label and off-compendia use of certain Medicare Part B prescription drugs and determine the extent to which specified compendia provide support for coverage. Identify CMS oversight mechanisms related to off-label use of drugs.

For prescription drugs to be covered, Federal law generally requires that they be prescribed according to medically accepted indications, such as those approved by the Food and Drug Administration (FDA) or supported in one or more of the authoritative drug compendia identified by the Secretary of Health and Human Services (HHS). Therefore, most drugs are covered when used off-label as long as one of the designated compendia has determined that there is sufficient evidence that the drug is safe and effective for treating the condition.

• Physicians’ and Hospitals’ Experiences With Drug Shortages

Determine the extent to which hospitals report drug shortages. Determine the extent to which physicians/providers of selected Part B-covered drugs in short supply report difficulty acquiring those drugs.

During shortages, physicians/hospitals may have to ration their supplies of certain drugs; delay treatments; use different drugs, which may be less effective; or resort to potentially untrustworthy sources to acquire drugs. The OIG states it will ask providers to describe their behavior when facing a drug shortage as well as any effect on pricing, quality of care, and market availability.

• Manufacturer Sales of Prescription Drugs in Short Supply

Quantify the effect of drug shortages on manufacturer sales. According to FDA, a record number of drugs were in short supply in 2010 and the number of drug shortages continued to grow in 2011. The OIG will also use data from CMS to determine the extent to which demand and average sales prices of drugs changed when the drugs were reportedly in shortage. For any drug that did not show substantial decline in unit during the shortage quarter, the OIG will analyze Part B claims data to determine whether there was an increase in Part B utilization during that period.

• FDA—Oversight of Wholesale Prescription Drug Distributors

Assess the adequacy of FDA’s oversight of wholesale prescription drug distributors and determine the extent to which FDA ensures that States are licensing wholesalers according to applicable State and Federal laws. All drug wholesalers must be licensed under State licensing systems, which must in turn meet the FDA guidelines.

• Local Coverage Determinations—Impact on Physician Fee Schedule, Services, and Expenditures

Determine to what extent Part B services and items paid under the Medicare Physician Fee Schedule are affected by Local Coverage Determinations (LCD) and the variation in coverage of these services and items as a result. The OIG will also assess CMS’s efforts to evaluate and adopt new LCDs for national coverage as required by the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (MMA).

Medicare delegates the establishment of LCDs to third-party contractors. A contractor may establish an LCD to enforce its decision about whether a particular item or service is considered reasonable and necessary and is therefore covered under Medicare. These coverage decisions are not national, meaning Medicare could pay for a service for a beneficiary in one location, but deny payment for that service to a beneficiary elsewhere.