American Society of Anesthesiologists - CMS Releases Proposed Rule for 2018 Medicare Physician Fee Schedule

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CMS Releases Proposed Rule for 2018 Medicare Physician Fee Schedule

The Centers for Medicare & Medicaid Services (CMS) released its proposed rule for the CY2018 Medicare Physician Fee Schedule. This 815-page rule includes several issues relevant to anesthesia and pain medicine.

Proposed Conversion Factor:

These figures are subject to change pending CMS decisions in the final rule to be posted this fall. The adjustments include the positive 0.5% adjustment under the Medicare Access and CHIP Reauthorization Act (MACRA) as well as other required adjustments. The anesthesia conversion factor also includes an additional adjustment for practice expense and malpractice updates.

  2017 2018
RBRVS $35.8887 $35.9903
Anesthesia $22.0454 $22.0353

Anesthesia for GI Endoscopy: 

Anesthesia codes 00740 and 00810 have been under review since 2016. These anesthesia codes will be deleted for CY2018 and replaced with five new codes to more specifically describe this anesthesia care. ASA did not agree with CMS’s assessment that these codes were potentially misvalued based on the agency’s assertion that the codes should be revalued because of the “significant change in the relative frequency with which anesthesia codes are reported with colonoscopy services.” In comments to CMS in response to the proposed rule for the CY2016 fee schedule, ASA pointed out that CMS itself recognized the importance of screening colonoscopy and took actions that included eliminating beneficiary co-pays and deductibles in many cases for both the procedure and associated anesthesia care to encourage patients to undergo these procedures. ASA further noted that increased utilization was not driven by a valuation anomaly, but rather by recognition that these services are so important that patients are encouraged to undergo them via use of appropriate payment policies.

A summary of these code changes and proposed base unit values are as follows:

Code Descriptor Current Base Unit Value Proposed Base Unit Value
Deleted: 00740 Anesthesia for upper gastrointestinal endoscopic procedures, endoscope introduced proximal to duodenum 5  
New 007X1 Anesthesia for upper gastrointestinal endoscopic procedures, endoscope introduced proximal to duodenum; not otherwise specified   5
New 007X2 Anesthesia for upper gastrointestinal endoscopic procedures, endoscope introduced proximal to duodenum; endoscopic retrograde cholangiopancreatography (ERCP)   6
Deleted 00810 Anesthesia for lower intestinal endoscopic procedures, endoscope introduced distal to duodenum 5  
New 008X1 Anesthesia for lower intestinal endoscopic procedures, endoscope introduced distal to duodenum; not otherwise specified   4
New 008X2 Anesthesia for lower intestinal endoscopic procedures, endoscope introduced distal to duodenum; screening colonoscopy   4
New 008X3 Anesthesia for combined upper and lower gastrointestinal endoscopic procedures, endoscope introduced both proximal to and distal to the duodenum   5

Anesthesia for upper GI endoscopy will hold steady and see an increase for anesthesia for ERCP. ASA is pleased that CMS is proposing a value above the survey’s 25th percentile for anesthesia for screening colonoscopy but note that CMS is specifically seeking comments on whether it should value 008X2 at 4 base units or adopt the RUC recommendation of 3 base units.

Intravascular Catheterization Procedures:

Placement of a non-tunneled centrally inserted central venous catheter in patients age 5 or older CPT code 36556) was flagged as potentially misvalued due to high expenditures. ASA did not agree with CMS’s identification code 36556 as being potentially misvalued and pointed out the its utilization was in fact experiencing decreases in recent years.

CMS concerns about the value of code 36556 resulted in review of this code and three others as they were considered part of the same code family. CMS is proposing the following work RVUs for these codes.

Code Descriptor Current Work RVU Proposed Work RVU
36555 Insertion of non-tunneled centrally inserted central venous catheter; younger than 5 years of age 2.43 1.93
36556 Insertion of non-tunneled centrally inserted central venous catheter; age 5 years or older 2.50 1.75
36620 Arterial catheterization or cannulation for sampling, monitoring or transfusion (separate procedure); percutaneous 1.15 1.00
93503 Insertion and placement of flow directed catheter (eg, Swan-Ganz) for monitoring purposes 2.91 2.00

Percutaneous Implantation of Neurostimulator Arrays:

These services have also been under review and CMS is proposing significant increases to the work RVUs assigned to these services. ASA worked with other specialties whose members perform these services to survey the codes and prepare and present recommendations to the AMA/Specialty Society RVS Update Committee (RUC).

Code Descriptor Current Work RVU Proposed Work RVU
64553 Percutaneous implantation of neurostimulator electrode array; cranial nerve 2.36 6.13
64555 Percutaneous implantation of neurostimulator electrode array; peripheral nerve (excludes sacral nerve) 2.32 5.76

Overall Impact on Allowed Charges:

If CMS finalizes its rule as proposed, it forecasts the estimated impact on allowed charges for anesthesia and pain as follows:

Specialty Allowed Charges (mil) Impact of Work RVU Changes Impact of Practice Expense RVU Changes Impact of Malpractice RVU changes Combined Impact
Anesthesiology $2,009 -1% 0% 0% 0%
Interventional Pain Mgmt $830 0% 0% 0% 0%
Nurse Anes/Anes Asst $1,238 -1% 0% 1% -1%

Source:  CMS-1676-P, Table 40: CY 2018 PFS Estimated Impact on Total Allowed Charges by Specialty
(Note: Final column may not equal sums of previous columns due to rounding.  Rounding may also prevent display of  values other than whole numbers)

Proposed Modifications to the 2018 PQRS Payment Adjustment and Value-Based Payment Modifier:

For the 2018 payment year, CMS is proposing to change the current PQRS program policy that requires reporting of 9 measures across 3 National Quality Strategy domains to only require reporting of 6 measures for the PQRS. This is significant for many practices who have previously struggled to reach the higher threshold.

In addition, CMS is proposing to ease downward adjustments in the value-based payment modifier. As written the proposal reduces the automatic downward payment adjustment for not meeting minimum quality reporting requirements from negative four percent to negative two percent (-2.0 percent) for groups of ten or more clinicians; and from negative two percent to negative one percent (-1.0 percent) for physician and non-physician solo practitioners and groups of two to nine clinicians. In addition, the proposal would hold harmless all physician groups and solo practitioners who met minimum quality reporting requirements from downward payment adjustments for performance under quality-tiering for the last year of the program.

MACRA Patient Relationship Categories and Codes:

The Medicare Access and CHIP Reauthorization Act requires establishment of codes and modifiers to define clinician/patient relationships and to be used as part of determining cost attribution. CMS is proposing the following modifiers to be used on claims for services provided on/after January 1, 2018.

Proposed Modifier Patient Relationship Category
X1 Continuous/broad services
X2 Continuous/focused services
X3 Episodic/broad services
X4 Episodic/focused services
X5 Only as ordered by another clinician

ASA will thoroughly review this proposed rule and submit detailed comments to CMS.

The full rule is available at https://s3.amazonaws.com/public-inspection.federalregister.gov/2017-14639.pdf

A CMS Fact Sheet can be viewed https://www.cms.gov/Newsroom/MediaReleaseDatabase/Fact-sheets/2017-Fact-Sheet-items/2017-07-13-2.html?DLPage=1&DLEntries=10&DLSort=0&DLSortDir=descending

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