CMS targets ‘misvalued’ urology codes in rule

September 1, 2015

The first annual Medicare physician fee schedule rule in the post-sustainable growth rate era has been proposed by the Centers for Medicare & Medicaid Services, and includes several provisions of specific interest to urologists, including attention to certain services that are considered misvalued by the agency and some modifications to Stark law regulations.

Washington-The first annual Medicare physician fee schedule rule in the post-sustainable growth rate era has been proposed by the Centers for Medicare & Medicaid Services (CMS), and instead of being locked in a battle to avoid draconian pay cuts, physicians can expect an across-the-board .5% increase in payments.  

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The rule, published July 8, will be finalized after comments from providers and other interested parties have been considered by CMS. It includes several provisions of specific interest to urologists, including attention to certain services that are considered misvalued by the agency and some modifications to Stark law regulations.

Overall, the impact on urologists’ payment rates does not appear to be particularly significant. In fact, notes the AUA in an online discussion of the fee schedule rule, “For 2016, CMS estimates the overall impact on payment rates for urology services based on physician work, practice expense, and malpractice relative value units (RVU) changes to be zero.”

However, the AUA cautioned, the actual impact on individual urology practices will differ based on annual changes to RVUs, patient volume, and mix of services.

NEXT: Urology services potentially misvalued

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Urology services potentially misvalued

The AUA pointed out that several urology services and procedures were identified as potentially misvalued based on a screen of high Medicare expenditures per specialty. The Protecting Access to Medicare Act of 2014 (PAMA) gave the Department of Health and Human Services (HHS) authority to review codes that account for the majority of Medicare fee schedule spending.

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In the fee schedule regulation, CMS identified the top 20 CPT codes per specialty in terms of allowed Medicare charges of $10 million or more. Federal law has identified a target for recovery of expenditures of 1%, and CMS plans to gather information needed to value services from a representative sample of physicians by Jan. 1, 2017.

These are the urology codes identified as meeting that $10 million threshold:

  • 51700, Irrigation of bladder

  • 51702, Insert temp bladder cath

  • 51720, Treatment of bladder lesion

  • 51728, Cystometrogram w/ voiding pressure studies

  • 51729, Cystometrogram w/ voiding and urethral pressure profile studies

  • 51784, Anal/urinary muscle study

  • 51797, Intra-abdominal pressure test

  • 51798, US urine capacity measure

  • 5200, Cystoscopy

  • 55700, Biopsy of prostate.

The AUA pointed out that the PAMA directed HHS to establish a program to promote use of appropriate use criteria (AUC) for advanced diagnostic imaging services. CMS is requesting comment on those criteria, and the AUA noted that if its proposal were adopted, national professional medical specialty societies would be qualified by Medicare to develop or endorse AUC.

NEXT: Stark Law modification proposed

 

Stark law modification proposed

Meanwhile, CMS proposes in its rule to modify several provisions of the Stark regulations, many of which are intended to avoid severe consequences of a technical violation, like failure to obtain proper signatures on documents.

Essentially, the Stark law prohibits physicians who have financial relationships with entities from referring to those entities for health services unless the arrangement meets an exception. Over the years, exceptions have been substantially expanded as Medicare and the health care industry have evolved.

The new proposed exceptions include:

Recruitment/retention of physicians. CMS proposed an exception to permit remuneration to physicians and physician organizations to employ non-physician practitioners, which are defined as physician assistants, nurse practitioners, clinical nurse specialists, and certified nurse midwives-but only to provide primary care services.

Timeshare arrangements. CMS offers a new exception for timeshare leasing, protecting instances when a hospital or physician organization leases on a timeshare basis to a physician and would permit predominately evaluation and management services as well as certain CLIA-waived tests.

“For instance, advanced imaging equipment, clinical or pathology lab equipment, and similar DHS [designated health services] equipment is not permitted to be used in such an arrangement. CMS cites its concern with independent diagnostic testing facilities or clinical laboratories that offer such a turnkey operation to physicians to lock up referrals,” notes a memo by Washington health care law firm Morgan Lewis.

Morgan Lewis points out that with the rise of coordinated care efforts, like accountable care organizations, “The Stark law may at times seem out of place with the federal government’s current goals.”

Recognizing this, CMS is seeking comments on the Stark law’s impact on health care delivery and payment reforms. CMS is required to issue two reports to Congress by April 2016, one addressing application of the Stark law to alternative payment models and the other proposing changes to federal law to permit gainsharing arrangements.

Earlier this summer, LUGPA commended the House Physicians Caucus for working with leadership of the House of Representatives to reject repeal of the in-office ancillary exception to the Stark law “as an offset for any future legislation.” The goal is to prevent Congress from repealing the exception to help cover the cost of other federal program changes.

“We applaud the House Physicians Caucus for recognizing how integrated, independent medical practices are invigorating competition among health care providers,” said LUGPA President Gary Kirsh, MD.

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