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Understanding CPT, RUC and the 2020 Proposed Rule

The Proposed Rule for the 2020 Physician Fee Schedule proposes values for intrathecal/epidural pump procedures (CPT codes 62367-62370), the new codes for injection and ablation of genicular nerves (temporary CPT 64XX0 and 64XX1) and sacroiliac joint (temporary CPT 6XX00 and 6XX01), and somatic nerve injections (CPT codes 64405, 64418, 64420, 64421, 64425, 64430, and 64450).

AAPM members report they have been contacted by industry regarding the proposed 2020 Medicare payment for analysis, programming, and refilling of implantable infusion pumps and the new code for radiofrequency ablation of the genicular nerves (temporary code 64XX1). The information below is intended to provide additional information about the background and the processes used to value services in general and these services in particular. The issues surrounding the other services addressed in the Proposed Rule are also reviewed.

Services on the Physician Fee Schedule are assigned relative value units (RVUs) based on three components: physician work, practice expense, and professional liability. Specialty societies and their members provide direct input into the first two components through surveys designed to capture the work involved in performing a service and the staff labor, supplies and equipment costs required. CPT codes and the resulting RVUs are intended to reflect the service as provided to the typical patient. This includes associated work and costs that occur before, during, and after the service (known as pre-service, intra-service and post-service work). Survey respondents are asked to indicate the time it takes to perform the service and to compare the time and intensity to other services they provide. The intra-service time reflected in the surveys is a significant factor in the work and practice expense values assigned. Survey respondents also are asked to indicate any additional services provided at the same encounter. CMS provides claims data to identify services typically reported together to avoid over-lap in work or practice expense between the services. This information, along with the findings from the physician surveys, are considered by the RUC (AMA/Specialty Society RVS Update Committee) when making recommendations on code values to CMS.

AAPM helps avoid cuts to for pump procedures

In the case of codes 62367-62370, CMS data indicated a change in the specialty providing these services from the specialty involved in the original survey. The interested specialty societies, including AAPM, convinced the RUC that the physician work was unchanged based on a recent survey of code 62369 (Electronic analysis of programmable, implanted pump for intrathecal or epidural drug infusion (includes evaluation of reservoir status, alarm status, drug prescription status); with reprogramming and refill and adjustments made at the time to the family of codes. Therefore, a survey of physician work was not required thus avoiding a potential revaluation of these codes. Under CMS and RUC rules, an increase in work RVUs (wRVU) for an existing service can only occur if the specialty societies provide "compelling evidence" that an increase is warranted. The compelling evidence criteria are difficult to meet and require more than survey findings alone.

Although there was not a requirement to survey work, the RUC did request a review of the practice expense (PE) inputs which had not been recently reviewed. For the PE inputs, AAPM and societies representing areas of pain management submitted to the RUC the clinical activities, supplies and equipment necessary to provide these services. The PE inputs include clinical labor time required for very specific activities provided in the pre-, intra, and post-service times. The process assigns standard times for the activities that are common to services across the Physician Fee Schedule. Specialty societies must be able to identify unique clinical circumstances before deviations from these standard times are made. CMS data also revealed that some services in this family were typically reported in conjunction with an E/M code. When these circumstances are identified, adjustments are made to the pre- and post-times assigned to clinical labor. Therefore, in addition to a review of all clinical activities identified by the specialty societies, adjustments were made to the pre- and post-time assigned to clinical labor based on the overlap of the pre- and post- activities between E/M services and some of the procedure codes. Likewise, any supplies included in both the E/M and the procedure must be removed to avoid duplication of payment.

Practice expense decreases

Unfortunately, the review resulted in a decrease in reimbursement based on the required PE adjustments. AAPM and other societies representing pain medicine physicians would have preferred to avoid the review and therefore the decreases. However, participation in the RUC process requires that AAPM and other specialty societies, adhere to the guidelines agreed upon by the RUC participants and the underlying principles of RBRVS. Not participating in the process would result in no direct involvement in the valuation of these or future services under the CMS Physician Fee Schedule.

In May 2018, the CPT Editorial Panel approved the addition of two codes to report injection of anesthetic and destruction of genicular nerves by neurolytic agent: 64XX0 (Injection(s), anesthetic agent(s) and/or steroid; genicular nerve branches including imaging guidance, when performed), and 64XX1 (Destruction by neurolytic agent genicular nerve branches including imaging guidance, when performed). These codes as well as another code in the family, 64640 (Destruction by neurolytic agent; other peripheral nerve or branch), were reviewed and discussed at the October 2018 and January 2019 RUC meetings. AAPM was involved in the survey process and presentation of these codes at the RUC and is providing comments to CMS on the proposed values.

As explained above, RUC recommendations are based on survey data submitted by specialty societies and comparisons to other services across the Fee Schedule. Four specialty societies, including AAPM, participated in the survey process for the genicular injection and RF ablation codes. The survey response rate was low with only 71 responses for the RF ablation code 64XX1 despite sending requests to hundreds of physicians to participate in the survey process. AAPM alone sent requests to 500+ members.

AAPM advocates at CMS for RUC-recommended codes

CMS accepted the RUC recommended work values for codes 64640 and 64XX0 however it did not accept the RUC value (2.62 wRVU) for 64XX1. CMS is proposing 2.50 wRVU. In the letter to CMS, AAPM protests the CMS methodology and rationale used to justify the decrease in wRVU and reiterates its support of the RUC recommended comparison code with similar times and intensity.

Industry has indicated that the proposed wRVU for this service represents a reduction in current reimbursement. It should be noted there have not been specific CPT codes for genicular injections or RF ablation. Any code(s) used to report these services was never valued for genicular procedures and was often reported multiple times for a single procedure. It was also reported that at least one company informed clients new CPT codes had been developed for "cooled RF". This was erroneous information. CPT codes are not developed for a specific brand or special technique for a procedure. Further, the majority of survey respondents indicated they utilized conventional RF when performing these services. Therefore, the PE inputs were based on conventional RF rather than the higher PE inputs that would be attributed to "cooled RF".

CMS has also proposed a change in PE inputs for code 64XX1 by refining the quantity of the cannula from 3 to 1 based on the assumption that the procedure would typically entail sequential ablation of the nerves utilizing a single cannula. This assumption also impacts the equipment time allotted for this service. AAPM strongly disagrees with these refinements and has provided a detailed explanation of standard practice and required supplies and equipment for performing this procedure to CMS.

CMS has also proposed refinements in the PE inputs for the new codes for sacroiliac injection (Temporary CPT 6XX00 (Injection(s), anesthetic agent(s) and/or steroid; nerves innervating the sacroiliac joint, with image guidance (ie, fluoroscopy or computed tomography))and RF ablations (Temporary CPT 6XX01 (Radiofrequency ablation, nerves innervating the sacroiliac joint, with image guidance (ie, fluoroscopy or computed tomography)). More specifically, CMS has proposed reductions in the number of needles and cannulas recommended by the RUC. As with the genicular codes, AAPM is providing a detailed explanation of the services and urging CMS accept the RUC recommendation.

The family of somatic nerve injections (CPT codes 64400, 64408, 64415, 64416, 64417, 64420, 64421, 64425, 64430, 64435, 64445, 64446, 64447, 64448, 64449, and 64450) was recently revised by CPT and subsequently reviewed by the RUC. AAPM participated in the CPT and RUC processes for codes 64405, 64418, 64420, 64421, 64425, 64430, and 64450.

CMS accepted the recommended wRVUs for codes 64405, 64418, and 64450 but proposed changes to work values for codes 64420, 64421, 64425 and 64430. CMS also proposed changes to the time associated with one of the PE inputs associated with several of the codes. In the response letter to CMS, AAPM provided supporting arguments for the RUC recommendations and urged CMS to accept the RUC recommended wRVUs and PE inputs for these codes.

Following review of all comments, CMS will release a Final Rule in November finalizing payment rates and policies for 2020. AAPM will apprise members of the provisions of importance to pain medicine physicians and practices.

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