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Upcoming RUC Survey

In the next few weeks we will be contacting a random selection of members to participate in an important AMA/Specialty Society Relative Value Scale Update Committee (RUC) survey of physician work for codes 64633-64636 which describe destruction of facet joints. The Medicare payment schedule is based on physician work, practice expense and professional liability insurance. Our specialty needs your help to assure relative values will be accurately and fairly presented to the Centers for Medicare and Medicaid.  

AAPM is conducting this survey for the RUC in partnership with several other medical specialties including the American Academy of Physical Medicine and Rehabilitation, American Society of Anesthesiologists, and the Spine Intervention Society. If you are a member of one or more of these additional societies, you may see a survey request from them (rather than from AAPM). In such instance, we ask that you treat their request as similarly vital. We will compile all relevant survey data from the partnering societies for our presentation to the AMA RUC.

The survey is being conducted at the request of the RUC and stems from issues related to budget neutrality. As part of the RUC process, specialty societies must provide an estimated utilization for any new or revised family of codes. CMS productivity data dating back to 2014 identified concerns related to the use of the add-on codes that identify each additional joint treated. The possibility of incorrect coding of per nerve instead of per joint was discussed and a CPT Assistant article was published in February 2015. Changes were made to the 2016 CPT guidelines for this group of codes clarifying the correct reporting of the add-on codes. The RUC allowed time for these efforts to take effect and reviewed the utilization data again in October 2019. The Relativity Assessment Workgroup (RAW) of the RUC noted that the growth in these services is appropriate as patient population requiring these services has grown. However, due to the extensive growth and original incorrect assumptions about distribution of reporting, the Workgroup determined that a new survey is required.

If you receive a request to survey these codes, please remember your input in this survey is vital. The specialty societies ability to impact the work recommendations is dependent on robust and meaningful data. If you have any questions, please contact Emily Hill, AAPM Coding and Reimbursement Liaison, at: [email protected].

CMS Issues Final Rule for Physician Fee Schedule for 2020

The Centers for Medicare & Medicaid Services (CMS) issued its Final Rule for 2020 that that includes proposals to update payment policies, payment rates, and quality provisions for services furnished under the Medicare Physician Fee Schedule (PFS). As proposed, the 2020 PFS conversion factor is $36.09 which is $0.05 above the 2019 conversion factor. The conversion factor is multiplied by the total adjusted Relative Value Units (RVUs) to achieve a payment amount for the services included in the Medicare Physician Fee Schedule.

 The Final Rule also addresses public comments submitted in response to the Proposed Rule released in July. AAPM provided written comments to several areas of importance to Pain Medicine physicians that were outlined in the September 25 AAPM E-News.

AAPM specifically addressed the practice expense inputs for the new genicular injection and RFA codes (codes 64624 and 64454). CMS had proposed a decrease in the AMA/Specialty Society Relative Value Update Committee (RUC) recommended practice expense inputs for these services. The Proposed Rule included only one cannula and one RF kit for code 64624. After consideration of comments submitted by AAPM and others, CMS agreed to increase the number of cannula and kits from one to three. This change also resulted in acceptance of the RUC recommended equipment time which was also decreased in the Proposed Rule. AAPM also opposed the CMS change to the recommended work RVUs (wRVU) for the RFA code. Unfortunately, CMS did not accept the submitted comments, therefore the wRVU for code 64624 (Destruction by neurolytic agent genicular nerve branches including imaging guidance, when performed) will be 2.50 rather than 2.62 as recommended by the RUC.

Similarly, CMS proposed decreases in the practice expense inputs for the new codes for sacroiliac injection and RFA (codes 64451 and 646250. The Final Rule considered the AAPM submitted comments and increased the number of spinal needles included in the PE from 3 to 4 and accepted the RUC recommended equipment time for these services.

AAPM and other societies responded to the CMS proposal to decrease the RUC recommended wRVUs for many of codes in the revised family of somatic nerve injections. Despite the comments and rationales provided by several societies, CMS is maintaining the wRVUs as outlined in the July Proposed Rule.

Of other interest, CMS confirmed its plan to align its E/M coding with changes adopted by the American Medical Association (AMA) Current Procedural Terminology (CPT) Editorial Panel for office/outpatient E/M visits. Further, it accepted the RUC recommended work values for these services. These changes will not be incorporated until 2021.

CMS is also finalizing broad modifications to its documentation policy so that physicians, physician assistants, and advanced practice registered nurses can review and verify (sign and date), rather than re-documenting, notes made in the medical record by other physicians, residents, physician assistants, and APRN students, nurses, or other members of the medical team.

AAPM is hosting a webinar that will review these areas and other important payment policies that impact Pain Medicine practices, as well as a review of the CPT and ICD-10 changes for 2020. The webinar “Preparing for 2020: Update on Coding and CMS Policy Changes” will be held on December 11 at 2-3PM CT. Registration information can be found here.

The CMS fact sheet on the Final Rule can be accessed here. The complete Final Rule can be accessed here.

Understanding CPT, RUC and the 2020 Proposed Rule

This article provides additional information on the background and processes used to value services in the Proposed Rule for the 2020 Physician Fee Schedule, including the advocacy efforts with CMS and RUC by AAPM and other specialty societies representing pain medicine physicians. The Proposed Rule recommends 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). The article also reviews the issues surrounding the other services addressed in the Proposed Rule. 

Understanding CPT, RUC and the 2020 Proposed Rule

This article provides additional information on the background and processes used to value services in the Proposed Rule for the 2020 Physician Fee Schedule, including the advocacy efforts with CMS and RUC by AAPM and other specialty societies representing pain medicine physicians. The Proposed Rule recommends 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). The article also reviews the issues surrounding the other services addressed in the Proposed Rule.

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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American Academy of Pain Medicine