RUC and CPT Update: Coding and Reimbursement Changes in 2014
It is critical that Academy members keep in mind that maintaining value for otolaryngology-head and neck surgery services is an enormous success in light of the rigorous review and cost-saving focus of the AMA Relative Update Committee (RUC), MedPAC and the Centers for Medicare & Medicaid Services (CMS). While Otolaryngology will see some minor reductions in reimbursement for some services in CY 2014, we are pleased that for many of the new codes presented to the AMA RUC in late 2012-2013, the assigned relative value units (RVUs) are higher than the previously reported CPT codes for that work. Specifically, all six of the new rigid, transoral esophagoscopy codes will be reimbursed substantially higher than the previously reported 43200 code series. Academy Collaboration with other Specialty Societies Specific fluctuations in reimbursement for the services reviewed by the AMA RUC, and subsequently CMS, are outlined within the table following this article. The Academy participated either directly, or via comment and/or monitoring, in the development of recommendations to the AMA RUC for all of the following procedures. For several codes, such as the esophagoscopy family of codes, the Academy was asked to collaborate with other specialty societies (e.g. American Gastroenterological Association, Society of American Gastrointestinal and Endoscopic Surgeons, and the American Society for Gastrointestinal Endoscopy) to develop relative value and practice expense recommendations. Recommendations for all these codes were then reviewed by the AMA RUC and either approved or modified from the Academy’s original recommendations via the AMA RUC survey process. CMS is then presented with the AMA RUC’s value recommendations and may either approve or modify the physician work values and direct practice expense inputs for these services. They then post their final determinations in the final Medicare physician fee schedule (MPFS) each year. What were the Key Factors in Assigning Values for CY 2014? Members should remember that for CY 2014, several factors led to the modified values for all physician services, including lower times reported by members on their RUC surveys for certain procedures reviewed in CY 2013, recommended reductions in value by the AMA RUC for some services, CMS’ decision to revise the Medicare Economic Index (which reduced practice expense RVUs for services with high practice expense costs), and CMS’ modification (additions and subtractions) to the direct practice expense inputs for several services reviewed by the RUC in 2013. In sum, these policy changes result in the RVUs reflected below for CY 2014. For detailed information on the MEI policy or other specific modifications made by CMS in the final rule, access the Academy’s full 2014 MPFS summary on our website at http://bit.ly/CMSregs. Academy Next Steps The table below reflects the approved values by CMS for CY 2014. Notably, CMS elected to modify several of the AMA RUC’s recommended values for ENT services reviewed. The Academy is actively reviewing CMS’ detailed rationale for changes to both physician work RVUs, as well as practice expense direct inputs and clinical staff time associated with these services. Additional detail on these modifications by CMS will be captured in the February 2014 Bulletin, which will include the summary of the 2014 MPFS. The Academy plans to comment to CMS directly on areas of concern related to their modifications to RVUs for CY 2014 via our comment letter on the 2014 final MPFS, which are due by January 27, 2014. We also are in the process of arranging an in-person meeting with the Agency to discuss their alteration of RVUs for ENT services for CY 2014. It is our hope that as in years past, these direct discussions with CMS will help to achieve corrections and modifications to the RVUs for otolaryngology services that we believe are mis-valued or undervalued. Members should note, however, that any revisions to values would not take effect until the CY 2015 final rule due to statutory rulemaking requirements CMS must adhere to. In the event members have questions regarding the above information or modifications to specific codes, please contact us at healthpolicy@entnet.org.
Academy Collaboration with other Specialty Societies
Specific fluctuations in reimbursement for the services reviewed by the AMA RUC, and subsequently CMS, are outlined within the table following this article. The Academy participated either directly, or via comment and/or monitoring, in the development of recommendations to the AMA RUC for all of the following procedures. For several codes, such as the esophagoscopy family of codes, the Academy was asked to collaborate with other specialty societies (e.g. American Gastroenterological Association, Society of American Gastrointestinal and Endoscopic Surgeons, and the American Society for Gastrointestinal Endoscopy) to develop relative value and practice expense recommendations. Recommendations for all these codes were then reviewed by the AMA RUC and either approved or modified from the Academy’s original recommendations via the AMA RUC survey process.
CMS is then presented with the AMA RUC’s value recommendations and may either approve or modify the physician work values and direct practice expense inputs for these services. They then post their final determinations in the final Medicare physician fee schedule (MPFS) each year.
What were the Key Factors in Assigning Values for CY 2014?
Members should remember that for CY 2014, several factors led to the modified values for all physician services, including lower times reported by members on their RUC surveys for certain procedures reviewed in CY 2013, recommended reductions in value by the AMA RUC for some services, CMS’ decision to revise the Medicare Economic Index (which reduced practice expense RVUs for services with high practice expense costs), and CMS’ modification (additions and subtractions) to the direct practice expense inputs for several services reviewed by the RUC in 2013.
In sum, these policy changes result in the RVUs reflected below for CY 2014. For detailed information on the MEI policy or other specific modifications made by CMS in the final rule, access the Academy’s full 2014 MPFS summary on our website at http://bit.ly/CMSregs.
Academy Next Steps
The table below reflects the approved values by CMS for CY 2014. Notably, CMS elected to modify several of the AMA RUC’s recommended values for ENT services reviewed. The Academy is actively reviewing CMS’ detailed rationale for changes to both physician work RVUs, as well as practice expense direct inputs and clinical staff time associated with these services. Additional detail on these modifications by CMS will be captured in the February 2014 Bulletin, which will include the summary of the 2014 MPFS.
The Academy plans to comment to CMS directly on areas of concern related to their modifications to RVUs for CY 2014 via our comment letter on the 2014 final MPFS, which are due by January 27, 2014. We also are in the process of arranging an in-person meeting with the Agency to discuss their alteration of RVUs for ENT services for CY 2014. It is our hope that as in years past, these direct discussions with CMS will help to achieve corrections and modifications to the RVUs for otolaryngology services that we believe are mis-valued or undervalued. Members should note, however, that any revisions to values would not take effect until the CY 2015 final rule due to statutory rulemaking requirements CMS must adhere to.
In the event members have questions regarding the above information or modifications to specific codes, please contact us at healthpolicy@entnet.org.