The Society submitted comments to the Centers for Medicare & Medicaid Services on the 2013 Medicare Physician Fee Schedule Final Rule issued in November 2012. In the comment letter, the Society raises concerns about CMS’s decision to assign a reduced work value to two new ablation add-on codes, despite recommendations to the contrary from the Relative Value Scale Update Committee (RUC). Read the full comment letter to CMS.

Background

On November 1, 2012, the Centers for Medicare & Medicaid Services (CMS) issued two final rules that update payment policies and payment rates for services furnished under the Medicare Physician Fee Schedule (MPFS) and for hospital outpatient departments (HOPDs) and ambulatory surgical centers (ASCs) on or after January 1, 2013.

The physician payment rule adjusts payments for cardiac diagnostic testing, and implements the addition of new codes as well as modifications to quality reporting and improvement program. HRS submitted comments on the proposed rule in the rule-making process. View the summary of how CMS responded to each of the Society's concerns in the final rule.

As part of the ongoing effort to evaluate potentially misvalued services, new CPT codes have been created to bundle electrophysiology (EP) services with ablation. CMS also reduced payment to the family of EP/ablation codes. The Society is working with other medical specialty societies to address these flawed decisions. The Heart Rhythm Society hosted a webinar Monday November 19 that reviewed the coding changes to the family of EP/ablation codes and provided an extensive overview of the intricacies of medical record documentation for heart rhythm care services. 

In addition, in a separate rule for hospital payment outpatient departments and ambulatory centers, CMS finalized a number of changes to payments and programs that impact the delivery of heart rhythm care. For more information, view the comprehensive summary of the HOPDs and ASCs final rule. 

Both rules contain issues related to EP practice. Changes affecting EP practice include the valuation of the new codes for ablation services, application of the multiple procedure payment reduction for some cardiology diagnostic services, a recommendation to re-value the codes for Implantable Loop Recorder implant and explant procedures, revisions to the application of the Physician Quality Reporting System, and the upcoming 26.5 percent cut to the Medicare Sustainable Growth Rate (SGR).

Highlights of the MPFS:  

Sustainable Growth Rate
The SGR is an economic impact calculation used to annual set the conversion factor; the dollar figure that translates the Medicare Fee Schedule's relative values into a payment amount. The statutorily required update for 2013 results in a 26.5 percent across-the-board cut in Medicare fees based in a conversion factor of $25.008. However, Congress has overridden the required reduction every year since 2003.

In addition, since this is the last year of the four-year transition to the methodology for calculating practice expense relative value, and the impact other her specialties' new/revised codes, CMS projects an overall 2 decrease decrease in fees for cardiology services.

Re-Valuation of ILR Procedures
CPT codes 33282 (Implantation of patient-activated cardiac event recorder) and 33284 (Removal of an implantable, patient-activated cardiac event recorder) were nominated for review as potentially misvalued codes. An entity—not HRS—asserted to CMS that the codes are misvalued in the nonfacility setting because they currently are only priced in the facility setting. The commenter requested that the Agency establish appropriate payment for the services when furnished in a physician office. While CMS does not believe that the codes are mis-valued, they are recommending that the AMA/Specialty Society Relative Value Scale Update Committee (RUC) review the codes' work and practice expanse relative values. HRS objected to the commenter's request in its August letter to CMS and will be working with the RUC to address this issue.

Multiple Procedure Payment Reduction
Medicare has a longstanding policy to reduce payment for the second and subsequent surgical procedures performed on the same patient by the same physician or physician group practice on the same day, largely based on presumed efficiencies in the practice expense (PE) and pre- and post-surgical physician work. For CY 2013, CMS will apply a multiple procedure payment reduction policy to the technical component of certain cardiovascular diagnostic services. CMS proposed to make full payment for the highest paid cardiovascular diagnostic service and reduce the technical component payment for subsequent cardiovascular or ophthalmological diagnostic services furnished by the same physician or group practice to the same patient on the same day by 25 percent.  

HRS objected to this plan during the proposed rule's comment period noting that different types of staff and equipment are utilized over the course of a patient's evaluation. Despite our comments, and those submitted by the American College of Cardiology (ACC), the Society for Cardiovascular Angiography and Interventions (SCAI) and others, CMS adopted the plan. CY 2013 proposal to apply an MPPR to the TC of diagnostic cardiovascular and ophthalmology services, with a modification to apply a 20 percent reduction for diagnostic ophthalmology services rather than the 25 percent reduction proposed. The reduction percentage for diagnostic cardiovascular services remains at 25 percent, as proposed. HRS will continue to fight this plan.

Valuation of New Codes for EP Study/Ablation Procedures CPT codes 93651 and 93652 (ablation services) were identified as potentially misvalued since they were billed with EP studies greater than 75 percent of the time. The CPT Editorial Panel deleted CPT codes 93651 and 93652, and replaced them with new CPT codes 93653 through 93657 for CY 2013.
CMS reviewed the new codes and agreed with most of HRS/ACC's work relative value recommendations. HRS will be working with the RUC to push for acceptance of our survey recommendations.

CMS states the following regarding the values and their ultimate decision about the codes' valuation:

• 93653 (Comprehensive electrophysiologic evaluation including insertion and repositioning of multiple electrode catheters with induction or attempted induction of an arrhythmia with right atrial pacing and recording, right ventricular pacing and recording, his recording with intracardiac catheter ablation of arrhythmogenic focus; with treatment of supraventricular tachycardia by ablation of fast or slow atrioventricular pathway, accessory atrioventricular connection, cavo-tricuspid isthmus or other single atrial focus or source of atrial re-entry),
• 93654 (Comprehensive electrophysiologic evaluation including insertion and repositioning of multiple electrode catheters with induction or attempted induction of an arrhythmia with right atrial pacing and recording, right ventricular pacing and recording, his recording with intracardiac catheter ablation of arrhythmogenic focus; with treatment of ventricular tachycardia or focus of ventricular ectopy including intracardiac electrophysiologic 3d mapping, when performed, and left ventricular pacing and recording, when performed), and
• 93656 (Comprehensive electrophysiologic evaluation including transseptal catheterizations, insertion and repositioning of multiple electrode catheters with induction or attempted induction of an arrhythmia with atrial recording and pacing, when possible, right ventricular pacing and recording, his bundle recording with intracardiac catheter ablation of arrhythmogenic focus, with treatment of atrial fibrillation by ablation by pulmonary vein isolation).

CMS believes that the survey 25th percentile work RVUs of 15.00 for CPT code 93653, 20.00 for CPT code 93654, and 20.02 for CPT code 93656 accurately accounts for the work involved in furnishing these services. The AMA RUC recommended these values as well, with 180 minutes of intra-service time for CPT code 93653, and 240 minutes of intra-service time for CPT codes 93654 and 93656. CMS agreed with these values.

Accordingly, CMS is assigning a work RVU of 15.00 for CPT code 93653, a work RVU of 20.00 for 93654, and a work RVU of 20.02 for CPT code 93656, with no refinements to the AMA RUC-recommended time, on an interim final basis for CY 2013.

After reviewing CPT codes:

• 93655 (Intracardiac catheter ablation of a discrete mechanism of arrhythmia which is distinct from the primary ablated mechanism, including repeat diagnostic maneuvers, to treat a spontaneous or induced arrhythmia [list separately in addition to code for primary procedure]) and
• 93657 (Additional linear or focal intracardiac catheter ablation of the left or right atrium for treatment of atrial fibrillation remaining after completion of pulmonary vein isolation [list separately in addition to code for primary procedure]),

CMS believes these CPT codes have a very similar level of intensity as their related base codes: CPT codes 93653, 93654, and 93656. CPT codes 93653, 93654, and 93656 are all valued at 5.00 RVUs per 1 hour of intraservice time. CMS believes this is the appropriate increment for CPT codes 93655 and 93657 as well, which include 90 minutes of intra-service time. Therefore, CMS believes that a work RVU of 7.50 accurately accounts for the work of these services and reflects the appropriate relativity within this family of CPT codes. The AMA RUC recommended a work RVU of 9.00 for CPT code 93655 and a work RVU of 10.00 for CPT code 93657. CMS is assigning a work RVU of 7.50 to CPT codes 93655 and 93657 with no refinements to the AMA RUC-recommended time, on an interim final basis for CY 2013.

For more information, read the comprehensive summary of the Medicare Physician Fee Schedule final rule.