American Society of Hematology

Physician Payment Advocacy Highlights for 2012

Published on: November 14, 2012

ASH has been very active on physician payment issues during 2012. Following the passage of the Affordable Care Act, there is a recognition that the delivery of healthcare services is changing and the reimbursement system must change with it. ASH along with the American Medical Association and other medical and surgical specialty societies have advocated repeatedly for the elimination of the archaic formula known as the SGR that subjects physicians to potential cuts in reimbursement on an annual basis. In addition, ASH has advocated that cognitive specialists, such as hematologists, should be provided enhanced payments similar to those provided to primary care physicians as they often serve as the principle if not primary care provider of patients with rare bleeding disorders. This year, ASH has also been an active participant in CPT Coding and Relative Value Update Committee (RUC) processes for services of particular interest to ASH members including Bone Marrow Harvesting and Transplant services and infusion services as well as providing CMS with recommendations on standards for utilization of blood and blood products, clotting factors, anti-emetics and other cancer treatments. ASH continues to provide input to CMS both nationally and locally on coverage policies related to the treatment of patients with bleeding disorders. Highlights of ASH physician payment advocacy are described below.

Medicare Reimbursement for Physician Services 

While Medicare annually updates payment rates for inflation for most provider services, physician services are updated by a formula mandated in legislation known as the Sustainable Growth Rate (SGR). "Patching" the SGR has become an annual exercise in Congress, and with each "patch," the potential cuts facing physicians continue to grow. The most recent scheduled cut, on March 1, 2012 was to have been 27.4 percent. Congress averted the scheduled reduction in physician fees by passing a 10-month extension of current physician payment rates and now has until January 1, 2013 to develop a longer-term solution to this problem or physicians again will face a 26.5 percent reduction in payment. ASH will continue to advocate for repealing the SGR and replacing it with a predictable and stable system for updating fees to fully and realistically account for the costs of operating a medical practice.  

Congressional Consideration of Long-Term Physician Reimbursement Strategies  

The three congressional committees with jurisdiction over the Medicare program have been evaluating options and funding mechanisms for repealing the SGR and finding a more permanent strategy for reimbursing physician services under Medicare. At the end of April, the Committee on Ways and Means' Republican Members sent a letter to the major medical specialty societies, including ASH, seeking input on a "permanent, fiscally responsible solution to the SGR." ASH provided the Committee with a comprehensive response seeking the repeal of the SGR and recognition of and enhanced payment for cognitive specialists.

Enhanced Payment for Cognitive Services 

ASH actively advocated for making cognitive specialists, including hematologists, eligible for enhanced payment proposals historically limited to primary care providers. ASH is pleased to report that CMS has proposed payment for two new codes for transitional care management (TCM) services provided to patients being discharged from acute, rehabilitation, or long-term acute hospital stays into the community. Primary care providers and specialists can bill these for new services within 30 days following discharge. In addition, a recent Medicaid rule implementing a provision of the Affordable Care Act was released stipulating that Medicaid reimbursement for certain primary care services equal Medicare rates in 2013 and 2014. Subspecialists, including pediatric and adult hematologists, who are board-certified in family medicine, internal medicine or pediatrics will be eligible, resulting in increased payments for adult and pediatric hematologists. Physicians will have to attest to their board certification or show that 60 percent of all Medicaid services that they bill, or provide in a managed care environment, are for the specified E&M services. The federal government will reimburse states 100 percent of the difference between the states' 2009 payment rate and the Medicare rate for 2013 and 2014.

Coding, RUC, and Medicare Payment Policies for Hematology-Specific Services 

ASH is an active participant in the AMA's CPT Coding and Relative Value Update Committee (RUC) activities. Dr Sam Silver, ASH's CPT and RUC representative along with ASH staff and consultants have successfully advocated for improvements in coding and payment for hematology services.

  • Bone Marrow Harvesting and Transplantation Codes – ASH joined with ASBMT to request two separate codes for bone marrow harvesting (for allogeneic and autologous transplants) and to revise the bone marrow transplantation CPT codes. ASH and ASBMT were successful in having the codes valued at the RUC, but CMS reduced the work values for the harvesting codes in the 2012 fee schedule. In 2012, ASH submitted comments on the bone marrow harvesting codes to CMS explaining the time and intensity of the work involved and the potential risks to patients and participated in a call with CMS on the need to revise these values. In the recently published Medicare Physician Fee Schedule for 2013, CMS accepted increased values for all of the bone marrow harvesting and transplantation codes, providing a payment increase of 12 percent for the harvesting codes and over a 30 percent increase for the transplantation codes.
  • Infusion Codes - Over the past few years, CMS has identified a number of codes for reexamination by the RUC on the grounds that they are potentially mis-valued. Two families of infusion codes have been targeted for review by CMS this year: chemotherapy infusion codes (96413, 96415 and 96417) and Codes for IV infusion for therapy, prophylaxis or diagnosis (96365, 96366, 96367 and 96368). Both the professional work and practice expenses assigned to these codes will be reexamined.

    ASH and ASCO, along with the societies for Infectious Disease and Rheumatology are surveying its members on the professional work for these services and representatives of the societies participated in a day-long meeting to reach agreement on the practice expense inputs – clinical staff, supplies and equipment. The societies' recommendations for these codes will be presented at the RUC meeting in January and CMS will determine the final relative values for the services to take effect in 2014.
  • Medicare's Medically Unlikely Edits (MUEs) Throughout the year, ASH was contacted by a contractor for CMS, the National Correct Coding Initiative (NCCI) to advise them on proposals to set limits on the number of units of treatments for certain hematologic disorders. NCCI seeks input from medical societies on an as-needed and confidential basis prior to submitting its recommendations to CMS. CMS institutes these limits as a measure of what it considers to be medically necessary usage and believes that imposing such limits will prevent fraud and abuse when Medicare is billed for a volume of services exceeding the edit. The specific limit (i.e., how many units) cannot be disclosed to providers, as CMS believes that if the edits were disclosed, some providers would routinely bill at the established threshold.

    ASH provided recommendations to the NCCI on several categories of MUEs including blood and blood products, oral cancer and anti-emetic drugs and clotting factor therapies. NCCI accepted some, but not all of ASH's recommendations. The new limits are known as Medically Unlikely Edits or MUE's and apply to treatments and services provided in the hospital outpatient and ambulatory/physician office settings. Since ASH expressed concerns that the MUEs could result in denials of medically necessary claims, especially for clotting factor treatments provided by hemophilia treatment centers, the NCCI offered strategies for coding and agreed to assist treatment centers with appeals. ASH sent a letter to the Medical Directors of the hemophilia treatment centers in the US with this information.

Medicare Coverage Policies 

As Medicare continues to seek an evidence-basis for coverage of new services and treatments, ASH will respond to CMS requests for public comment on national coverage decisions. This year ASH wrote a letter in support of an NCCN request to expand coverage for Aprepitant for chemotherapy-induced emesis. While CMS has expanded its national coverage determinations, many coverage decisions continue to be made at the contractor or local level. ASH also assists members directly with local coverage problems. Staff is currently working with the Practice Committee leadership and several specialists to improve coverage of interferon for Myeloproliferative Neoplasms, especially for Polycythemia Vera.

Analysis of Medicare and Medicaid Regulations and Legislation Impacting Practice 

ASH staff and its consultants prepare and disseminate detailed analysis of the major regulations and legislation impacting hematologists. ASH provides its members with detailed analysis of the major Medicare regulations showing payment rates for hematology-related procedures and evaluation and management services provided in the physician office and hospital inpatient and outpatient settings. ASH sends out a bi-weekly practice update to keep practicing physicians updated to constant changes to the federal reimbursement programs.

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