New CMS payment cuts skip imaging to focus on radiation therapy

The U.S. Centers for Medicare and Medicaid Services (CMS) has released proposed payment rates for 2015. The agency's all-powerful gaze skipped over medical imaging to land once again on radiation oncology, which is being targeted for additional payment cuts.

Under the proposed Medicare Physician Fee Schedule (MPFS) for 2015, reimbursement for radiation oncology services would be cut by 4%, while payments to radiation therapy centers would be cut by 8%, according to the document. The cuts come on top of significant payment reductions in recent years.

Why the continued focus on radiation oncology? It could be part of the agency's effort to reduce payments to areas it considers to be overvalued.

Overall, the proposed rule doesn't include further direct attacks on radiology, but the news for radiation oncology and therapy is bad enough, said Cynthia Moran, executive vice president for government relations at the American College of Radiology (ACR). Also, some selected procedures, such as chest x-rays conducted outside of a hospital, will be cut by as much as 6%.

"This is a pre-election sort of rule; CMS isn't going out of its way to make enemies," Moran told AuntMinnie.com. "But it does take a bite out of payments to radiation therapy centers and radiation oncology services."

If adopted into a final rule, the proposal would negatively affect patient care, according to the American Society for Radiation Oncology (ASTRO).

"ASTRO is very concerned by these proposed cuts and their potential impact on patient access to cancer care," the organization said in a statement.

Streamlining mammography

The 2015 MPFS rule also suggests a change for mammography payments: It proposes that G codes for mammography be discontinued beginning in 2015 and that mammography be paid exclusively through existing CPT codes. The G codes were established to pay for digital mammography, while CPT codes have been used to pay for analog. However, since mammography is typically being performed with digital technology, using two sets of codes doesn't make sense.

"We do not believe there is a reason to continue the separate use of the CPT codes and the G codes for mammography services since both sets of codes would have the same values when priced based upon the typical digital technology," CMS wrote.

No news on MPPR, SGR

This rule does not address the multiple procedure payment reduction (MPPR) or the sustainable growth rate (SGR), other than to note that on April 1 President Barack Obama signed a 12-month patch for the SGR. HR 4302 -- the Protecting Access to Medicare Act (PAMA) of 2014 -- replaced a 24% payment cut in physician fees with a 0.5% increase through December of this year and established a 0% update from January 1 to March 31, 2015.

In March, before PAMA was enacted, CMS estimated that physician payment rates in 2015 would decrease 21% after the legislation's terms end. Once again, averting this cut will depend on congressional action.

Taking on transparency

In the new rule, CMS proposes adopting a way of setting payment rates that takes public comment into consideration.

Since MPFS began in 1992, CMS has implemented rates for new payment codes for the following calendar year in the final rule, according to the agency. But under CMS' "misvalued codes" initiative, in which it seeks to correct codes that don't appropriately reflect the costs involved in delivering healthcare services, the agency has begun reviewing rates for existing codes. The new policy will ensure that revisions of misvalued codes go through notice and comment rule-making before being adopted, CMS said.

"We have become concerned about our practice of implementing changes in payment rates under the misvalued codes process prior to an opportunity for public comment ... and [have] been working with the American Medical Association's CPT Editorial Panel and Relative Value Update Committee to change the process for receiving information on new and revised codes," the agency said.

If this policy is finalized, the new process will make sure that, by 2016, changes to payment rates for particular services (excluding entirely new services never before valued under the fee schedule) will be effective only after CMS has responded to public comment.

But CMS has a long way to go toward transparency, Moran said.

"CMS mentions that the Protecting Access to Medicare Act of 2014 requires it to make publicly available data it used to justify the MPPR but doesn't actually disclose anything," she said. "It's like we're waiting for Godot."

Marking misvalued codes

In the document, CMS continues its effort to identify and review potentially misvalued codes, adding about 80 more to its list -- 20 of which relate to imaging, including interventional radiology, MRI, CT, plain x-ray, and radiation oncology.

"We identified most of these by reviewing high-expenditure services by specialty that have not been recently reviewed," CMS said.

PAMA mandates a two-year phase-in for reductions of at least 20% in relative value units (RVUs) for potentially misvalued codes, which CMS will address in future rule-making, the agency said.

The rule also suggests a way to refine how CMS calculates infrastructure costs associated with radiation therapy equipment, ensuring that the way it accounts for these costs would be the same across the fee schedule.

"This change would result in a payment reduction to radiation therapy services to be redistributed to other PFS services," CMS said. "In addition, we are updating our practice expense inputs for x-ray services to reflect that x-rays are currently done digitally rather than with analog film."

How to pay for secondary interpretations?

CMS also addresses the question of whether and under what circumstances it is appropriate for Medicare to pay physicians for providing subsequent interpretations of existing images, and whether uncertainty associated with payment for secondary readings prevents physicians from seeking out, accessing, and using existing images in cases where avoiding a new study would save Medicare money.

"We are seeking comment to assess whether there is an expanded set of circumstances under which it would be appropriate to allow more routine Medicare payment for a second professional component for radiology services, and whether such a policy would be likely to reduce the incidence of duplicative advanced imaging studies," CMS said.

In this proposed rule, the agency seeks feedback on the following questions:

• For which radiology services are physicians currently providing secondary interpretations, and what, if any, policies are in place to determine when existing images are used? To what extent are physicians seeking payment for these secondary interpretations from Medicare or other payors?
• Should routine payment for secondary interpretations be restricted to advanced diagnostic imaging services such as MRI, CT, and nuclear medicine (including PET)?
• How should the value of routine secondary readings be set?
• Although CMS believes most secondary reads take place in the hospital setting, are there other settings in which claims for secondary interpretations would be likely to reduce duplicative imaging services?
• Is there a limited time period within which an existing image should be considered adequate to support a secondary interpretation?
• Would allowing for more routine payment for secondary interpretations be likely to generate cost savings to Medicare by avoiding potentially duplicative imaging studies?

The proposed rule will be published in the Federal Register on July 11. CMS will accept comments on it until September 2, and it plans to post the final rule on November 1.

"There's no direct attack on radiology here, like we've had in the past," Moran said. "But still, they're kind of nickel and diming us to death."