The Issue
Overview of the Rule
- Practice expense
- Bundled codes for myocardial perfusion / SPECT imaging
- Consultations
- Malpractice
- Equipment utilization
- Sustainable growth rate
Practice expense
CMS has chosen to incorporate the results of the American Medical Association's Physician Practice Information Survey into its formula for calculating practice expense relative value units (RVUs). In a slight change from the proposed rule, the agency has said the cuts will be phased in over a four-year period versus all at once. With the exception of evaluation and management services, nearly all services that cardiologists perform will see cuts ranging from 10 percent to more than 40 percent for individual services phased in over four years. A few key examples for 2010 alone:
- SPECT Myocardial Perfusion Imaging (78452) – 36 percent cut
- Transthoracic echo with spectral and color flow Doppler (93306) – 10 percent cut
- Coronary Stent (92980) – 4 percent cut
- EKG (93000) – 5 percent cut
- Level 4 established patient office visit (99214) – 7 percent increase
Bundled codes for myocardial perfusion / SPECT imaging
CMS's continued pressure to bundle together imaging services reported with multiple codes has now hit myocardial perfusion imaging. In 2010 myocardial perfusion imaging / SPECT studies including wall motion and ejection fraction will be reported with a single code. CMS decided to substantially reduce the payment for myocardial perfusion imaging as part of this rule by reducing both the physician work value and the practice expense value. To make matters worse, because there is a new code for the service, CMS apparently is not applying the four-year transition of the practice expense cuts and instead is using the fully implemented value. The result is a 36 percent cut in payment for 2010. This change alone accounts for more than one-third of the projected payment cut to cardiology.
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Consultations
Payments for consultations provided in office and hospital settings are eliminated under the final rule. The RVUs assigned to these codes will be redistributed to office and hospital visits, and services now billed as consultations will be billed as hospital or office visits. This will reduce payments to varying degrees for consultation services.
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Malpractice
CMS has chosen to update the malpractice RVUs with data from a new survey of specialty-level malpractice premiums. In addition, CMS has proposed a new method for determining malpractice RVUs for technical component services. The proposed new malpractice RVUs would reduce cardiology payments by 1 percent. However, the impact will vary depending on the mix of services provided.
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Equipment utilization
CMS has finalized its proposal to change the agency's formula for calculating the per-procedure cost of diagnostic medical equipment worth more than $1 million. The proposal would assume that all diagnostic equipment with an acquisition cost greater than $1 million is used 90 percent of the time an office is open, thus driving down the practice expense RVUs for services using that equipment. Within cardiology, cardiac MR and cardiac CT services will be subject to payments set based on this utilization assumption. CMS did agree not to apply this cut to equipment for non-hospital cardiac catheterization services.
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Sustainable growth rate
As required by current law, the final rule includes a 21.5 percent reduction in Medicare physician ayment as of January 1, 2010. This cut is in addition to the payment reductions that result from the proposed policy changes described above. In short, there could be as high as a 30 percent cut in Medicare payments for cardiology. However, as in previous years, Congress is expected to pass a one-to-two-year fix in the coming weeks. CMS did finalize its proposal to remove physician-administered drugs from the accumulated SGR debt, which makes a fix to SGR less expensive.
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