CMS' physician fee final rule includes enormous cuts for cardiology

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, according to the just-released Centers for Medicare and Medicaid Services (CMS) 2010 Medicare Physician Fee Schedule final rule. The cuts will be phased in over a four-year period, which is a slight change from the proposed rule.

CMS has attempted to mitigate the impacts of the cuts by spreading them out over a four-year period, but, according to the American College of Cardiology (ACC), “the impact of the cuts is still enormous both for 2010 and beyond." The college said that “cuts of this magnitude—whether enacted this year or spread over four years—cannot be absorbed and we will continue to fight the implementation of this data.”

Despite much opposition, CMS has incorporated 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. With the exception of evaluation and management services (E&M), 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 examples for 2010 are:
• SPECT/myocardial perfusion imaging (78452): 36 percent cut
• Transthoracic echo with spectral and color flow Doppler (93306): 10 percent cut
• Coronary stenting (92980): 4 percent cut
• EKG (93000): 5 percent cut
• Level 4 established patient office visit (99214): 7 percent increase

SPECT/myocardial perfusion imaging: CMS has decided to bundle codes together for SPECT/myocardial perfusion imaging, which was previously reported with multiple codes. In 2010, SPECT/myocardial perfusion imaging studies including wall motion and ejection fraction will now be reported with a single code.

CMS decided to reduce the payment for myocardial perfusion imaging as part of this rule by reducing both the physician work value and the practice expense value. Also, because there is a new code for the service, CMS is not applying the four-year transition of the practice expense cuts and instead is using the fully implemented value for 2010—resulting in a 36 percent cut.

The ACC said this change alone will account for “more than one-third of the projected payment cut to cardiology." The college also said it will begin immediate “strategies to mitigate this cut.” Specifics on the new codes and tips on how to work with health plans to transition to the new codes will be included in the November issues of American College of Cardiology journals.

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, which will reduce payments to varying degrees for consultation services, according to the ACC.

Malpractice: CMS updated 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 could reduce cardiology payments by 1 percent.

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. If the healthcare reform bills pass, this rate could be reduced. Yet, if the 90 percent sticks, cardiac MR and cardiac CT services will be subject to payment sets based on this utilization assumption within cardiology. However, CMS did not apply this cut to equipment for non-hospital cardiac catheterization services.

Sustainable growth rate (SGR): As required by current law, the final rule includes a 21.5 percent reduction in Medicare Physician Payment as of Jan. 1, 2010. 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, which is currently being played out in the Senate and the House. Also, CMS finalized its proposal to remove physician-administered drugs from the accumulated SGR debt, which makes a fix to SGR less expensive.

“The Administration tried to avert the pending fee schedule cut in the FY 2010 budget proposal that it submitted to Congress, and remains committed to repealing the SGR,” said Jonathan Blum, director of the CMS Center for Medicare Management. “While this decision will not affect payments for services during CY 2010, CMS projects it will have a positive effect on future payment updates.”

However, taken together with the payment cuts cardiology has already experienced, the ACC said that “CMS' final rule represents a grave threat to cardiology practices and to patient access.”