News and noteworthy information for November 2017:
- ISASS Advocacy
- NCCI Edits – Cage & Instrumentation Coding
- CMS Issues 2018 Final Physician Fee Schedule
- CMS Issues 2018 Final Hospital Outpatient and ASC Rule
- CMS Issues 2018 Final Quality Payment Program Rule
- Quality Payment Program – Act NOW to Avoid Losing 4% of your Medicare Reimbursements
Chair of the ISASS Coding & Reimbursement Task Force and winner of the 2017 ISASS Distinguished Service Award, Morgan Lorio, MD highlights the Society’s advocacy work over the past year.
“ISASS’ advocacy action takes many forms across multiple forums, but at the most basic level, our number one goal is to support spine surgeons and spine patients,” Lorio said. “We do this through education—educating our members on the most pressing issues facing our practice, educating regulators on the impact of regulations on the surgeon/patient relationship, and educating payers with the most up-to-date literature on surgical spine procedures and technologies.”
Since taking the helm of ISASS in April 2017, ISASS President Jeffrey Goldstein, MD has focused on expanding the Society’s advocacy efforts. “ISASS is well known for its high-quality educational courses and meetings,” Goldstein said, “but our members also benefit from our tireless advocacy work with regulators and payers to ensure our patients have access to the best surgical spine care.”
Here are just a few examples of ISASS’ advocacy at work over the past year:
- ISASS successfully advocated for Anthem Blue Cross Blue Shield to retract coding edits bundling additional-level posterior/posterolateral fusions (22614) with the first-level procedure (22600, 22610, 22612, 22630, and 22633).
- ISASS led a coalition of specialty societies to successfully advocate for the Centers for Medicare and Medicaid Services (CMS) and the National Correct Coding Initiative (NCCI) to retract planned coding edits to bundle anterior instrumentation codes 22845-22847 with 22859. CMS will allow the use of modifier 59 to report separate anterior instrumentation (22845-22847) unrelated to anchoring the device, with CPT codes 22853 and 22854.
- After consideration of data gathered by ISASS in the form of two paired comparison surveys on the work involved in minimally invasive sacroiliac joint fusion (CPT code 27279), in the 2018 final Physician Fee Schedule rule, the Centers for Medicare and Medicaid (CMS) flagged CPT code 22729 as potentially misvalued and asked the Relative Value Scale Update Committee (RUC) to re-evaluate the code. CPT code 27279 is currently valued at 9.03 work RVUs, however data gathered by ISASS suggests this procedure is undervalued and should be valued at 14.23 work RVUs. ISASS will participate in the RUC process in the coming months to re-evaluate the code.
- ISASS issued a policy statement on decompression with interlaminar stabilization to be used by the Society, surgeons and patients to inform payer coverage policies. ISASS has several new policy statements under development at this time.
- ISASS joined Blue Cross Blue Shield Association’s Evidence Street Program in order to provide valuable feedback on the Association’s health technology assessments, which are used by the Blues plans to develop and update coverage policies.
There is never a shortage of issues to address,” Lorio said, “and we are always looking for surgeons who want to contribute to ISASS’ advocacy efforts particularly related to coding, coverage, reimbursement and regulatory matters.” If you are interested in becoming a member of ISASS or becoming more involved in the Society, please email email@example.com.
NCCI Edits – Cage & Instrumentation Coding
On November 21, the National Correct Coding Initiative (NCCI) provided clarification of previously finalized CCI edits bundling anterior instrumentation codes (22845-22847) with biomechanical device/cage codes 22853 and 22854. Acknowledging the difference between stand-alone cages with integral instrumentation/fixation for device anchoring and cages without integral instrumentation/fixation for device anchoring, the Centers for Medicare and Medicaid Services (CMS) has added the following information to the 2018 version of the National Correct Coding Initiative Policy Manual for Medicare Services, Chapter 4, Section F (Spine (Vertebral Column)), Subsection 10:
- CPT codes 22853 and 22854 describe insertion of interbody biomechanical device(s) into intervertebral disc space(s). Integral anterior instrumentation to anchor the device to the intervertebral disc space when performed is not separately reportable. It is a misuse of anterior instrumentation CPT codes (e.g., 22845-22847) to report this integral anterior instrumentation. However, additional anterior instrumentation (i.e., plate, rod) unrelated to anchoring the device may be reported separately appending an NCCI-associated modifier such as modifier 59.”
CMS Issues 2018 Final Physician Fee Schedule
On November 2, 2017, the Centers for Medicare & Medicaid Services (CMS) issued a final rule that updates payment policies, payment rates, and quality provisions for services furnished under the Medicare Physician Fee Schedule (PFS) on or after January 1, 2018. The PFS pays for services furnished by physicians and other practitioners in all sites of service. These services include but are not limited to visits, surgical procedures, diagnostic tests, therapy services, and specified preventive services. As part of the final rule, CMS issues final values for new codes and codes deemed misvalued. Please see the spine code spreadsheet for a comprehensive comparison of RVUs and reimbursements of spine procedures from the 2017 final rule to the 2018 final rule. Some highlights of the final rule include:
- CMS finalized the RUC-recommended value (1.16 work RVUs) for a new Category I code to report bone marrow aspiration for bone grafting in spine surgery (CPT Code 20939 – Bone marrow aspiration for bone grafting, spine surgery only, through separate skin or fascial incision).
- CMS flagged CPT code 27279 (minimally invasive sacroiliac joint fusion) as potentially misvalued after consideration of data gathered by ISASS in the form of two paired comparison surveys on the work involved in the procedure. CMS asked the Relative Value Scale Update Committee (RUC) to re-evaluate the code. ISASS will participate in the RUC process in the coming months.
- CMS is delaying implementation of the Appropriate Use Criteria for Diagnostic Imaging Services to January 1, 2020.
- CMS finalized five new modifiers for reporting patient relationship categories. Voluntary reporting of the modifiers starts January 1, 2018. CMS anticipates enforcing mandatory reporting of patient relationship categories at a later date, after physicians gain familiarity with the categories and modifiers.
CMS Issues 2018 Final Hospital Outpatient and ASC Rule
On November 1, 2017, the Centers for Medicare & Medicaid Services (CMS) released the 2018 Hospital Outpatient Prospective Payment System (OPPS) and Ambulatory Surgical Center (ASC) Payment System policy changes, quality provisions, and payment rates final rule. Please note that physician payment is made under the Physician Fee Schedule; hospitals are paid for outpatient services under the OPPS and ASCs are paid under the ASC payment system, both detailed in this rulemaking.
CMS is increasing the OPPS payment rates by 1.35 percent for 2018. After considering all other policy changes under the final rule, including estimated spending for pass-through payments, CMS estimates an overall impact of 1.4 percent payment increase for hospitals paid under the OPPS in 2018. CMS updates ASC payments annually by the percentage increase in the Consumer Price Index for all urban consumers (CPI-U). The Medicare statute specifies a multi-factor productivity (MFP) adjustment to the ASC annual update. For 2018, the CPI-U update is 1.7 percent. The MFP adjustment is 0.5 percent, resulting in a 2018 MFP-adjusted CPI-U update factor of 1.2 percent. Including enrollment, case-mix, and utilization changes, total ASC payments are projected to increase approximately 3 percent in 2018.
As part of the final rule, CMS is adding CPT codes 22856 and 22858 to the ASC covered procedures list:
CPT Code Long Descriptor Final ASC Payment Indicator Final 2018 Payment Rate 22856 Total disc arthroplasty (artificial disc), anterior approach, including discectomy with end plate preparation (includes osteophytectomy for nerve root or spinal cord decompression and microdissection); single interspace, cervical J8 – Device-intensive procedure; paid at adjusted rate $11,213.08 22858 Total disc arthroplasty (artificial disc), anterior approach, including discectomy with end plate preparation (includes osteophytectomy for nerve root or spinal cord decompression and microdissection); second level, cervical (list separately in addition to code for primary procedure) N1 – Packaged service/item; no separate payment Packaged; no separate payment
CMS Issues 2018 Final Quality Payment Program Rule
On November 2, 2017, the Centers for Medicare and Medicaid Services (CMS) released a final rule to continue implementation of the Quality Payment Program (QPP) required by the Medicare Access & CHIP Reauthorization Act of 2015 (MACRA). MACRA was bipartisan legislation signed into law in the spring of 2015 to permanently repeal the Sustainable Growth Rate (SGR), streamline quality reporting programs, and provide incentive payments for participation in advanced alternative payment models.
After an initial rulemaking last year, the QPP went into effect January 1, 2017. Based on feedback from stakeholders over the last several months, CMS has finalized some changes to the QPP and its two tracks for Medicare payment in 2018 and beyond: Merit-Based Incentive Payment System (MIPS) and Advanced Alternative Payment Models (Advanced APMs). Some of these changes include:
- Increasing the low volume threshold so more clinicians are exempt from participating in the program
- Offering a new means of participation in MIPS through virtual groups
- Continuing to allow use of the 2014 Edition of Certified Electronic Health Record Technology (CEHRT) without penalty
- Creating a new hardship exception for clinicians in small practices under the Advancing Care Information performance category
- Creating a small practice bonus
- Creating a complex patient bonus
- Automatically weighting the Quality, Advancing Care Information, and Improvement Activities performance categories at 0% of the MIPS final score for clinicians impacted by Hurricanes Irma, Harvey and Maria and other natural disasters
Quality Payment Program – Act NOW to Avoid Losing 4% of your Medicare Reimbursements
Are you required to report data to CMS by December 31 under the Quality Payment Program’s Merit Based Incentive Payment System (MIPS)? Click here to find out.
The Quality Payment Program (QPP) is the new physician payment system created by the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) and is administered by the Centers for Medicare and Medicaid Services (CMS). Because the QPP is new in 2017, you need to know how to participate. Since 2017 is a transition year, you only need to report at least one quality measure for one patient during 2017 in order to avoid a payment penalty in 2019 under the Merit-based Incentive Payment System (MIPS).
You still have time to report data under MIPS in 2017. A short video developed by the AMA, “One patient, one measure, no penalty: How to avoid a Medicare payment penalty with basic reporting,” offers step-by-step instructions on how to report now so you can avoid a negative 4-percent payment adjustment in 2019. Also on this website, there are links to CMS’ quality measure tools, an example of what a completed 1500 billing form looks like, a link to the CMS MIPS eligibility tool, and other materials. Additionally, the AMA recently released a new customizable resource, the MIPS Action Plan, to help you think strategically about how to successfully participate in MIPS.
CPT codes and descriptions are copyright of the American Medical Association. All Rights Reserved.
The coding opinions referenced do not constitute legal advice. Every effort is made to ensure the accuracy of information provided, however, these opinions do not replace information contained in public or private payer policies or any published CPT material. The final decision for coding any procedure must be made by the surgeon, considering regulations of insurance carriers and any local, state or federal laws that apply to the surgeon’s practice. ISASS nor any of its officers, directors, agents, employees, committee members or other representatives shall have any responsibility or liability for any claim, including but not limited to any claims for costs, legal fees, Medicare or insurance fraud, arising from the use of these opinions.