ACC: Unlocking the secrets of reimbursement

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NEW ORLEANS— An expert panel offered strategies for navigating new Medicare codes and provided tips for preparing for the ICD-10 transition, during a Monday presentation at the annual meeting of the American College of Cardiology.

The ACC has benefited from many advocacy successes in the last year, when success is defined as stable, rather than declining, value, according to moderator Robert N. Piana, MD, professor of medicine at Vanderbilt University in Nashville, Tenn.

James Blankenship, MD, of the American Medical Association (AMA) Resource-Based Relative Value Score (RBRVS) committee, confirmed what many cardiologists know. The RVU (relative value unit) has decreased significantly since 2000.

However, Medicare payment is based on three inputs, explained Blankenship: physician work expense, practice expense and liability insurance expense.

The payment process begins with code development for individual procedures. The AMA RBRVS committee recommends a value, and the Centers for Medicare & Medicaid Services (CMS) accepts or rejects the recommendation.

Over the last few years, Blankenship confided, the AMA has seen more pushback from CMS. Another recent wrinkle in reimbursement trends has been pressure on the RUC to bundle codes. The impetus is to cut payment for duplicative work, explained Blankenship.

RUC has bundled multiple cardiology codes including echocardiography, stress echocardiography and nuclear cardiology, which has resulted in value drops of 17 percent, 7 percent and 30 percent, respectively.

“It’s a pattern,” opined Blankenship, who shared that Medicare also directed the RUC to bundle cath codes, which dropped the value by 10 percent. However, the total RVU actually increased for caths performed in physician-owned labs because CMS increased the practice expense and liability insurance expense components.

Other codes on the docket include those for intracardiac catheter ablation of arrythmogenic focus for treatment of ventricular tachycardia, external cardiovascular device and event monitoring  and coronary stenting.

Blankenship peeled back the layers on the process, explaining that Medicare is requiring the RUC to re-value coronary stenting codes in the RVU revision process. “Current payments are based on skin-to-skin time of two hours, but the procedure requires before and after procedure work amounting to 3 hours and 45 minutes,” he explained. If the AMA survey shows less skin-to-skin time, the RVU and payments will decrease roughly proportionately, he cautioned. He recommended that cardiologists participate in the ACC survey process to inform and possibly circumvent future cuts.

How to avoid pitfalls in coding
“Increased specificity is required in coding,” asserted Linda Gates-Striby, St. Vincent’s Medical Group in Indianapolis. That’s because payor quality initiatives and ICD-10 hinge on specificity and details.

Gates-Striby shared her experience with quality and cost programs in Indiana, with physician rankings already impacting patients’ out-of-pocket costs.

“Payors are setting the stage for a tiered network based on physician quality,” she explained. She recommended that cardiologists diligently report details on co-morbidities and other diagnosis codes that increase severity. Otherwise, patients may be classified as lower risk than they are, which could result in misaligned profiles that don’t reflect the severity of the patient’s condition.

Medicare, she said, is following suit and developing its own payment modifier.

Adhering to such parameters is good training for ICD-10, which affects physicians as well as coders. Gates-Striby warned that ICD-10 increases diagnosis codes from 14,000 in ICD-9 to 70,000.