January 2003
News in Pain Practice Management
Specialty Designations for Pain Management
Specialty Designation for Pain Management (72) awarded September 21, 2001
Specialty Designation for Interventional Pain Management (09) awarded November 1, 2002
2 specialties allows for differences in treatment approaches, training, utilization patterns and costs between Pain Management specialists and IPM specialists.
– Enable Medicare to track utilization data.
– Enable physicians to represent themselves better with regards to utilization for interventional pain procedures.
– Will also assist in serving a member of the state society on the Carrier Advisory Committee, thus, having influence in the formation of Local Medicare Review Policies.
– After 3 to 4 years, will assist in establishing practice expenses for interventional pain procedures at a much higher level than those previously used (anesthesiology levels).
If you are currently using a specialty designation other than 72 or 09, there is a significant risk that you will be targeted for a Medicare audit because the Medicare program thinks (incorrectly) that your utilization is "inconsistent with your peers."
http://www.cms.gov/providers/enrollment/forms/
• Electronic version or PDF version-(CMS 855B)
• Download, complete and print
• Send directly to your Medicare Carrier-
http://cms.hhs.gov/contacts/incardir.asp
Medicare Professional Fees
l Medicare provider “giveback” legislation, S. 3018,
l If Congress fails to act on this issue, all providers will receive a 12% cut over the next three years
l The AMA reports that physicians are already refusing to accept new Medicare patients and expects the situation to worsen in the coming months.
l Congress received a great deal of pressure from provider groups to respond to this issue before the end of 2002; however, they failed to do so.
l Many provider groups are weighing-in on this issue urging action before the implementation of the 2003 fee schedule
l Congress must act to correct a faulty reimbursement formula that will lead to 12% cuts over the next three years if left alone.
Reimbursement for Drugs
l January 1, 2003, CMS implemented a single drug pricer (SDP) for drugs and biologicals covered under Medicare Part B
l Drugs were previously paid based on 95 percent average wholesale price (AWP) but priced by local carriers
l SDP intent is to correct identified differences among local carriers by establishing this uniform Medicare payment allowance
l CMS will continue to base prices on published compilations (e.g., RedBook and First Data Bank) to identify wholesale drug prices
Ambulatory Payment Classification System And Ambulatory Payment Groups
Currently Two Different Medicare Payment Systems
Ü Outpatient Prospective Payment System (OPPS)- paid by Ambulatory Payment Classification System (APC) for Medicare payment to Hospital Outpatient Departments (HOPD)
Ü Ambulatory Surgery Centers-paid by Medicare payment groups (APG) for Medicare payment to the ASC
Ü The payment differentials exist because Medicare calculates the rates using different mechanisms and as a result the payment rates are different.
Old News
Ü The Medicare statute requires that Medicare conduct a cost survey every five years and that payments reflect the costs determined by those surveys.
Ü But..Medicare has not conducted a successful ASC cost survey since the late eighties when many of the devices used in today’s surgeries did not exist.
Ü Legislation was secured that prevented HCFA (now CMS) from implementing APCs for ASCs prior to January 1, 2002.
Ü Legislation required CMS to provide a current ASC cost analysis
Ü Any change in methodology would require a 4 year phase in period
Ü Although CMS has not indicated that APCs will not be implemented at a later date – prior to January 145, 2003 it had appeared safe to assume that APCs would not be implemented in 2003 or even 2004.
Medicare Payment Advisory Committee (MedPAC)
1. Reflect actual costs of practice expense for physician reimbursement
2. Study the specific barriers imposed by Medicare on the provision of pain management procedures in hospital outpatient departments, Ambulatory Surgery Centers and physician’s offices.
Latest News-January 15, 2003
l Medicare Payment Advisory Commission (MedPAC) approved a recommendation to Congress that ASCs receive no inflation update in Medicare payments for 2004
l No surgical procedure to be paid more in an ASC than in a hospital outpatient department.
l If Congress takes no action ASCs would receive an inflation update equal to the consumer price index for urban consumers on October 1, 2003.
l The recommendations made will be included in the report that MedPAC sends to Congress in March.
l Absent Congressional action there will be no major changes in ASC payments in 2003.
Only a few hundred of the 2300 procedures that Medicare reimburses in an ASC receive a higher reimbursement in the ASC. Many of these procedures are high volume procedures and procedures most likely to be provided in a Single-Specialty ASC.
Based on MedPac recommendations, the impact for a Single-Specialty Pain Management ASC or an ASC that provides Interventional Pain Management procedures would not be significant. For ASC’s that provide transforaminal epidurals, intercostals nerve blocks, facet joint injections and Neurolytics, their fees would actually increase.
HOPD MEDICARE PAYMENTS MEDICARE ASC PAYMENTS
LEVEL I (Trigger Points, Nerve Blocks)- $105.61
LEVEL II (Epidurals, Spinal Puncture)- $249.63
LEVEL III (Includes intercostals, transforaminals, facets)- $300.67
LEVEL IV - (neurolytics)
$614.99
Implantables- $7,266.61 - $11,876.71
Level I – most not covered
Level 11- All $333.00
Level 111- Most $333.00
Level IV- Most $333.00 – 1 at $446.00
Implantables- $446.00 plus cost of device