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MEDICARE CUTS OF EPIDURAL INJECTIONS (CPT 62310, 62311)
AMERICAN SOCIETY OF INTERVENTIONAL PAIN PHYSICIANS
Impact of Cuts 100% IPM physicians are affected 100% office based practices: severe impact
• 40% of total IPM physicians
40%-50% of cases changed• Into expensive settings• To expensive procedures
> 30% will lose access Increase $50-$150 million in Medicare expenses
No explanation for projected increase of $4 million from $640 to $644 million for IPM
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Hospitals can purchase an office and bill at HOPD rate at any time without any changes in services or facility
Additional Impact Medicaid
• 80% of Medicare Affordable Care
• 65%-100% of Medicare• High co-pays and deductibles
Medicare Advantage• 80%-100% of Medicare fee-for-service• High co-pays and deductibles
Private insurers• 80%-120% of Medicare fee-for-service• High co-pays and deductibles
Lack of Coverage = Lack of Access
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Cuts+
Lack of Coverage=
No Savings
IN FACT:
Increase expenses to Medicare
Increase profits for insurers
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Relative Values of Epidural Injections
2013 versus 2014CPT Code CY 2013 Work
RVUsAMA RUC
Recommended Work RVUs
CY 2014 Work RVUs
Percent Change in Work RVUsfrom 2013 to
2014
62310 1.91 1.68 1.18 -38.2%
62311 1.54 1.54 1.17 -24.0%
62318 2.04 2.04 1.54 -24.5%
62319 1.87 1.87 1.50 -19.8%
Magnitude of Reductions of Epidural injections
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Comparison of Epidural Procedures Payments in Various Settings
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Comparison of Interventional Procedures Payments in Various Settings
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CPT
Overhead / Facility payments OfficeOverheadOffice
ASC HOPDPhysician Overhead 77003-TC Overhead total ASC HOPD
62310Cervical Epidural
$74.15 $36.54 $60.18 $96.72 $370.07 $669.91 26% 14%
62311Caudal Epidural
$72.72 $36.18 $60.18 $96.36 $370.07 $669.91 26% 14%
64479Cervical Transforaminal
$139.35 $104.96 - $104.96 $370.07 $669.91 28% 16%
64480Add-on
68.48 49.57 - 49.57 None None - -
64483Lumbar Transforaminal
$116.42 $108.90 - $108.90 $370.07 $669.91 29% 16%
64484Add-on 54.57 35.31 - 35.31 None None - -
64490Cervical Facets
$117.77 $84.54 - $84.54 $370.07 $669.91 23% 13%
64491Level 2
$63.48 $33.17 - $33.17 None None - -
64492Level 3
$64.20 $32.81 - $32.81 None None - -
64493Lumbar Facets
$94.57 $ 82.57 - $ 82.57 $370.07 $669.91 22% 12%
64494Level 2
$54.21 $34.24 - $34.24 None None - -
64495Level 3
$54.92 $33.89 - $33.89 None None - -
Conversion of ownership of office earns HOPD rates
62310 – Pattern of reimbursements for physician payments, office-based procedures, ASCs, and hospital outpatient departments
Office overhead payments, including fluoroscopy increased 19% for 62310 from 2001 to 2013 with major fluctuations over the years and decreased by 44% from 2001 to 2014.
ASC payments decreased by 2% from 2001 to 2013, whereas they increased by 15% from 2001 to 2014.
In contrast, hospitals have consistently gained increases of 213% from 2001 to 2013 and 271% from 2001 to 2014.
For 62310, physician payments increased 18% from 2001 to 2013 and decreased 21% from 2001 to 2014.
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Reimbursement History for CPT 62310 (Cervical/Thoracic Epidural Injection)
Physicianpayments
Facility/Overhead paymentsIncluding Fluoroscopy
Proportion of Office overhead Payments over ASC & HOPD
CPT Office ASC HOPD ASC HOPD
2001 $93.73 $173.31 $323.00 $180.53 54% 96%
2002 $88.69 $165.78 $333.00 $182.75 50% 91%
2003 $93.07 $211.87 $333.00 $249.63 64% 85%
2004 $94.84 $213.20 $333.00 $288.49 64% 74%
2005 $101.57 $209.95 $333.00 $331.91 63% 63%
2006 $101.57 $210.33 $333.00 $357.90 63% 59%
2007 $100.81 $186.46 $333.00 $390.95 56% 48%
2008 $100.17 $164.92 $322.77 $449.34 51% 37%
2009 $95.22 $134.89 $295.98 $473.78 46% 28%
2010 $101.08 $140.64 $295.98 $485.34 48% 29%
2011 $103.29 $160.03 $294.00 $522.67 54% 31%
2012 $107.22 $174.27 $300.76 $521.88 58% 33%
2013 $110.23 $206.86 $317.46 $565.75 65% 37%
2014 $74.15 $96.72 $370.07 $669.91 26% 14%
Change from 2001 to 2013
18% 19% -2% 213%
Change from 2001 to 2014
-21% -44% 15% 271%
Conversion of ownership of office earns HOPD rates
$0
$100
$200
$300
$400
$500
$600
$700
$800
2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014
Office ASC HOPD
282% Difference
593% Difference
Reimbursement history of facility payments in multiple settings for CPT 62310 (Cervical/Thoracic Epidural Injection)
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62311- Pattern of reimbursements for physician payments, office-based procedures, ASCs, and hospital outpatient departments
Office overhead payments, including fluoroscopy, increased 1% for 62311 from 2001 to 2013 with major fluctuations over the years and decreased by 48% from 2001 to 2014.
ASC payments decreased by 2% from 2001 to 2013, whereas they increased by 15% from 2001 to 2014.
In contrast, hospitals have consistently gained increases of 213% from 2001 to 2013 and 271% from 2001 to 2014.
For 62311, physician payments increased 17% from 2001 to 2013 and decreased 5% from 2001 to 2014.
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Conversion of ownership of office earns HOPD rates
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Reimbursement History for CPT 62311 (Lumbar/Caudal Epidural Injection)
Physicianpayments
Facility/Overhead PaymentsIncluding Fluoroscopy Proportion of Office Overhead
Payments over ASC & HOPDCPT Office ASC HOPD ASC HOPD2001 $76.52 $186.31 $323.00 $180.53 58% 103%2002 $72.42 $186.40 $333.00 $182.75 56% 102%2003 $76.51 $218.13 $333.00 $249.63 66% 87%2004 $78.41 $218.05 $333.00 $288.49 65% 76%2005 $84.51 $216.40 $333.00 $331.91 65% 65%2006 $84.13 $216.78 $333.00 $357.90 65% 61%2007 $83.75 $187.60 $333.00 $390.95 56% 48%2008 $83.41 $162.25 $322.77 $449.34 50% 36%2009 $78.99 $127.68 $295.98 $473.78 43% 27%2010 $83.74 $130.68 $295.98 $485.34 44% 27%2011 $84.94 $145.76 $294.00 $522.67 50% 28%2012 $87.82 $155.89 $300.76 $521.88 52% 30%2013 $89.82 $187.46 $317.46 $565.75 59% 33%2014 $72.72 $96.36 $370.07 $669.91 26% 14%
Change from2001 to 2013 17% 1% -2% 213%
Change from2001 to 2014 -5% -48% 15% 271%
$0
$100
$200
$300
$400
$500
$600
$700
$800
2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014
Office ASC HOPD
595% Difference
284% Difference
Reimbursement History of Facility Payments in Multiple Settings for CPT 62311 (Lumbar/Caudal Epidural Injection)
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Explosive Growth: Spinal Interventional Pain Management Techniques
* - (excluding vertbroplasty/kyphoplasty, implantables and stimulators, brachial plexus, suprascapular nerve, para-cervical, peripheral nerve or branch, continuous epidurals, intraarticular injections, trigger point and ligament injections)
Misinterpretation and Misclassification of Explosive Growth: Epidural Injections
Year Interlaminar Epidurals Transforaminal epidurals All Epidurals
Services Rate Services Rate Services Rate
2000 694,103 1,751 145,371 367 839,474 2,118
2001 787,098 1,966 201,936 504 989,034 2,4702002 886,036 2,188 286,212 707 1,172,248 2,894
2003 948,641 2,307 394,188 958 1,342,829 3,265
2004 1,008,823 2,418 603,064 1,445 1,611,887 3,863
2005 1,087,002 2,558 660,769 1,555 1,747,771 4,113
2006 1,093,709 2,524 750,473 1,732 1,844,182 4,255
2007 1,082,444 2,445 832,783 1,881 1,915,227 4,327
2008 1,071,055 2,359 946,077 2,083 2,017,132 4,442
2009 1,063,669 2,322 1,048,842 2,290 2,112,511 4,612
2010 1,073,171 2,288 1,132,136 2,413 2,205,307 4,701
2011 1,114,458 2,375 1,174,755 2,504 2,289,213 4,879
Change from 2000 to 2011
61% 36% 708% 583%173% 130%
GA 4.40% 2.80% 20.90% 19.10% 9.50% 7.50%
GA – Geometric average annual change
Explosive Growth: Facet Joint Interventions
FACET JOINT BLOCKS FACET NEUROLYSISAll Facet Joint InterventionsCervical/Thoracic Lumbar/Sacral Cervical/Thoracic Lumbar/Sacral
year 64470 64472 Total Rate 64475 64476 Total Rate 64626 64627 Total Rate 64622 64623 Total Rate Services RateF2000 24751 33573 58324 147 101539 153252 254791 643 2750 6054 8804 22 15117 38206 53323 135 375242 947F2001 34500 47684 82184 205 121234 175854 297088 742 3815 8334 12149 30 18792 47632 66424 166 457845 1143F2002 41935 61981 103916 257 155620 240243 395863 977 5190 12202 17392 43 25744 63522 89266 220 606437 1497F2003 49958 75489 125447 305 189263 299802 489065 1189 6877 15301 22178 54 35315 83166 118481 288 755171 1836F2004 77620 126145 203765 488 286394 467823 754217 1807 10691 23461 34152 82 57053 132351 189404 454 1181538 2831F2005 86541 141999 228540 538 316158 519689 835847 1967 12015 26298 38313 90 63228 146688 209916 494 1312616 3089F2006 121312 204178 325490 751 370809 636673 1007482 2325 14207 31993 46200 107 79289 226299 305588 705 1684760 3887F2007 108103 179279 287382 649 365372 599568 964940 2180 17689 39710 57399 130 88069 209416 297485 672 1607206 3631F2008 114497 201857 316354 697 385491 634775 1020266 2247 20729 48089 68818 152 100606 240268 340874 751 1746312 3845F2009 126730 214802 341532 746 418036 663690 1081726 2362 25510 57973 83483 182 112627 263386 376013 821 1882754 4111F2010 114753 175887 290640 620 386897 557572 944469 2013 26588 59219 85807 183 116959 261802 378761 807 1699677 3623F2011 124431 192789 317220 676 402507 587942 990449 2111 29904 67622 97526 208 125630 280748 406378 866 1811573 3861Change 403% 474% 444% 359% 296% 284% 289% 228% 987% 1017% 1008% 836% 731% 635% 662% 544% 383% 308%Annualchange 15.8% 17.2% 16.6% 14.9% 13.3% 13.0% 13.1% 11.4% 24.2% 24.5% 24.4% 22.5% 21.2% 19.9% 20.3% 18.4% 15.4% 13.6%
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CRNA, NP & PA 21 171 359 621 1,649 1,862 2,627 2,605 2,630 2,873 3,532 4,953
Other Physicians 3,050 6,606 3,589 1,584 2,951 3,296 3,152 3,251 4,508 3,609 4,584 5,122
General Physicians 1,260 2,663 2,950 4,781 9,047 9,817 16,132 9,627 10,177 10,023 11,360 11,079
Radiology 2,171 1,606 2,210 3,020 4,155 4,566 4,880 5,582 6,187 6,563 6,570 7,288
Surgery 2,778 4,316 5,101 5,925 7,507 8,215 8,996 9,464 10,748 11,552 9,473 9,005
Interventional Pain Management 40,274 70,302 87,540 112,933 147,395 160,850 176,141 182,960 194,437 194,326 202,386 215,207
F2000 F2001 F2002 F2003 F2004 F2005 F2006 F2007 F2008 F2009 F2010 F2011
Explosive Growth: SI Joint Injections
Growth of Medicare population 18%Annual (GM) increase 1.5%
Increase from 2000 to 2011 = 308%Annual (GM) Increase = 13.6%
Saga of AMA RUC Survey Potentially misvalued codes
• Process starts with premise that the current values are correct
• Misvalued conclusion requires compelling evidence
Entire VALUE was called into question!• Physician work
• Practice expense
• TIME and intensity – not just time
All specialty societies of AMA RUC• AAPM
• AAPMR
• ASA
• ASIPP
• ISIS
• NASS
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Unanimously agreed to RUC values and a decrease for 62310 and a decrease for TIMEbut high INTENSITY
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AMA RUC Letter to CMS
CMS Actions
Disagreed with RUC• Work RVU was not comparable to the reduction in time.• Assumed that the times on file were correct.
o This was inaccurateo Times from original 1999 survey were an “outlier” compared to
previous Harvard times of 42 minutes.
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CMS Actions
CMS arrived at lower work RVUs ($42 per procedure) for all codes• By adoption of the survey low for codes 62318 and 62319
o Outliers at the extremes of survey resultso Used the outlier values for 62310 and 62311
Using time as the sole reason for the reduction is inappropriate• Original time data were inaccurate
o Results in inaccurate and unfair value
CMS also reduced practice expense value
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CMS Actions
Data from 62318 and 62319 may be used only when:• They were accurate• They were valued fairly
MUST not use single outlier survey value at the extreme low end of responses.
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RUC Survey Components
Work value:The risk of significant
• Complications • Morbidity and mortality
Extensive training, skill and judgment of physicianEstimated risk of malpractice liability with poor
outcome
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Integrity of Process
Misvalued codes• RUC survey• RUC recommendations October 2012
Proposed Rule June 2013• Did not include the cuts
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Comments
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Over 65,000 letters to congress
Over 11,000 letters to CMS
40 Congressional letters to CMS
ASIPP meetings with CMS and Members of Congress
Personal phone call to Marilyn Tavenner from Congressman Ed Whitfield
Arkansas Delegation’s teleconference meeting with Marilyn Tavenner
Requested Actions
Accept AMA RUC RecommendationsOR
Reverse to the proposed levelsOR
Send to Refinement Panel
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Laxmaiah Manchikanti, MDChairman of the Board and Chief Executive Officer, ASIPP and SIPMS
Medical Director, Pain Management Center of PaducahClinical Professor, Anesthesiology and Perioperative Medicine
University of Louisville, Kentucky 2831 Lone Oak RoadPaducah, KY 42003
Phone: 270-554-8373 ext. 101Fax: 270-554-8987
E-mail: [email protected]
Thank you
