Transcript Key Points: Relieving Pain in America: A Blueprint

Reimbursement issues:
Neuromodulation
December 8, 2012
North American Neuromodulation Society
16th Annual Scientific Meeting
Wynn Hotel, Las Vegas Nevada
Joshua P. Prager, M.D., M.S.
Highlights of the Inpatient Hospital Final Rule
 Update for FY 2013 is 2.8%
 Market-basket update of 2.6% for hospitals that report
quality information
 Reduction of -0.7% for multifactor productivity adjustment
 Reduction of -0.1 required by the Affordable Care Act
 Net adjustment of +1.0% for documentation and coding
 With additional neutrality and other contributing factors,
payment impact analysis shows aggregate payments
increasing by 2.3% in FY 13.
 CMS projects that Medicare operating payments will
increase about $2.45 billion in FY 2013.
‒ Rates do not include the impact of a -2% reduction to
Medicare provider payments (2013-2021) from the
automatic “sequester” provisions enacted in the Budget
Control Act (BCA) of 2011, slated to take effect after
January 1, 2013 and applied across the board to all
Medicare payments. Barring congressional action to
delay or replace this provision, cuts will take effect.
Outlier Threshold FY13 is $21,821.
from $22,385 (FY12)
Charge Compression
CMS finalized its proposal not to use data from the new implantable
device cost center to calculate weights in FY2013
•
Hospital Readmissions Reduction Program
– This program will begin in FY 2013 with payment reductions
to certain hospitals that have excess readmissions for three
selected conditions: heart attack, heart failure and
pneumonia.
•
Discussion of Add-On Payments for New Services &
Technologies
– CMS received 6 applications for New Tech Add-On Payment;
2 applicants later withdrew. CMS finalized three new
technology add-on payments in the final rule and denied
one.
•
Impact to SCS, TDD and ITB
– DRGs that typically come into play for SCS, TDD (Pain &
ITB) to see an increase in FY 13 with one exception-(DRG
040).
Highlights of the Inpatient Hospital Final Rule SCS & TDD (Pain)
Highlights of the Outpatient Hospital Final Rule
•
2013 Update
– The 2013 payment conversion factor for OPPS is finalized at
$71.313, which reflects a 1.8% increase.
– CMS projects that Medicare operating payments will increase about
$4.6 billion in CY 2013.
 Call to Action-Pump refills
– CMS elected not to reclassify the CPT 62369-70 to a more
appropriate APC that would more accurately reflect the complexity
and time associated with a pump refill. These codes will continue to
map to APC 0691, however, this APC has a 14.5% increase in
reimbursement.
 Pharmacy
– Separately payable drugs are moving from current ASP +4% to
ASP+6%. The added 6% includes combined acquisition and
pharmacy overhead.
Highlights of the Outpatient Hospital Final Rule, cont’
– $80 per day cost/packaging threshold for CY 2013. Current
threshold is $70. Lioresal (J0475 & J0476) and Prialt (J2278)
meet the cost threshold and are separately payable in the
hospital outpatient site of service.
•
Charge Compression
– As discussed in the proposed rule, CMS finalized the use of
the new “implantable devices charged to patient” cost center
to set payments under the OPPS. This was established in
2009 to reflect that hospitals typically mark-up higher-cost
devices less than they mark-up lower cost devices. This
results in approximately 6% of the payment increase for
neurostimulator devices and implantable infusion pumps.
Highlights of the Outpatient Hospital Final Rule
Spinal Cord Stimulation
•Reimbursement for neurostimulator insertion to increase 8.1%
to $16,395.
•Reimbursement for paddle lead insertion to increase 9.3% to
$6,792.
•Reimbursement for percutaneous lead insertion to decrease
slightly by 1.4% to $4,400.
•Programming services will see reimbursement reductions
Highlights of the Outpatient Hospital Final Rule
Spinal Cord Stimulation
CPT
CPT Description
63650 Implant neuroelectrodes
2012
Final
Relative
Weight
63.7054
2012
Final
APC
Payment
$ 4,460.40
2013
Final
Relative
Weight
61.6966
2013
%
Final
Change
APC
Payment
$ 4,399.77 -1.4%
63655 Implant neuroelectrodes
88.7278
$ 6,212.37
95.2427
$
6,792.04
9.3%
63661 Remove spine eltrd perq aray
20.9261
$ 1,465.16
21.1894
$
1,511.08
3.1%
63662 Remove spine eltrd plate
20.9261
$ 1,465.16
21.1894
$
1,511.08
3.1%
63663 Revise spine eltrd perq aray
63.7054
$ 4,460.40
61.6966
$
4,399.77
-1.4%
63664 Revise spine eltrd plate
63685 Insrt/redo spine n generator
63.7054
216.5685
$ 4,460.40 61.6966
$ 15,163.26 229.8982
$ 4,399.77
$ 16,394.73
-1.4%
8.1%
$ 2,165.58
36.4346
$
2,598.26
20.0%
63688 Revise/remove neuroreceiver
30.9298
95970 Analyze neurostim no prog
1.2013
$
84.11
1.1195
$
79.83
-5.1%
95972 Analyze neurostim complex
1.6007
$
112.07
1.5631
$
111.47
-0.5%
95973 Analyze neurostim complex
1.2013
$
84.11
1.1195
$
79.83
-5.1%
Highlights of the Outpatient Hospital Final Rule
Targeted Drug Delivery
•Reimbursement for bolus/single day trials to increase 8.2% to
$566.
•Reimbursement for continuous infusion/multiple day trials to
decrease 5.1% to $857.
•Permanent catheter insertion to increase 11.5% to $3,251.
•Pump Insertion to increase 4.5% to $14,111.
•Pump refills to increase 14.5% to $192.
Highlights of the Outpatient Hospital Final Rule
Targeted Drug Delivery
CPT
CPT Description
2012
Final
Relative
Weight
2012
Final
APC
Payment
2013
Final
Relative
Weight
2013
Final
APC
Payment
%
Change
62311 Inject spine lumbar/sacral
7.4678
$
522.87
7.9333
$
565.75
8.2%
62319 Inject spine w/cath lmb/scrl
12.8874
$
902.32
12.0130
$
856.68
-5.1%
62350 Implant spinal canal cath
41.6627
$
2,917.06
45.5890
$
3,251.09
11.5%
62351 Implant spinal canal cath
50.8484
$
3,560.20
52.7056
$
3,758.59
5.6%
62355 Remove spinal canal catheter
12.8874
$
902.32
12.0130
$
856.68
-5.1%
62361 Implant spine infusion pump
192.8554
$ 13,502.96
197.8775
$ 14,111.24
4.5%
62362 Implant spine infusion pump
192.8554
$ 13,502.96
197.8775
$ 14,111.24
4.5%
62365 Remove spine infusion device
36.0096
$
2,521.25
34.7984
$
2,481.58
-1.6%
62367 Analyze spine infus pump
2.3904
$
167.37
2.6879
$
191.68
14.5%
62368 Analyze sp inf pump w/reprog
2.3904
$
167.37
2.6879
$
191.68
14.5%
75809 Nonvascular shunt x-ray
1.0781
$
75.48
0.9933
$
70.84
-6.1%
76000 Fluoroscope examination
1.2588
$
88.14
1.6023
$
114.26
29.6%
95990 Spin/brain pump refil & main
1.8088
$
126.64
2.0507
$
146.24
15.5%
95991 Spin/brain pump refil & main
1.8088
$
126.64
2.0507
$
146.24
15.5%
Highlights of the ASC Final Rule
•
2013 Update
– ASC payment rates will increase by 0.6 percent—the
projected rate of inflation of 1.4 percent minus a 0.8 percent
productivity adjustment required by law.
– CMS projects that Medicare operating payments will
increase about $310 million in CY 2013.
 Pharmacy
– Separately payable drugs are moving from current ASP +4%
to ASP+6%. The added 6% includes combined acquisition
and pharmacy overhead.
– $80 per day cost/packaging threshold for CY 2013. Current
threshold is $70. Lioresal (J0475 & J0476) and Prialt (J2278)
meet the cost threshold and are separately payable in the
hospital outpatient site of service.
•
Charge Compression
– As discussed in the proposed rule, CMS finalized the use of
the new “implantable devices charged to patient” cost center
to set payments under the OPPS. This was established in
2009 to reflect that hospitals typically mark-up higher-cost
devices less than they mark-up lower cost devices. This
results in approximately 6% of the payment increase for
neurostimulator devices and implantable infusion pumps.
Highlights of the ASC Final Rule
Spinal Cord Stimulation
•Reimbursement for neurostimulator insertion to increase of
8.1% to $15,431.
•Reimbursement for paddle lead insertion to increase 11% to
$5,861.
•Reimbursement for percutaneous lead insertion to decrease
slightly by 2.1% to $3,551.
Highlights of the ASC Final Rule:
Spinal Cord Stimulation
 Spinal Cord Stimulation
CPT
63650
63655
63685
63661
63662
63663
63664
63688
Description
Perc Lead Implant
Lami Lead Implant
IPG Placement or Replacement
Removal of Perc Lead
Removal of Lami Lead
Revision or Replacement Perc Lead
Revision or Replacement of Lami Lead
Removal of IPG
2012 ASC
$3,628
$5,280
$14,275
$846
$846
$3,628
$3,628
$1,251
2013 ASC
$3,551
$5,861
$15,431
$848
$848
$3,551
$3,551
$1,458
% Change 2012-2013
-2.1%
11.0%
8.1%
0.2%
0.2%
-2.1%
-2.1%
16.5%
Targeted Drug Delivery
•Reimbursement for bolus/single day trials to increase 5% to
$317.
•Reimbursement for continuous infusion/multiple day trials to
decrease 7.7% to $481.
•Permanent catheter insertion to increase 8.2% to $1,824.
•Pump Insertion to increase 4.2% to $12,969.
Highlights of the ASC Final Rule:
Targeted Drug Delivery
CPT
62311
61319
62350
62362
62355
62365
62367
62368
62370
Description
Inject Spine (L/S)
Inject Spine with Catheter (L/S)
Catheter Implant
Pump Implant, Programmable
Catheter Removal
Removal of Pump
Analysis of Pump
Analysis and Programming of Pump
Refill and Programming by Physician
2012 ASC
$302
$521
$1,685
$12,441
$521
$1,456
$23
$97
$97
2013 ASC
$317
$481
$1,824
$12,969
$481
$1,392
$18
$77
$75
% Change 2012-2013
5.0%
-7.7%
8.2%
4.2%
-7.7%
-4.4%
-21.7%
-20.6%
-22.7%
Highlights of the Medicare Physician Final Rule
•
Sustainable Growth Rate (SGR)
–
As in past years, CMS again indicates that the fee schedule conversion
factor will decline; for 2013 the decrease is set at 26.5%. (The conversion
factor is used as the multiplier for the total relative value units (RVUs) to
determine the payment for a procedure.)
–
This decrease is required by the SGR formula, called for in Medicare
statute, to calculate payment.
–
Current expenditures are a component for the formula and since the SGR
does not account for more Medicare beneficiaries, longer life spans, new
technology, etc. negative updates are the result.
– Over the last ten years, CMS, Congress and the President
have taken administrative and legislative steps eliminating
conversion factor decreases. It is anticipated that additional
legislative action will be taken in late 2012 or early 2013
Highlights of the Medicare Physician Final Rule
•
Spinal Cord Stimulation Office Trials
– In the 2013 proposed rule, CMS reviewed SCS trialing performed in
an office setting, also referred to as a non-facility setting. CMS
stated that CPT code 63650 is frequently furnished in the office
setting, but because there are no relative value units (RVUs) for the
non-facility setting, it is not priced accordingly.
– CMS has proposed to establish values for 63650 in an office setting
by combining the costs of trial leads as a non-facility direct practice
expense (PE) input into the payment, and requested input from the
AMA RVU update committee (RUC) and others to value the code
appropriately.
– CMS states they will pay for trial leads in the office for 2013. It is
unknown whether they will pay via 63650 and L8680, as is the
current practice. The payment mechanism is not yet established.
•
Pharmacy
– Medicare has clarified that drugs used by a physician to refill
an implantable pump to be within the “incident to” benefit
category and not the DME benefit category. Therefore, the
physician must buy and bill for the drug and a non-physician
supplier that has shipped the drug to the physician’s office
may not bill independently.
– Separately payable drugs continue to be reimbursed at ASP
+6% The added 6% includes combined acquisition and
pharmacy overhead.
Spinal Cord Stimulation – National Coverage
Determination – Update
 Tuesday 11/27/2012:
 CMS intent to review SCS National Coverage
Determination
 AHIP (America's Health Insurance Plans) proposed that
CMS review Implantable Pain Stimulators and the
associated evidence to ensure that this is used as a last
resort for non-malignant pain. (The current NCD mentions
“late or last resort”.)
CMS Potential NCD’s
 On November 27, the Centers for Medicare &
Medicaid Services (CMS) posted an updated list
of 32 potential topics for future national coverage
determinations (NCDs).
 Implantable neurostimulators for chronic pain
were listed amongst the many technologies on
the list.
 It is important to note that this technology
already has a National Coverage Determination.
 Epidural and Transforaminal Injections
 No NCD, only local coverage decisions in place
 Vertebroplasty and Kyphoplasty
 No NCD, only local coverage decisions in place
 The last time CMS reviewed potential NCD
topics was in 2008. Of the 20 topics listed,
CMS acted on 7.
Questions??
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