This article is more than 5 years old. Information may no longer be current.
Rheumatologists sound alarm over 90% Medicare reimbursement cut for ultrasounds
Click Here to Manage Email Alerts
Rheumatologists are raising the alarm regarding a change buried within CMS’ proposed 2019 Medicare Physician Fee Schedule, which they say would significantly reduce reimbursements for the complete diagnostic musculoskeletal ultrasound by as much as 90% by 2029.
With the comment deadline — 11:59 p.m. on Monday, Sept. 10 — fast approaching, Andrew J. Laster, MD, FACR, CCD, a rheumatologist in Charlotte, North Carolina, and a member of the medical policy committee for United Rheumatology, said he and others from the organization are trying to warn colleagues and other physician and patient stakeholders regarding the cut before it is too late.
“Needless to say, these are Draconian cuts to a technology that is widely utilized,” Laster, who is affiliated with Duke University and the University of North Carolina, Chapel Hill, told Healio Rheumatology. “Ultimately, the result will be to guarantee that ultrasound will be dropped from most rheumatology practices, which will likely have a significant impact on the training of rheumatology fellows in ultrasound. That profound impact will affect patient care as well, in that we will be less likely to obtain an earlier diagnosis and less likely to impact on patient outcomes.”
According to Laster, the cut in question relates to reimbursements for CPT code 76881, or the complete ultrasound, extremity nonvascular, practice expense. If the 2019 Medicare Physician Fee Schedule proposed earlier this year is approved, it would cut the reimbursement rate by 19% each year through 2029, he said. This would reduce the practice expense relative value unit (RVU) for the complete ultrasound from 2.46 to 0.2 during that time.
“Reimbursements vary from state to state, but there is a national average,” Laster said. “The average for this procedure was $105.54 in 2017, and once the 90% cut is fully deployed, the average reimbursement will fall to $10.55.”
Cut out of the process
Adding to the frustration surrounding the proposed cuts is the revelation that rheumatologists were not among the subspecialists surveyed prior to CMS’ drafting process, according to Andrew L. Concoff, MD, a staff physician at Providence St. Joseph Health, St. Jude Medical Center in Fullerton, California, and another member of the United Rheumatology medical policy committee.
“We were not included in the consultations that led to this proposal,” Concoff told Healio Rheumatology. “As major stakeholders with patients who are treated almost entirely by our subspecialty, we have a right to be consulted about policies that will affect us. I think CMS needs to have a more robust representation of different subspecialists who may be impacted by their policy decisions or shortsighted determinations.”
When reached for comment regarding the lack of rheumatology voices informing the ultrasound reimbursement change, a spokesperson for CMS responded: “The public comment period is still underway and open until Sept. 10, 2018, for providers to provide input, and CMS plans to take into consideration all stakeholder feedback.”
According to both Concoff and Laster, CMS drafted its proposed 2019 Medicare fee schedule based on recommendations from the AMA that were developed through survey data. The problem, they said, is that the surveys polled only podiatrists and radiologists regarding ultrasound, with no involvement from rheumatologists.
Podiatrists are considered the dominant specialty using the complete ultrasound code, and the radiologists are the dominant specialty using the limited ultrasound code, Laster noted.
“However, it turns out those specialties have a different way of doing ultrasound than those of us in rheumatology,” Laster said. “Podiatry has a mobile device, with no dedicated room, and no professional PACS. In contrast, radiology has a dedicated room and a professional PACS reporting system, which comes with a higher expense than the podiatry setup. CMS strives for accuracy in their coding, but it can’t be accurate if the correct individuals impacted by this are not included.”
Impact on patients and practices
According to Concoff, in the past 15 to 20 years the complete musculoskeletal ultrasound has emerged as a critical diagnostic and therapeutic tool used by rheumatologists.
“It has been a major breakthrough for us,” he said. “We have adapted the technology in order to better care for patients from not only a diagnostic perspective, by seeing inflammation in the joints, but also to guide interventions, such as ultrasound-guided procedures of various types. This includes both traditional injections that have been done for many years as well as new procedures that take advantage of being able to see within the joints.”
Cuts to reimbursement will limit rheumatologists’ ability to provide this technology for patients, as more and more physicians determine that they can no longer afford them, Concoff added. This would present physicians with two choices for treating, for example, shoulder pain, he said.
“You either have to treat empirically using only the physical examination, which is often not adequate to determine the specific nature of the problem at its source,” he said, “or perform an MRI, which is often only available at a hospital.”
This could hurt patients financially, as MRI procedures can cost twice as much as ultrasound. According to Concoff, an MRI at a hospital in the Orange County, California area can cost $245, while an ultrasound, which can ben provided by a patient’s rheumatologist onsite, costs $114.
“Even more importantly, more than 70% of patients prefer to have the ultrasound than the MRI because the ultrasound is in real time, and they can see the result and receive a diagnosis that day,” Concoff said. “With an MRI, patients need to schedule it, come back and potentially miss another day of work, and then schedule an additional visit to go over the results, and then, finally, start treatment on another day. That difference in time is meaningful, particularly in a time when we are supposed to be focused on patient preferences.”
Not being heard
This is not the first time CMS has proposed cuts to ultrasound reimbursements in its Medicare fee schedule. Large cuts initially slated for the 2018 fee schedule were later reduced to 19% following a lobbying and advocacy effort by the American College of Rheumatology. However, the seemingly annual practice of proposed cuts, followed by a frantic push by advocacy and professional groups to combat those cuts, can be a drain on resources, Concoff said.
“This is getting brought up every year now,” Concoff said. “Advocacy efforts should not need to be applied to the same topic on a year-by-year basis. This is the sort of impression that is given to those of us using this technology: That the technology is on the chopping block, that it is considered not to be useful, not valued and under threat. For rheumatologists, continuing to marshal the resources to have this same conversation on this same topic year after year, is a waste of time, effort and energy. It also gives the impression that we are not really being heard or listened to at the policy level.”
According to Laster, it remains uncertain whether their efforts will ultimately convince CMS to change its proposed fee schedule. However, he is urging rheumatologists to reach out to CMS, if they already haven’t done so, as soon as possible.
“Comment should be submitted to CMS urging them to postpone further cuts to the code pending further comments from stakeholders and submission of evidence supporting a proper revaluation of the 76881 code,” Laster said. “Continuation of the cuts will result in a lack of access to care for a vulnerable patient population and increased costs in advanced imaging techniques as lower cost ultrasound imaging may no longer be financially feasible to perform in the office.” – by Jason Laday
Those who wish to submit a comment can do so at this link: https://www.regulations.gov/document?D=CMS-2018-0076-0621.
Disclosure: Concoff and Laster report no relevant financial disclosures.