AAFP, Others Push Back on Proposed Changes in Code Valuation Process

August 19, 2014 01:50 pm News Staff

The AAFP recently joined several dozen physician and other health care professional organizations, including the AMA, the American College of Physicians and the American Osteopathic Association, in asking CMS to reconsider some of its proposals in the 2015 Medicare physician fee schedule that relate to valuing CPT codes.

In the Aug. 13 letter to CMS Administrator Marilyn Tavenner, M.A., the organizations spelled out their support for the agency's plan for additional transparency and their gratitude for the opportunity to comment on the valuation of health care services provided by physicians and other health care professionals.

The letter went on, however, to point out problems with CMS' suggested shifting of schedules for the review of new, revised and potentially misvalued services. Initiating a new system -- albeit for reasons of greater transparency in the valuation process -- without a careful eye toward the calendar would shortchange the established review process and delay the implementation of some codes, said the letter.

"We believe that it would be highly inappropriate for CMS to implement this proposal" within the 2015 final rule due to be released on Nov. 1, said the organizations, "because the CPT Editorial process for the 2016 cycle will already be nearly complete by that date, and requiring publication in a proposed rule next summer will delay (the affected codes') implementation in Medicare by another year. Those that have solicited new and/or revised CPT codes deserve timely consideration of their applications."

Story Highlights
  • The AAFP joined dozens of other physician and health care professional organizations in asking CMS to reconsider proposed changes to the CPT code valuation process as outlined in the proposed 2015 Medicare physician fee schedule.
  • In a letter to CMS, the organizations took issue with, among other things, CMS' shifting of schedules for the review of new, revised and potentially misvalued services.
  • The organizations also urged CMS to keep intact the Refinement Panel that effectively serves as an appeals body when stakeholders disagree with valuations assigned by CMS.

The letter urged CMS to instead implement the new timeline and procedure for the CPT 2017 cycle and the 2017 Medicare physician fee schedule.

The signatories also took issue with CMS' proposed timeline that would require all recommendations from the AMA/Specialty Society's Relative Value Scale Update Committee (RUC) to be submitted by Jan. 15 of each year.

For 2016, said the groups, this would allow only a single opportunity for the medical community to offer descriptive information about and recommended valuation of new technology and code bundles. In subsequent years, the proposal would extend the period required to generate codes and relative values from 14 to 22 months from the time of application to between 22 months and 30 months "at a time when CMS, the CPT Editorial Panel and the RUC are being asked to reduce the amount of time needed to accommodate changes."

The organizations urged CMS to accept modifications in the CPT/RUC workflow proposed in the letter. Doing so would eliminate the need for CMS to create "G" codes -- special codes that essentially duplicate the CPT codes. The creation and adoption of such "temporary" G codes would add an unnecessary administrative burden on physicians and others providing health care services because they would be forced to learn new codes only to see them replaced in a relatively short period of time, said the letter.

"We believe that the G code proposal is entirely unworkable and should not be considered in finalizing the new process," the groups asserted.

The last section of the coalition letter deals with CMS' proposal to eliminate the Refinement Panel process the agency now uses to consider comments on interim relative values and that, in the eyes of stakeholders, has long served as an appeals process. The panel, organized by CMS, consists of members from primary care organizations such as the AAFP, contractor medical directors, the commenting specialty and a specialty related to the commenter.

For many years, said the letter, CMS deferred to the Refinement Panel's vote in finalizing values. More recently, however, CMS revised the consideration process and began independently reviewing the Refinement Panel's decisions.

"In many cases, the Refinement Panel supported the original RUC recommendation and the commenter's request, yet CMS chose instead to implement the original proposed value," said the letter. If the panel were to be eliminated entirely, CMS would rely solely on its own staff to make final decisions.

According to the letter, the lack of any perceived organized appeal process likely would lead to a fragmented lobbying effort rather than an objective review process. Furthermore, organizations with limited resources would be outspent by those able to bankroll opposition sufficient to overturn a CMS-proposed value.

For all of these reasons, the organizations urged CMS to "create a fair, objective and consistently applied appeals process that would be open to any commenting organization."

The end goal, according to the letter, is to achieve a "reasonable transition" to a new process that would allow greater transparency in the system with minimal disruption.


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