AAFP Urges CMS to Review, Correct Misvalued CPT Codes

February 04, 2014 02:48 pm News Staff

The AAFP recently took advantage of CMS' call for additional input on limited portions of the final 2014 Medicare physician fee schedule to revisit issues that continue to concern the AAFP.

[Medical billing statement with stethoscope]

In a Jan. 23 letter from AAFP Board Chair Jeff Cain, M.D.,(3 page PDF) of Denver, to CMS Administrator Marilyn Tavenner, M.A., Cain first thanked the agency for favorable policies included in the final schedule, such as revisions to the Medicare economic index, clarifications on "incident to" policy and further developments in establishing the payment for chronic care management services that is set to begin in 2015.

Cain then turned to areas in the 2014 fee schedule that CMS needs to revisit.

"The AAFP is disappointed that CMS did not take the opportunity to correct what we perceive to be a disturbing trend seen in the recommendations of the (AMA/Specialty Society) Relative Value Scale Update Committee (RUC)," said Cain, referring to the fact that the RUC makes recommendations to CMS on how CPT codes should be valued, which, in turn, aids the agency in determining how they should be paid. CMS is free to accept, reject or modify the RUC's valuation suggestions.

Story highlights
  • The AAFP recently took advantage of a commenting opportunity to thank CMS for some favorable policies included in the final 2014 Medicare physician fee schedule and then to revisit some areas of concern regarding valuation of services.
  • AAFP Board Chair Jeff Cain, M.D., questioned CMS' apparent acceptance of some recommendations from the AMA/Specialty Society Relative Value Scale Update Committee.
  • In particular, Cain asked CMS to re-examine the relative value units of any CPT codes for which the physician work relative value unit has not decreased in proportion to physician time to perform the service.

"Specifically, we note that the RUC has recommended dramatically decreased intra-service times for a number of codes while concurrently recommending unchanged or increased work RVUs (relative value units)" for those same codes, said Cain.

"Consequently, there is a significant increase in the calculated service intensity (i.e., intra-service work per unit of time) for those codes with no evidence that the service has, in fact, changed," he added.

The concern derives from the fact that, by accepting the RUC's recommendations in this particular situation, CMS agrees that certain procedures subspecialists typically perform will take less time to complete in 2014 -- perhaps because of increased physician skill or utilization of a new medical device -- but the agency still will pay the physician the same amount for performing that procedure.

Cain backed up his argument with several concrete examples in which he compared the 2013 and 2014 fee schedules. For example, he pointed out that in 2013, CPT code 35301 (thromboendarterectomy) had a work RVU of 19.61, an intra-service time of 144 minutes and total time of 431 minutes.

In 2014, CMS "apparently accepted" the RUC's recommendation that the work RVU be increased to 21.16, the intra-service time decreased to 120 minutes and the total procedure time decreased to 349 minutes.

"Thus, the work assigned to the code (RVU) increased 8 percent while intra-service time has decreased 17 percent and total time decreased 19 percent," wrote Cain.

Again, the concern is that CMS is saying some subspecialist procedures are taking less time, but the agency is not changing the work RVUs. That's important because a higher RVU translates to more money paid to the physician.

"To address these concerns, we encourage CMS to re-examine the RVUs of all of these codes and any others … where the physician work RVU has not decreased in proportion to physician time."

Cain pointed out that the Patient Protection and Affordable Care Act gives CMS the power to "evaluate overvalued and undervalued services provided by physicians," and he encouraged CMS to continue to evaluate overvalued services, as well as urging the agency to "use its authority to address undervalued services."

"In particular, we continue to believe that office-based evaluation and management (E/M) codes (99201-99215) are not appropriately valued and do not accurately capture the range of ambulatory E/M work done by physicians," said Cain.

Cain noted that new, as yet unpublished research seems to reaffirm previous findings that suggest the complexity and comprehensiveness of ambulatory E/M services vary widely by physician specialty, "with the complexity per unit of time being highest for primary care specialties." The AAFP is examining the implications of this research "for the current structure of ambulatory E/M codes and the values assigned to them" and, at the appropriate time, intends to share its conclusions with the agency, he added.

"In the meantime," Cain concluded, "we encourage CMS to do its own review of codes 99210-99215 and consider revaluing them in an appropriate manner."

Related ANN Coverage
Release of Final 2014 Medical Physician Fee Schedule Elicits AAFP Summary

AAFP Dissects, Responds to CMS' Proposed 2014 Medicare Physician Fee Schedule

AAFP Makes Case for New Primary Care E/M Codes
Letter, Supporting Research Materials Delivered to CMS


More From AAFP
Summary of the 2014 final Medicare physician fee schedule(27 page PDF)