2018 Physician Fee Schedule Recommendations
Following is a comment Jim Collins submitted to Medicare regarding their proposal to cut reimbursement for some pacemaker and defibrillator management services.
E. Potentially Misvalued Services Under the PFS
An impressive amount of data specific to remotely monitoring cardiac rhythm management devices was the basis for specialty society statements that establish remote monitoring as the standard of care.
“HRS Expert Consensus Statement on Cardiovascular Implantable Electronic Devices.”
Remote monitoring – a Class 1A recommendation “This consensus document reflects the wealth of recent clinical data generated by large randomized prospective trials from around the world that included patients with pacemakers, ICDs, and CRT-Ds from various manufacturers. These consistently show meaningful patient benefits from the early detection capabilities of automatic RM… These data form the basis of our recommendations that RM represents the new standard of care for patients with CIEDs”
AHA “Abstract 13944: Early Initiation of Remote Monitoring in CIED Patients is Associated with Reduced Mortality” “Our data show that survival is higher in patients who have a shorter time between device implant and remote monitoring initiation, across all CIED device types. These data suggest RM should be initiated as soon as possible following device implantation…early initiation of remote monitoring (within 91 days of device implant) reduces mortality by over 16%...”
One of the services I provide at CardiologyCoder.Com, Inc. is device clinic optimization. I frequently find that organizations are under billing, generating unnecessary administrative burden, and letting important clinical data go unchecked. Optimized device clinics include qualified nurses, device technicians, and physicians who work as a team to frequently evaluate data, communicate with patients, and coordinate care with other providers. Medicare payment policy makes it difficult to cover the cost of the staff needed to operate an optimized clinic. I appreciate this opportunity to make recommendations on the subject.
The proposed physician fee schedule presents codes 94726 (plethysmography), 76706 (abdominal aorta ultrasound), & 76586 (invalid code) as comparable to remote monitoring for pricing purposes. The first two codes are diagnostic tests that take place at one specific time – after the test is interpreted, the work stops. In contrast to that, remote monitoring is rendered over periods of either 30 or 90 days. Physicians occasionally receive multiple alerts within a monitoring period, must have multiple telephone conversations with patients during monitoring periods, and are effectively “on call” for all patients being remotely monitored, 24/7. Remote monitoring is far more physician and resource intensive than plethysmography and abdominal aorta ultrasound. More appropriate benchmarks should be used.
The proposed rule mentions that services related to the management and monitoring of cardiac rhythm management (CRM) devices like pacemakers, defibrillators, and implantable loop recorders are potentially misvalued. The proposed rule references the most misvalued code, 93299 - the technical component of remotely monitoring heart failure devices and implantable loop recorders, but indicates that no pricing changes are proposed for it.
I encourage Medicare to prioritize setting a fair payment rate for code 93299 because the current, contractor-priced, payment methodology is making the service price-prohibitive for patients in some regions of the country and not a viable service line for physicians in other regions. As outlined in the specialty society position statements above, remote monitoring should be the standard of care for all patients with CRM devices.
Under the contractor-priced methodology, Medicare Administrative Contractors have set payment levels for 93299 as low as $13 and as high as $204. This code is reported every 30 days. Because traditional Medicare patients incur a 20% coinsurance, patients in some states need to pay $31.20/year out of pocket while others must pay $489.60/year out of pocket for the same life-saving service. Additionally, physicians in some regions receive only $156 to provide the same service that another physician is paid $2,448 for.
Medicare pricing policy has suppressed the proliferation of remote monitoring. I request that Medicare consider a pricing policy that facilitates remote monitoring as the standard of care for all cardiac rhythm management and heart failure patients. To facilitate the proliferation of remote monitoring, I also request that Medicare explore options for eliminating the out of pocket expenses associated with remote monitoring. Since remote monitoring could be viewed as screening for arrhythmias and heart failure exacerbation, converting remote monitoring services to Medicare covered screening services may be an efficient way to eliminate the out of pocket expenses.
Patient visits, coronary, peripheral vascular, pacemaker/defibrillator, electrophysiology, & device clinic
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Jim Collins, CPC, CCC