Rheumatology Faces Some Heavy Reimbursement Cuts

When it comes to billing and coding in 2014, the biggest topic swirling around the healthcare industry is the impending October implementation of ICD-10. But, for rheumatology, there’s more going on with reimbursement than a single move to a system with more than 69,000 codes.

In a healthcare environment where policies are changing quickly, the American College of Rheumatology (ACR) recommends providers and their practices stay current with any and all coding changes. Doing so is a major part of ensuring they’re following regulations correctly, along with examining all parts of their business models and workflow.

“Managing an efficient practice requires seamless and transparent protocols for areas, such as collections, risk management, compliance, coding, and documentation,” the ACR said on its web site. “The healthcare industry is shifting focus on fraud and abuse, with the ultimate goal to facilitate quality patient care through proper documentation and medical necessity.”

A significant portion of providing proper documentation will be understanding the coding changes for the next year. And, thanks to this year’s final rule from the Center for Medicare & Medicaid Services (CMS), rheumatologists can expect to see deep cuts in payments for several frequently-performed procedures. To make it easier for providers to follow new regulations, the ACR has published its coding manual online.

Most reimbursement changes amount to a 1 percent to 2 percent increase or decrease in 2013 payments. However, CMS has mandated double-digit cuts for three procedures when they’re performed in non-facility environments, such as a physician’s office or a patient’s home. One service will also drop by nearly 30 percent in the hospital setting.

Specifically, reimbursement for arthocentesis of the intermediate joint (20605) will drop 23 percent to $50.61 in non-facility settings and 27 percent to $38.31 in hospitals. Also in non-facility settings, echo-guided biopsy (76942) plummets 64 percent to $74.56, and the technical component for the same procedure (76942-TC) falls by 77 percent to $40.50.

In addition, payment frustrations still exist with codes for the evaluation and management services, also called cognitive services, rheumatologists almost exclusively provide to ensure patients fully understand their health conditions and needed treatments. This family of codes – 99201-99205 for new patients and 99211-99215 for established patients – saw virtually no change in reimbursement from 2013.

But, according to a study published in an October issue of Journal of the American Medical Association (JAMA) Internal Medicine, payments that hold steady aren’t necessarily good news for rheumatologists who view cognitive services as their bread-and-butter. While the study didn’t focus exclusively on rheumatology services, the findings indicate that Medicare reimburses many procedures up to nearly 500 percent more than it does for the equivalent time spent on cognitive services required to explain those procedures to patients.

In fact, study authors, Christine A. Sinsky, MD, a physician from Dubuque, Iowa, and David C. Dugdale, MD, from the University of Washington-Seattle, point to such high reimbursement rates as factors in “the financial pressures that may contribute to the U.S. healthcare system’s emphasis on procedural care” rather than services that educate patients.

Bringing reimbursement levels for cognitive services more in-line with those for procedural services is critical to the financial survival of providers whose main responsibility is educating patients, according to Timothy Laing, MD, the ACR’s government affairs committee chair.

“Specialists like rheumatologists will typically provide highly complex and appropriate care for patients in a shorter time than others who do not have the training and expertise acquired by rheumatologists,” Laing stated in a letter to the U.S. Department of Health and Human Services. “Because of their additional training and expertise, a rheumatologist may spend less time to come to a superior conclusion for a patient than another provider who does not have that training and expertise.”

This extra level of competence deserves adequate compensation, he said.

Although the ACR continues to work with CMS to secure proper payment for all rheumatology services, individual providers and practices are still responsible for learning how these coding changes will affect their daily activities and bottom line. They should design and implement protocols that help them work within all CMS guidelines.

“It is vital for rheumatology practices to understand the risk areas in documentation and coding to avoid unnecessary audits, penalties, and fines,” the ACR wrote on its web site. “Compliance policies and procedures should be in place to address coding and billing issues, quality assurance, and medical necessity in 2014 and beyond.”