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Targeting Cancer Care

2013 proposed rule negatively impacts radiation oncology services

Medicare estimates a negative 15 percent impact


On July 6, 2012, the Centers for Medicare and Medicaid Services (CMS) issued a proposed rule that would revise several reimbursement payment policies and rates for services furnished under the Medicare Physician Fee Schedule as of January 1, 2013. The proposed changes would result in an overall 15 percent reduction in payment for radiation oncology services. The 15 percent cuts represent a $300 million loss for the provision of cancer care services. ASTRO is concerned that these proposed changes would significantly jeopardize access to care. The most significant portion of the cut, 7 percent, is due to a change in the treatment times for IMRT and SBRT procedure codes. Reduced procedure times would negatively impact patient safety.

Significant reductions proposed for IMRT, SBRT delivery services
CMS proposes to adjust the payment rates for intensity modulated radiation treatment (IMRT) and stereotactic body radiation therapy (SBRT). CMS is proposing to adjust the procedure time assumption for IMRT delivery (CPT code 77418) from 60 minutes to 30 minutes. CMS is also proposing to adjust the procedure time for SBRT delivery (CPT code 77373) from 90 minutes to 60 minutes. IMRT delivery reimbursement would decrease by 40 percent in 2013. SBRT delivery reimbursement would decrease by 28 percent in 2013. CMS is using “publicly available resources” such as patient information material to make these drastic changes, an approach they generally do not use. CMS requested recommendations from the AMA RUC and other public commenters on the direct PE inputs for these services.

One positive note is that for 2013, CMS is proposing to include the seven equipment items omitted from the RUC recommendation for CPT code 77418, which were not included in the 2012 fee schedule. ASTRO and other stakeholders made multiple requests to CMS to make this change, and the Society is pleased to see that CMS has responded to these requests.

CPT Code 77427, Radiation treatment management gets 3.65 percent increase
CPT code 77427, Radiation treatment management is experiencing an uptick in 2013 as a result of an increase in practice expense RVUs. The 2012 PE RVU for 77427 are 1.56 and CMS is proposing 1.75 for 2013.

2012 Medicare Rate  2013 Proposed Medicare rate  % Difference 
$177.00 $183.46 3.65%
2012 Medicare Conversion Factor ($34.037) used to calculate rates for both years.

Other proposals impacting radiation oncology services
Table 84 in the proposed regulations shows the proposed payment policy impact on physician services. These impacts do not include the effects of the negative January 2013 conversion factor change under current law. The cumulative impact on radiation oncology as a result of these various proposals is negative 15 percent.

TABLE 84: 2013 PFS Proposed Rule Estimated Impact on Total Allowed Charges by Specialty by Selected Proposal* 
(A) (B) (C ) (D) (E) (F) (G)
Specialty  Allowed Charges (mil)  Baseline (PPIS transition, new utilization and other factors)  Updated Equipment Interest Rate Assumption  Discharge Transition Care Management  Input Changes for Certain Radiation Therapy Procedures  Total (Cumulative Impact) 
Total  $85,485 0% 0% 0% 0% 0%
37-RADIATION ONCOLOGY $1,982 -3% -3% -2% -7% -15%
38-RADIOLOGY $4,724 -2% -1% -1% 0% -4%
57-RADIATION THERAPY CENTERS  $71 -4% -5% -2% -8% -19%

*Table 84 shows only the proposed payment policy impact on PFS services. We note that this impact does not include the effects of the negative January 2013 SGR conversion factor change under current law.   

  • Baseline (PPIS transition, new utilization and other factors) – The impact of this policy on radiation oncology services is negative 3 percent. This policy refers to the final year of a four-year transition to updated practice expense data and a proposed policy to expand the multiple procedure payment reduction for the technical component (TC) of cardiovascular and ophthalmology diagnostic tests furnished on the same day.
  • Updated Equipment Interest Rate Assumption - The impact of this policy on radiation oncology services is negative 3 percent. CMS is proposing to update the interest rates used in the practice expense (PE) methodology. Capital-intensive specialties are projected to decrease due to these proposed changes in how the interest rate used in the PE calculation is estimated. CMS is proposing to use a “sliding scale” approach based on the current Small Business Administration (SBA) maximum interest rates for different categories of loan size (price of the equipment) and maturity (useful life of the equipment). As a result, the interest rate assumptions will change from 11 percent to a range of 5.5 to 8 percent. 
  • Discharge Transition Care Management – The impact of this policy on radiation oncology services is negative 2 percent.  CMS published a proposal to refine PFS payment for post-discharge care management services. CMS will continue to consider other enhancements to payment for primary care services and complex chronic care coordination services, and they may publish further proposals in future rulemaking.
  • Input Changes for Certain Radiation Therapy Procedures – The impact of this previously described policy on radiation oncology services is negative 7 percent.

Numerous radiation oncology services identified for review
CMS is proposing to review and make adjustments to CPT codes with stand alone procedure time assumptions used in developing nonfacility PE RVUs. CMS has identified several codes (mostly radiation oncology codes) that have annual Medicare allowed charges of $100,000 or more, include direct equipment inputs that amount to $100 or more and have PE procedure times of greater than five minutes. Although there are other CPT codes that are valued in the same manner, they are not proposing to review them at this time. The following radiation oncology services have been identified:

  • 77280 Set radiation therapy field
  • 77285 Set radiation therapy field
  • 77290 Set radiation therapy field
  • 77301 Radiotherapy dose plan imrt
  • 77338 Design mlc device for imrt
  • 77372 Srs linear based
  • 77373 Sbrt delivery
  • 77402 Radiation treatment delivery
  • 77403 Radiation treatment delivery
  • 77404 Radiation treatment delivery
  • 77406 Radiation treatment delivery
  • 77407 Radiation treatment delivery
  • 77408 Radiation treatment delivery
  • 77409 Radiation treatment delivery
  • 77412 Radiation treatment delivery
  • 77413 Radiation treatment delivery
  • 77414 Radiation treatment delivery
  • 77416 Radiation treatment delivery
  • 77418 Radiation tx delivery imrt
  • 77600 Hyperthermia treatment
  • 77785 Hdr brachytx 1 channel
  • 77786 Hdr brachytx 2-12 channel
  • 77787 Hdr brachytx over 12 chan

Public nomination of potentially misvalued codes – CPT Code 77336 medical physics code identified
This year is the first year CMS is considering codes that they received through the new public nomination process for potentially misvalued codes. In the 60 days following the release of the 2012 PFS final rule, nominations and supporting documentation for review of 36 CPT codes. One of these nominations included CPT code 77336, Continuing medical physics consultation, including assessment of treatment parameters, quality assurance of dose delivery and review of patient treatment documentation in support of the radiation oncologist, reported per week of therapy.

CMS proposed to review CPT code 77336 as potentially misvalued and requested recommendations from the AMA RUC and other public commenters on the direct PE inputs for this service and physician work relative value units (RVUs) and direct PE inputs for the other services within this family of CPT codes.

Radiation oncology specific changes to the Medicare Physician Quality Reporting System (PQRS)
The Physician Quality Reporting System (PQRS) is a pay-for-reporting program that uses a combination of incentive payments and downward payment adjustments to promote reporting of quality information by eligible professionals (EPs). CMS made a number of changes to Medicare PQRS program. Two of these changes directly impact radiation oncology providers.

CMS proposes to retire PQRS #105 in PQRS 2014 and beyond (Prostate Cancer: Three Dimensional (3D) Radiotherapy).

Also, ASTRO is pleased to report that CMS is proposing an oncology measures group for PQRS 2013 and beyond as requested by ASTRO. Participating via a measures group versus individual measures significantly reduce the burden of participating in PQRS and increases the chances of success. The following measures are included in the proposed measures group:

  • 71 Breast Cancer: Hormonal Therapy for Stage IC-IIIC Estrogen Receptor/Progesterone Receptor (ER/PR) Positive Breast Cancer 
  • 72 Colon Cancer: Chemotherapy for Stage III Colon Cancer Patients 
  • 110 Preventive Care and Screening: Influenza Immunization 
  • 130 Documentation of Current Medications in the Medical Record 
  • 143 Oncology: Medical and Radiation – Pain Intensity Quantified 
  • 144 Oncology: Medical and Radiation – Plan of Care for Pain 
  • 194 Oncology: Cancer Stage Documented 
  • 226 Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention

Other Quality Related Proposals
The proposed rule also includes significant discussion on a variety of quality related proposals. While these proposals will be discussed in greater detail in a separate summary, brief highlights are included here.

  • Physician Compare Website – The Affordable Care Act requires CMS to implement a plan for making information on physician performance publicly available no later than January 1, 2013. The 2013 MPFS proposed rule outlines the next phase of the plan to publicly report physician performance information on Physician Compare.
  • Physician Quality Reporting System (PQRS) - CMS proposes several updates to the PQRS related to the 2013 and 2014 PQRS incentives and the 2015 and 2016 PQRS payment adjustments.
  • Electronic Prescribing Incentive Program - The Electronic Prescribing (eRx) Incentive Program is a reporting program that uses a combination of incentive payments and downward payment adjustments to encourage electronic prescribing by EPs. The program provides incentive payments through 2013 to individual EPs and group practices that are successful e-prescribers for covered professional (MPFS) services furnished to Medicare Part B fee-for-service beneficiaries. From 2012 through 2014, the program applies a payment adjustment to those EPs who are not successful electronic prescribers. CMS is proposing new criteria for being a successful electronic prescriber for groups of 2-24 EPs using the eRx GPRO. CMS is also proposing two additional significant hardship exemptions to the 2013 and 2014 payment adjustments related to participation in the EHR Incentive Program. Finally, CMS is proposing to establish an informal review process. CMS invites public comments on the eRx proposals.
  • Medicare Shared Savings Program - The proposals for the Medicare Shared Savings Program set forth in the 2013 MPFS proposed rule impose requirements that eligible professionals in group practices within accountable care organizations would need to satisfy for purposes of the PQRS payment adjustment under the Medicare Shared Savings Program as the proposals related to the ACOs for the PQRS payment adjustment mirror the requirements that were established for earning the PQRS incentives.
  • Physician Value-Based Payment Modifier and Physician Feedback Reporting - The proposed changes to the Physician Feedback Program will not impact 2013 physician payments under the PFS. However, CMS expects that their proposals to use the Physician Quality Reporting System (PQRS) quality measures in the Physician Feedback reports and in the value modifier, to be implemented in 2015, may result in increased participation in the PQRS in 2013.

Expanding the multiple procedure payment reduction policy (MPPR)
CMS is proposing to expand the MPPR policy and apply it to the TC of several cardiovascular and ophthalmology services. No radiation oncology services are being impacted by this proposal. For cardiovascular diagnostic services, CMS reviewed the code pair/combinations with the highest utilization in code ranges 75600 through 75893, 78414 through 78496 and 93000 through 93990.   

Due to a technical error, the MPPR is not being applied to CPT codes 78306 (Bone imaging; whole body when followed by CPT code 78320 (Bone imaging; SPECT). CMS will apply the MPPR to these procedures effective January 1, 2013.

CMS finalized a policy to apply the MPPR to the PC and TC of the second and subsequent advanced imaging procedures furnished to the same patient in the same session by a single physician or by multiple physicians in the same group practice for 2012. However, due to operational limitations, they were not able to apply this MPPR to multiple physicians in the same group practice during 2012. They have resolved the operational problems and, therefore, for services furnished on or after January 1, 2013, they will apply the MPPR to both the PC and the TC of advanced imaging procedures to multiple physicians in the same group practice (same group NPI). Again, no radiation oncology services are being impacted by this proposal.

Review of Harvard-valued services with Medicare allowed charges of $10 million or more
CMS proposes to review Harvard-valued services with Medicare allowed charges of $10 million or greater per year. No radiation oncology codes are on this list.

Ordering of portable X-ray services
CMS proposes to revise their current regulations, which limit ordering of portable X-ray services to only an MD or DO, to allow other physicians and nonphysician practitioners acting within the scope of their Medicare benefit and state law to order portable X-ray services. This proposed change would allow an MD or DO, as well as a nurse practitioner, clinical nurse specialist, physician assistant, certified nurse-midwife, doctor of optometry, doctor of dental surgery, doctor of dental medicine, doctor of podiatric medicine, clinical psychologist and clinical social worker to order portable X-ray services within their state scope of practice and the scope of their Medicare benefit. CMS has requested public comments on this change.

Global surgical packages
CMS is seeking comments on methods of obtaining accurate and current data on evaluation and management (E/M) services furnished as part of a global surgical package. They have requested comments on a claims-based data collection approach that would include reporting E/M services furnished as part of a global surgical package, as well as other valid, reliable, generalizable and robust data to help them identify the number and level of E/M services typically furnished in the global surgical period for specific procedures. Since radiation oncology services are typically not part of a global surgical package, this proposal is not likely to have impact on ASTRO members.

Malpractice RVU
There are no substantial proposals related to malpractice RVUs in 2013.

Geographic Practice Cost Indices (GPCIs)
This proposed rule does not include any new proposals related to the GPCIs.

The proposed regulations also address a number of other topics including telehealth Services, DME Face-to-Face proposal, Part B drug payments, elimination of prepayment medical review limitations, payment for molecular pathology and therapy data collection (non-RO issue) that have not been addressed in this summary.

The regulations are available on the CMS website. Comments are due September 4, 2012. ASTRO will be conducting a thorough analysis of the rule and submitting comments.

Content last updated 7/9/2012
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