Here’s How CMS’s Reimbursement Review Will Go Down

The Centers for Medicare and Medicaid Services (CMS) has ordered a review of Medicare reimbursements for total hip arthroplasty (THA, CPT Code 27130) and total knee arthroplasty (TKA, CPT code 27447) based on allegations that surgeons are overpaid (see Anthem Lobbying Hard to Slash TKA, THA Pay) and has asked the Relative Value Scale Update Committee (RUC) of the American Medical Association (AMA) and other stakeholders to comment.

Here’s how it will go down.

The medical societies’ and RUC’s part of the process for reviewing these seven Relative Value Units (RVU) is clear and well-mapped. It moves slowly. Under the CMS schedule, nothing will change in reimbursements for TKA and THA in 2019 or 2020.

However, small or even major changes in surgeons’ reimbursements for TKAs and THAs are possible in 2021. Then, cuts in reimbursements for other surgical procedures could follow.

“When CMS puts something forward like that, we send out to all the specialties what we call a “level of interest” form, which asks the specialties societies what they want to do,” said Peter K. Smith, M.D., chair of the AMA RUC. That has been done.

Then, Dr. Smith said, the societies would decide what to do. One of several options is to survey members on the time it takes for the procedure itself and other time the physician or practice takes for related activities.

William R. Creevy, M.D., M.S., the American Academy of Orthopaedic Surgeons (AAOS) representative to the RUC, said that for a 90-day CPT code (which both THA and TKA are), if a survey is done, then:

“In general, the RUC surveys inquire about physician time and effort…specific questions about time a physician spends in various components of the procedure(s) under review. These include ‘pre’ time (time spent evaluating a patient, time spent positioning a patient, and time spent in scrub, dress and wait) ‘intra’ time (skin to skin or actual procedure time, for example, time from incision…to closing the skin for the TKA), and ‘post’ time…both time on the day of the procedure while the patient is still in the facility, as well as post-operative time spent with patient for the 90-days post-operatively which includes patient visits in facility as well as in physician offices.”

“Survey respondents are also asked to assess the relative complexity and intensity of the procedure(s) being reviewed and to assign an approximate relative value unit for the procedure(s) under review. The surveys only address the work RVU. Practice expense RVUs and malpractice RVUs are determined through other processes and also reviewed by the RUC and forwarded to CMS as part of the total RVU calculations.”

If surveys are done, Dr. Creevy said, they’re usually distributed 2-3 months in advance of the RUC meeting at which the data will be presented. “The surveys are in the field for 3-4 weeks and then are summarized and recommendations developed which are then forwarded to the RUC approximately a month before the relevant RUC meeting.”

Dr. Smith said the RUC “would then evaluate all those components and the work value and vote on a recommendation, which would then be passed on to CMS for what the new values should be…It could be the same value, it could be a higher value, it could be a lower value and then CMS will decide if it agrees with that.”

The rest—that is, when a docket for public comments will open, and probably most important, what happens behind the scenes—are less clear. At some point in 2020, CMS will have to publish a proposed rulemaking.

Why There’s an “if” Regarding the Surveys

“The reason we say ‘if,’” an AAOS spokesperson explained, “is because none of the affected societies (as far as we know), including AAOS and AAHKS for the hip and knee codes, have determined the processes for developing recommendations to the RUC that will be utilized. We do intend to present them, as we have for all procedures we review at the RUC, and they can be derived from numerous sources and methods.”

“The typical method is to conduct the standard RUC surveys. However, reviewing societies have multiple methods, including crosswalks to recently valued and similar procedures, presentation of time and inputs from other data sources, and reaffirmation of recent surveys for the procedure(s) under review if a recent survey has been conducted, or any combination of the above.”

“The decision on which of these methods to use is still under review, by AAOS and AAHKS, and most likely other societies as well. The RUC staff is aware of this fact, and society staff have been in regular contact with them on these processes.”