HRS Leads Opposition to CMS CY22 Reimbursement Cuts

MARCH 2022

Summary of HRS efforts to prevent reductions to ablation reimbursement by CMS

DECEMBER 20, 2021

In its final rule in November 2021, the Centers for Medicare and Medicaid Services (CMS) ultimately did not change course. In direct contradiction to requests from HRS, ACC, and the AMA RUC, the final rule maintained the old value of the base codes with no additional compensation for the add-on codes.

WHAT IS HAPPENING AND HOW DID WE GET HERE?

I. BUNDLING AND REVALUATION OF THE ABLATION CODES:

• The SVT ablation code was redefined with bundled services to include LA pacing and 3D mapping.
• The AF ablation code was redefined with bundled services to include ICE and 3D mapping.

Why did this happen?

• An automatic review mechanism was triggered because the add-on codes noted above were consistently billed together with the main ablation codes in the vast majority of cases (>70% of the time performed together). This review led to the bundling of several services into the existing codes.
• The new bundled services were then surveyed to determine new valuation for the combined procedures. HRS CPT and RUC advisors advocated for our interests during this process.

How was the value determined?

• Per AMA RVS Update Committee (RUC) requirements, surveys were sent to randomly selected HRS members to document the time and intensity of these procedures (November 2020).
• HRS RUC Advisors raised concerns that the survey results may have been inaccurate. Respondents may not have understood that the services were to be bundled, resulting in the reported time and intensity being artificially low.
• The RUC permitted a second survey. This second survey (fielded in February 2021) was carefully crafted to emphasize the bundling of services for our member respondents.
• Because results of the second survey would not available by the January 2021 RUC meeting, HRS RUC Advisors (in collaboration with ACC Advisors) defended interim values based on the first survey for calendar year (CY) 2022, emphasizing the intensity of ablation procedures (since those initial survey results indicated that the duration of the procedure was greatly reduced compared to existing values).

• The recommendation to accept the January interim values was sent to CMS.
• In the meantime, the second survey results were similar to the initial survey (i.e., showing greatly reduced times for performance of the procedures). At the April 2021 RUC meeting, HRS RUC Advisors (in collaboration with ACC Advisors) defended the proposed values based on the intensity of the procedures, which we continue to believe are appropriate even with the apparent reductions in procedural times.
• In the CY 2022 Medicare Physician Fee Schedule (MPFS) proposed rule (released in July 2021), CMS did not accept the interim value recommendations from the RUC. Instead, CMS decided to simply keep the original values of the base codes without accounting for the codes that will be bundled beginning on January 1, 2022.

What did HRS do to prevent the proposed rule values from becoming final?

• HRS and ACC vehemently protested this proposed rule. We employed multiple strategies to galvanize the heart rhythm community to come together to protest the flawed logic that led to the values in the proposed rule and the potential unintended consequences. These efforts included:
  • Two meetings with CMS
  • 20+ meetings with allies and partners, including ACC, AMA RUC, patient advocacy groups, and industry
  • 30,000+ emails to HRS members with calls-to-action and suggested talking points
  • Numerous social media posts, website updates, and member Community posts
• This HRS-led campaign resulted in 700+ comment letters opposing the proposed rule, submitted to CMS on behalf of organizations, clinicians, patients, hospital systems, and other partners.

What was the result of these combined efforts?

• In November 2021, CMS ultimately did not change course in its final rule, maintaining the old value of the base codes with no additional compensation for the add-on codes.
• In direct contradiction to requests from HRS, ACC, and the AMA RUC, for 2022, CMS finalized the same 2021 work relative value units (wRVUs) for cardiac ablation CPT codes 93653 and 93656 without any recognition that in 2022 these codes will also represent the work captured in what had been separately billable codes (CPT codes 93613, 93621, and 93662) prior to 2022.
• CMS holds the authority and discretion to address these issues; CMS stated in the CY 2022 MPFS final rule that it will consider the information from the April 2021 AMA RUC meeting as part of its CY 2023 MPFS rulemaking cycle.

II. CMS REDUCTIONS SCHEDULED FOR 2022 THAT AFFECT EVERY SPECIALTY (SEQUESTRATION, PAYGO, ETC.):

• CMS finalized a CY 2022 MPFS conversion factor over 3.7% lower than in 2021. This reduction is due to the expiration of the 3.75% payment boost Congress provided to the conversion factor for 2021. A legislative package was aimed at avoiding a scheduled 10.6% cut in the 2021 conversion factor triggered by budget neutrality. The budget neutrality adjustment was due to the significant increases in the office and outpatient evaluation and management code set in 2021. The expiration of the 3.75% payment boost was a major driver of the 2022 MPFS conversion factor reduction.
  • As a result of advocacy efforts across the entire field of medicine, on December 10, 2021, President Joseph R. Biden signed the Protecting Medicare and American Farmers from Sequester Cuts Act into law. This Act mitigates the planned cut to the CY 2022 MPFS conversion factor by including another one-year increase to the conversion factor, this time for 3.0%.
• The severe cuts to reimbursement would have been further exacerbated if Congress had not avoided two additional statutory cuts. These are what you have likely heard referred to as “sequestration” reductions:
  • One sequestration reduction is a mechanism that had been in place prior to the COVID-19 public health emergency (PHE) and is capped at -2.0% as it applies to Medicare payments. In COVID response legislation, Congress lifted this sequestration cut temporarily. Until the passage of the Protecting Medicare and American Farmers from Sequester Cuts Act, the cut was scheduled to return for claims for services furnished beginning January 1, 2022. The statute now leaves a moratorium in place on the -2.0% sequester for the first quarter of 2022. A sequester will then begin to be phased in, with a 1.0% reduction to Medicare payments for Q2 2022. The full sequester will return for the rest of 2022, starting on July 1, 2022.
  • A second sequestration reduction is triggered by federal “pay-as-you-go” (PAYGO) rules requiring cuts in spending when legislation is enacted that does not raise enough revenue to fund the increased spending it brings. As a result of the passage of the American Rescue Plan, Congressional action was needed to waive this additional -4.0% sequestration of Medicare payments. The Protecting Medicare and American Farmers from Sequester Cuts Act addressed this by postponing the PAYGO sequestration for a year. However, additional Congressional action could be needed to avoid these cuts in CY 2023.
• Cumulatively, these relief provisions mitigate what would have been a roughly 9.0% cut in overall payments to an approximately 2.0% reduction throughout 2022, keeping in mind that the sequestration relief is different at different points in the year.

OUR COMMITMENT AND ACTIVITY TO SUPPORT YOUR PRACTICE

In addition to the turbulence of practicing in the COVID-19 pandemic, these combined federal policies are poised to place enormous pressure on EP practices and departments. Our efforts to represent your interests and the field of EP remain diligent. We are committed to continuing this push in the face of these tremendous external pressures and want to ensure that you are aware of the work that we have done to date:

• HRS is actively working to mitigate these reductions, including close collaboration with ACC in concert with other organizations to maximize our effectiveness.
• Because we understand that navigating these rough waters requires information, we published resources on this page dedicated to creating awareness and advocating against these cardiac ablation developments. As we previously reported, these resources resulted in tremendous outreach by you and your colleagues.
• HRS Advisors represent our Society’s interests and regularly advocate on our behalf within the rules of each organization, panel, and committee. We also collaborate with ACC Advisors and staff on these processes. Through HRS, you are represented on the:
  • AMA House of Delegates
  • AMA CPT Panel
  • AMA RUC

Please continue to visit this page for ongoing updates and notifications of new advocacy opportunities to convince CMS to accept the AMA RUC recommended work RVUs in 2023 and phase in any remaining reductions in reimbursement.

WHAT’S NEXT?

For the policies specifically affecting the cardiac ablation codes:

• We will continue to partner with the AMA RUC and ACC to push for implementation of the AMA RUC recommended work RVUs for these codes. Together with ACC, we have submitted a letter to CMS urging them to accept the RUC recommendations and phase in ablations cuts. HRS RUC representatives intend to reference this letter at the January 2022 RUC meeting.
• Additionally, we are working to meet with CMS again as soon as possible to continue this push and phase in any remaining reductions in payment.
• Physicians with compensation that is RVU-based will need to consider the implications when working on future salary structures, understanding the overall value of the ablation procedures. Hospital payments have been increased by nearly 3.0% for the same codes for which physician payments will be cut. Please reference the available resources on this page to help you assess the impact of these changes on your practice and support future discussions around compensation.
• We will keep you apprised of these activities and notify you of additional opportunities to conduct outreach to achieve these goals.

HRS understands there is a tremendous amount of pressure on your practices. The current environment in which you practice has only made these payment policy challenges all the more difficult. Yet, in this difficult environment, so many of you have taken the time to help in these advocacy efforts, and we cannot thank you enough. Our fight continues on these issues with the same vigor that many of you have demonstrated since the beginning.

ADDITIONAL RESOURCE

NOVEMBER 2, 2021

CMS released the CY 2022 Medicare Physician Fee Schedule (MPFS) and Hospital Outpatient Prospective Payment System (OPPS) Final Rules. The cardiac ablation codes were finalized as proposed.

The final rule puts forward a CY 2022 MPFS Conversion Factor (CF) of $33.5983. This includes a slightly modified CY 2022 budget neutrality adjustment of only 0.10% — it was 0.14% in the proposed rule. However, the overall drop in the CF from CY 2021 is still over 3.7% due to the expiration of the Congressional 2021 payment increase of +3.75%.

While HRS is disappointed with the final rule, learning that CMS will consider the RUC recommendations in 2022 offers hope that there could be a slight increase in 2023. HRS, alongside our members, partners, and patients will remain diligent in the fight for fair compensation and the prevention of unintended consequences.

• MPFS:
  • Full Rule: Click Here
  • CMS MPFS Press Release: Click Here
  • CMS MPFS Fact Sheet: Click Here
• OPPS:
  • Full Rule: Click Here
  • CMS OPPS Press Release: Click Here
  • CMS OPPS Fact Sheet: Click Here

OCTOBER 27, 2021

The comment submission period closed on September 13, 2021. HRS expects to learn if its joint efforts had an impact on the proposed code changes during the first week of November 2021.

In the meantime, HRS would like to thank all of the HRS members who contributed their time and expertise to combating these proposed changes. Additionally, HRS thanks its allies and partners in this fight, including the American College of Cardiology (ACC), the American Medical Association RVS Update Committee (AMA RUC), patient advocacy groups such as StopAFib.org, and industry partners.

Together, our grassroots campaign to activate hospital system leadership, patients, and congressional representatives ensured that the EP community's collective voice of deep concern was heard.

AUGUST 31, 2021

HRS submitted its recommendations to the Centers for Medicare and Medicaid Services (CMS) on the Agency's proposed payment impact to EP services under the Medicare Physician Fee Schedule for Calendar Year 2022.

AUGUST 15, 2021

What can you do?

1. Write and submit your own letter to CMS before the September 13, 2021, deadline. Please reference these additional resources to help you get started. It is important to note that CMS will likely disregard your letter if it contains recurring boilerplate language. Thus, HRS recommends expressing your thoughts and concerns in your own words.
    
   • Summary: Potential Unintended Consequences of Proposed CMS Cuts to AF Ablation Code
      
   • Sample Letter 1
      
   • Sample Letter 2
      
2. Talk with your hospital system to ensure their awareness of these proposed cuts and convince them to submit their own letters to CMS.
    
3. Contact your federal lawmakers to ensure they are aware of the cuts and the impacts these cuts will have on healthcare delivery.

AUGUST 14, 2021

HRS Action Plan to Address Proposed Cuts

This extreme CMS undervaluation of ablation services is of the highest priority and HRS will vigorously advocate on behalf of you, your patients, and the services that you perform.

Since the release of CMS' proposed physician payments for 2022, HRS has been collaborating with the American College of Cardiology (ACC), the American Medical Association's Relative Value Scale Update Committee (RUC), and industry partners to develop and deliver a unified response.
 
On August 24, 2021, HRS, ACC, and RUC staff will meet with CMS leaders to learn more about the Agency's decision to propose these drastic cuts and to recommend that CMS apply the RUC's recommendations. HRS President Fred M. Kusumoto, MD, FHRS, will also arrange a meeting with CMS and fellow HRS leaders to discuss the unintended consequences that the proposal will have on patient care, EP programs, and hospitals.
 
HRS will submit a comment letter to CMS before the submission deadline on September 13, 2021. The CY 2022 MPFS final rule is expected in early November 2021.

JULY 13, 2021

Proposed Changes

*As of August 17, 2021

CMS Proposes to Reduce the MPFS Conversion Factor by Nearly 3.75%

If finalized and without Congressional intervention, the CY 2022 MPFS conversion factor would be reduced by nearly 3.75%, going down from $34.8931 in 2021 to $33.5848 in 2022. This reduction would span across all services and continue the sustained assault on overall Medicare payments. HRS will urge CMS and Congress to avoid these continued financial pressures on physician practices while Medicare payments to facilities continue to see year-over-year inflationary increases in their payments. These cuts could be exacerbated by the 2022 sequestration cuts expected if Congress does not intervene.

CMS Proposes to Ignore Recommendations on Work Valuation for Bundled Ablation Services

As expected, CMS addressed the work values for revised CPT codes 93653 (SVT ablation) and 93656 (AF ablation). CPT codes 93653 and 93656, typically furnished in conjunction with add-on codes CPT 93613, and CPT 93621 or 93662, were expected to bundle the services associated with the add-on codes. In conjunction with that bundling, the work RVU value was expected to increase to reflect that the services in the add-on codes were now bundled into the base codes. However, CMS has inexplicably proceeded with the bundling of the add-on codes into the base codes without any congruent increase in the work values of the base codes to reflect the increased level of service. HRS vehemently opposes the CMS decision to maintain the work values for a base code that is now intended to reflect the work associated with previously billed add-on codes. This undervaluation of EP services is unjustifiable, and HRS will work with CMS, ACC, and the AMA to prevent these unsubstantiated cuts to services that you provide and from which patients benefit every day.

CMS Proposes Drastic Fluctuations in Practice Expense RVUs

HRS will continue to analyze the proposals and provide additional information. However, the proposed rule will also have a significant impact on reimbursements for practice expenses (PEs). For example, due to a combination of the new bundling policy and other PE changes made in the rule, RVUs for PE for CPT 93653 will drop by approximately 35% under the new proposals[b3] if CMS continues to treat the add-on codes as bundled even though it inappropriately refused to make requisite changes to the RVUs.