Press Releases

ACR Responds to 2018 Medicare Physician Fee Schedule Proposed Rule

Rheumatology community applauds CMS for incorporating stakeholder input and offers suggestions regarding practice expense codes, E/M services, and payment for biosimilar therapies under Medicare Part B

WASHINGTON, DC – The American College of Rheumatology (ACR) today submitted detailed comments to the Centers for Medicare and Medicaid Services in response to the CY 2018 Physician Fee Schedule Proposed Rule.

The ACR applauded CMS for its willingness to seek robust stakeholder input and praised numerous elements of the proposed rule – including changes to practice reporting requirements, value modifier program adjustments, relative value units (RVUs), and appropriate use criteria (AUC) – that would achieve greater program flexibility and simplification for providers.  

A principal area of concern that rheumatology leaders would like to see modified in the final rule is CMS’ proposed reimbursement cuts for musculoskeletal ultrasound services. Additional areas include revisions to Medicare’s evaluation and management (E/M) codes, and the agency’s plan to assign the same billing and payment code to all biosimilar products of a reference biologic.

“We welcome the opportunity to share with CMS our feedback about the impact of this proposed rule on rheumatology providers, especially those serving rural and underserved Medicare patient communities,” said Sharad Lakhanpal, MBBS, MD, President of the ACR. “After detailed review of the proposed rule, the ACR has outlined several areas of concern that must be addressed to ensure Medicare patients living with rheumatic diseases are able to continue accessing high-quality rheumatology care.”

While the rheumatology community generally supports CMS’ approach to relying on the American Medical Association’s Relative Value Scale Update Committee (RUC) recommendations in determining reimbursement rates, the ACR is troubled by the agency’s proposed reduction to current procedural terminology (CPT) code 76881, which covers musculoskeletal ultrasound services. Musculoskeletal ultrasound is emerging as a vital point-of-care tool for rheumatologists. The ACR believes that CMS’ proposed cut will reduce patient access to this important diagnostic test while increasing the use of more expensive advanced imaging, such as magnetic resonance imaging.

Concerning evaluation and management (E/M) billing codes, the ACR agrees with CMS that the current codes are potentially outdated and in need of revision. However, the ACR believes the agency’s focus on using history of present illness (HPI) and a physical exam in new code determination is not sufficient to address the growing complexity and requirements of E/M visits. As a result, the current proposal will likely result in codes that fall short of capturing the full breath of services required by many Medicare beneficiaries, especially those with multiple, chronic conditions that need extensive evaluations and complex, multi-pronged treatment regimens. Therefore, the ACR believes that CMS should place less emphasis on the HPI and physical exam features and instead allow physicians to document complexity in the components of the assessment and plan. The agency should also continue to study E/M codes throughout this process to ensure that all services are appropriately valued.

The ACR also reiterates its suggestion to assign a unique J-code to each biosimilar of a particular reference product. This will allow physicians to better track and monitor their effectiveness and ensure adequate pharmacovigilance. It would also give physicians more freedom to make decisions while fostering a more clinically sound biologic and biosimilar prescribing process.

“In order for Medicare patients to continue receiving high-quality rheumatology care, payment programs must be designed to reflect the complexities inherent in the care provided by rheumatologists,” concluded Lakhanpal.  “The ACR appreciates CMS’s willingness to work with the rheumatology provider community to address these concerns and will continue to serve as a resource to the agency as it finalizes its Physician Fee Schedule for 2018.” 

Jocelyn Givens
404-633-3777, ext. 810
jgivens@rheumatology.org

###

The American College of Rheumatology (ACR) is the nation’s leading advocacy organization for the rheumatology care community, representing more than 9,500 rheumatologists and rheumatology health professionals. As an ethically driven, professional membership organization committed to improving healthcare for Americans living with rheumatic diseases, the ACR advocates for high-quality, high-value policies and reforms that will ensure safe, effective, affordable and accessible rheumatology care.

© 2019 American College of Rheumatology.  All rights reserved.  Website & Privacy Policies | Sitemap | Help | Contact Us