RheumWATCH Archives

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Read the RheumWATCH archives on topics such as rheumatology advocacy, policy updates, insurance advocacy, and practice management.

07

A Look Ahead to Advocacy in 2015

Medicare Payments to Be Held for First Two Weeks of 2015

Medicare claims processing contractors recently indicated that technical corrections are being made to 2015 payment rates. Consequently, CMS announced that claims for 2015 dates of service will be held for the first two weeks of 2015.

The announcement from Medicare follows:

Holding of 2015 Date-of-Service Claims for Services Paid Under the 2015 Medicare Physician Fee

On November 13, 2014, the CY 2015 Medicare Physician Fee Schedule (MPFS) final rule was published in the Federal Register. In order to implement corrections to technical errors discovered after publication of the MPFS rule and process claims correctly, Medicare Administrative Contractors will hold claims containing 2015 services paid under the MPFS for the first 14 calendar days of January 2015 (i.e., Thursday January 1 through Wednesday January 14). The hold should have minimal impact on provider cash flow as, under current law, clean electronic claims are not paid sooner than 14 calendar days (29 days for paper claims) after the date of receipt. 

MPFS claims for services rendered on or before Wednesday Dec 31, 2014 are unaffected by the 2015 claims hold and will be processed and paid under normal procedures and time frames

The ACR will provide updates as new information becomes available. If you have questions, contact Antanya Chung at achung@rheumatology.org.

New Bundled Codes for DXA Services

The American Medical Association Relative Value Update Committee identified CPT™ codes 77080 (dual-energy X-ray absorptiometry [DXA], bone density study) and 77082 (vertebral fracture assessment) as being reported together 75% of the time or more. As a result of these data, the CPT Editorial Panel has deleted CPT™ code 77082 and added new code 77085, which bundles the bone density study and the vertebral assessment. 

Bone/Joint Studies:

77080  Dual-energy X-ray absorptiometry (DXA), bone density, 1 or more sites; axial skeleton (e.g., hips, pelvis, spine)

  • Do not report 77080 in conjunction with 77085, 77086

77081  Appendicular skeleton (peripheral) (e.g., radius, wrist, heel)

  • 77082 has been deleted. To report, use 77086

(For dual-energy X-ray absorptiometry [DXA] body composition study, use 76499)

 77085  Axial skeleton (e.g., hips, pelvis, spine), including vertebral fracture assessment 

  • Do not report 77085 in conjunction with 77080, 77086

77086  Vertebral fracture assessment via dual-energy X-ray absorptiometry (DXA)

  • Do not report 77086 in conjunction with 77080, 77085

Additionally, CPT™ code 77086 was created to report a vertebral fracture assessment via DXA. Note, exclusionary language has been added in the CPT manual for instructions on how to appropriately bill for these two new codes.

For additional information on coding and billing for these new procedure codes, contact Melesia Tillman, ACR coding and billing specialist, at mtillman@rheumatology.org or 404-633-3777 x820.

RheumPAC Sets High Goals for the New Year

RheumPAC continued its impressive growth trend for the seventh straight year, raising more than $135,000. Thank you to all RheumPAC donors for contributing in 2014! A special thank you to the RheumPAC leadership circle: Nilsa Cruz, BS, Timothy Laing, MD, Ed Herzig, MD, Herb Baraf, MD, Ed Herzig, MD, Gene Huffstutter, MD, Steven Klein, MD, Gwen Melton, MD, Max Hamburger, MD, Joseph Flood, MD, David Borenstein, MD, Paul DeMarco, MD, Will Harvey, MD, MPH, James Jenkins, PhD, MPH, Stuart Kassan, MD, Steven Kimmel, MD, Charles King, MD, Sharad Lakhanpal, MD, Jeffrey Lawson, MD, Rudy Molina, MD, Meera Oza, MD, William Palmer, MD, Bill St.Clair, MD, and Ananda Walaliyadda, MD

Looking forward to 2015, the RheumPAC Committee has set an ambitious agenda for the next election cycle. RheumPAC will set out to raise $150,000 in 2015, host political fundraisers in home states, increase opportunities for RheumPAC donors to attend events, attract members of Congress to state society meetings, identify new champions on the Hill and achieve 8% participation among ACR members.

If you would like to be involved with RheumPAC in the coming year, please contact us at rheumpac@rheumatology.org.

Message from the Government Affairs Chair

Will HarveyAdvocates,

Happy New Year! Last year was a busy one, with a lot of challenges, a number of accomplishments and a mountain of unfinished business. We have great deal more to do in 2015 to achieve our shared goal of Advancing Rheumatology! But if we stick together and work together, I believe 2015 can be a successful year. And it’s going to begin with a bang—some big things are happening even before the end of the first quarter.

Our interest: Broadening our base of advocates. This includes not only those willing to donate to RheumPAC and/or to go to the Hill or their state legislatures on our behalf, but also people willing to develop relationships locally with federal and state officials. It includes people willing to take 10 minutes out of their day to “pen” an e-mail or make a quick call. It includes partnerships with patients through our own efforts and those of the Arthritis Foundation and other patient groups.

Roadblocks: I don’t have time. I don’t have money. I don’t know how. I don’t know who. It doesn’t make a difference. The ACR doesn’t work on the issues most important to me.

My take: This may surprise you, but I think every one of these is absolutely true, depending on your point of view. That’s why our job is to find ways that other overworked, underpaid people can contribute. We’ll be exploring more micro-volunteer opportunities this year and fostering a key contacts program to help people get started. We’ll also be taking steps to develop educational and advocacy mentorship-type experiences to get people off the ground. The latter two roadblocks deserve special mention, because at their root lies an important gap—communication. I believe the ACR is making a difference with our advocacy efforts, and I believe we are working on things that are central to our membership. But I take very seriously—and I think the ACR would agree—the obligation to communicate our activities, both successes and failures, to our membership. That is why I’ve been dedicated to posting on the list serve whenever possible. It’s why the College re-vamped RheumWatch. I look forward to exploring new ways to communicate with you and with the entire membership so that we continue to fight for what is important to you and that you hear about our efforts. If we are successful, we’ll end 2015 with even more advocates in our corner.

Congress

Our interest: Having Congress pass more legislation. We have seen a general unwillingness for CMS to change things on an administrative level. We’ve seen insurers very willing to use the shield of “cost containment” to shrink access to drugs and providers through legally available loopholes. We need Congress to step in on a number of these issues. That requires them to actually pass bipartisan legislation that the President will sign.

Roadblocks: Congress again seems poised to attempt to repeal and or defund the ACA, which will not sit well with the President. The President is poised to start using executive actions to circumvent Congress, which even the Democrats won’t like. The question is, will they quiet down the rhetoric enough to get some things done?

My take: Yes, but maybe not by April. I think there are enough cool Republican heads, especially in the Senate, who don’t want to squander the opportunity to show that they can effectively govern the country ahead of the 2016 election. But the window will be short because the 2016 election cycle is already starting to get attention, and we need to see as much action as possible before the year-long countdown starting in November.

SGR

Our interest: Passing a permanent repeal. Is that deal as good as we would like it? No. But we can’t move on without moving on. If the deal passes, we will need to lobby for improvements on certain aspects (like more appropriately reimbursing E&M services for cognitive specialists). But if the bill doesn’t pass, then getting those things is basically impossible.

Roadblocks: Money. The policy is bipartisan, but not the pay-for. There are also some, including some well-respected members of our College, who believe that the best option is not to fix SGR, or even to let the cuts take place. If Congress only responds to disasters, maybe they need one.

My take: The money required is likely the lowest it’s ever going to be. I also think commenting at all on how to pay for this is like stepping into a minefield—it looks like a harmless step onto solid ground, but there won’t be many people holding out tree branches on our behalf. It doesn’t matter that the money isn’t real—only theoretical future dollars. The philosophy behind the money is real enough. The “nuclear” option, to be honest, has a certain pleasant “I-told-you-so” feel to it, but the GAC and the College leadership agree that it is not in our best interest. Too many members depend entirely on Medicare reimbursement, and too many seniors rely on their care to advocate for this stance. Regardless, my take is that passing a permanent repeal is less likely than a coin toss. I’m not sure Congress will be in the sort of bipartisan mood necessary to spend $140 billion dollars on this by April. I’m happy to be surprised, but our strategy doesn’t end there. Last year’s patch taught us that we may be able to get something in exchange for not permanently fixing SGR. And we will spend some effort thinking and talking to some key contacts about what those might be if it is patched again.

ICD-10

Our interest: We continue to support any efforts to ease the burden of ICD-10, from further delay to safe harbor periods.

Roadblocks: The combined lobbying force of coders, IT professionals, and the American Hospital Association, who, for their own varied reasons, don’t want further delays.

My take: There were rumors about another delay getting added to the lame duck appropriations package, but it didn’t happen. We will spend some time ferreting out why and if that is still an option. But my take is that another delay is very unlikely. So I think we need to keep working on how to ease the transition after Oct. 1. I gave an interview with NPR station WHYY in Philadelphia on New Year’s Eve about the real burden (financial and intellectual) of piling ICD-10 in addition to other things like meaningful use, value-based purchasing, alternative payment models, etc., on small businesses. We need to keep sending that message to our elected officials.

Patients’Access to Treatments Act (PATA)

Our interest: Removing discriminatory barriers to accessing essential treatments for our patients.

Roadblocks: The insurance industry feels unfairly singled out in trying to hold down costs, particularly when pharma is free to charge whatever they like for medications. Toward the end of 2015, the inscos finally revealed this as their primary objection to our bill. I also heard discussed for the first time the notion that fairly high turnover in the insurance marketplace (plan switching) diminishes the perceived return on investment for expensive treatments that have mostly long-term return on investment.

My take: Two titans of industry will spend a lot of time, energy and money fighting with each other this year about the relative virtues of pricing controls on insurance and drugs. It seems to me that our PATA and other things like new hepatitis C treatments have helped bring this to a head. I’m not really sure where this will shake out, except to say that we want to continue to provide a catalyst for resolution that is beneficial to our patients. To that end, we have been assured that PATA will be re-introduced early this year, and there will likely be a closed-door briefing with all of these stakeholders to get this all on the table. A post-Festivus airing of grievances. Further, an original co-sponsor of the House bill has been elected to the Senate, and we hope to expand our work from last year by introducing a Senate version. This bill has been a real conversation starter and we are looking forward to it progressing.

Beyond the federal government, there will also be a great deal of activity happening at the state level that affects our practices and patients. Look for an upcoming column on those issues, including specialty tiers, step therapy, prior authorization, biosimilars and more.

I wish you all health, happiness and prosperity in 2015. More importantly, I hope you’ll join me in working hard to make sure all of those things come true for our membership and profession. To get connected with our ACR advocacy team, write to advocacy@rheumatology.org.

Yours,

Will Harvey

GAC Chair