Spine surgeon payment could undergo several changes over the next year that will make a huge impact on the field.
Here are five updates — some controversial — coming down the pipe.
1. The Centers for Medicare and Medicaid Services released the 2015 Hospital Outpatient Prospective Payment System and Ambulatory Surgical Center Payment System Policy Changes and Payment rules in July. The proposed for next year include 10 new spine procedures approved on the ASC payable list:
• Neck spine fusion & removable c2
• Neck spine fusion
• Lumbar spine fusion
• Spine fusion extra segment
• Neck spine disc surgery
• Laminectomy single lumbar
• Removal of spinal lamina (code 63045)
• Removal of spinal lamina (code 63047)
• Decompression spinal cord
This is significant as more spine surgeons invest in ambulatory surgery centers. Surgeons have been performing spine cases in ASCs for more than a decade and are now beginning to see more willingness from payers — including Medicare — to cover those procedures. There is a huge Medicare patient population, and many who are surgical candidates could have their cases in the ASC if the proposed policy updates are approved for next year.
However, some are still weary of taking spine cases into the outpatient setting despite studies showing success with appropriately-selected patients. Additionally, in some markets ASCs and hospitals have an adversarial relationship, seeing each other as competitors for patients, and as high acuity cases spine procedures are among the most coveted procedures.
2. CMS is also proposing a transition of all 10-day and 90-day global codes to 0-day global codes by 2017 and 2018 because current global packages may not reflect the typical operative care provided. It's difficult to obtain data verifying the number, level and cost of postoperative visits in the global package. Many physician groups are opposed to the measure and have commented on the proposed rule, including the North American Spine Society.
"While NASS is supportive of efforts to ensure payment accuracy, we are concerned that the proposed changes would not accurately account for the physician work, practice expense and malpractice risk involved in services performed during the postoperative period. Furthermore, NASS has significant concerns about the potential impact of the proposal on patient care as well as the administrative burden that would be placed on patients, physicians and insurers," wrote NASS President William Watters, MD, a comment letter to CMS.
AANS/CNS are also opposed to eliminating the 10- and 90-day global packages, instead calling for a different method of achieving accurate value without overhauling the current payment structure. If the services are unbundled, patients would be required to pay separate co-pays for every visit, which could become a financial burden and prevent some follow-up and post-surgical care.
3. Several new procedures will receive CPT codes next year, or updated category classifications. The AMA Editorial Panel also announced a new Category I CPT code for two-level cervical total disc arthroplasty. The procedure was previously reported by a Category III CPT code. The transition to a Category I Code will allow for the existing Category III CPT code to be updated to describe a three- or more-level arthroplasty.
Additionally, minimally invasive sacroiliac joint fusion is currently reported by a Category III CPT code, 0334T. The AMA created this procedure code effective July 2013. At the recent Editorial Panel meeting it was determined that the procedure had satisfied the evidence threshold necessary to transition to a Category I CPT. Effective January 1, 2015 a Category I CPT code will be implemented to describe percutaneous/minimally invasive sacroiliac joint arthrodesis.
"I think it's important for patients and spine surgeons to know this information now to open a dialogue with various insurance carriers across the nation," says Morgan Lorio, MD, Chair Coding & Reimbursement Task Force for the International Society for the Advancement of Spine Surgery. "We've gone from a Category I to Category III and back to Category I code with this procedure in about a year period. I think that speaks to the fact that the medical terrain is changing at a phenomenal rate, and physicians and industry are responding quickly to answer questions about the effectiveness of their procedures."
In 2014, several Medicare contractors have updated their coverage to include minimally invasive sacroiliac joint fusion procedures.
4. CMS proposed increasing the requirements for successful PQRS reporting, but also would like to decrease the number of measures reported. The decrease would remove the Back Pain Measures Group and the Perioperative Measures group next year while still requiring spine care providers to meet nine measures across three National Quality Strategy domains. Spine care participants would have to report on peripheral measures to satisfy requirements — but those measures won't have an impact on spine care.
"If CMS' true goal is to improve patient care without creating an undue administrative burden on physicians, it should either lower the reporting threshold or, at the very least, maintain the measures proposed for removal for another one to two years," a letter from NASS reported.
5. The 2014 CMS Final Physician Fee Schedule rule included several updates for in-office spinal procedures, such as spinal cord stimulation and epidural steroid injections. The 2014 CMS Final Physician Fee Schedule Rule significantly reduced reimbursements for several interventional pain procedures, including cuts for cervical and lumbar epidurals. Physicians now receive $42 payment for performing these procedures.
The 2014 CMS Final Physician Fee Schedule Rule that included payment rate decreases for physicians performing spinal cord stimulation in-office trials. However, facilities supporting procedures will receive an increase. Beginning Jan. 1, 2014, physicians were required to bill CPT 63650 for each lead implanted, which has been revalued to include the cost of trial leads. Additionally, CMS will pay the highest value CPT code at 100 percent and each additional CPT code at 50 percent, according to a report form St. Jude Medical.
Professional spine and interventional pain societies have advocated for a change, but with the environment in Washington unstable and healthcare such a big topic, future coverage changes are uncertain.