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Neurologists See Some Gains in CMS' 2014 Fee Schedule

Butcher, Lola

doi: 10.1097/01.NT.0000442988.74173.b5


Neurologists won a major victory in the 2014 Medicare Physician Fee Schedule when the federal government killed a proposal that would have sharply reduced payments for electroencephalography (EEG) performed in the office.

In July, the Centers for Medicare & Medicaid Services (CMS) proposed a cap on practice expense values so that payment for eight EEG codes would not exceed the hospital outpatient payment rate, which is based on CMS' ambulatory payment classification system. If the plan had proceeded, neurologists who bill globally — both for technical and professional components — in the office would have seen a nearly 50 percent cut in EEG payments.

Amanda Becker, the Academy's senior director of medical economics and quality, attributed the victory in part to Academy members who were engaged in helping to convince CMS to change its plan.

“It was great to get such member involvement in the advocacy on this issue,” she said. “We really had our voices heard.”

In another win for neurologists, the CMS final rule for 2014 payment increased the Relative Value Units (RVUs) for two electromyography (EMG) codes (see “Increased RVUs for EMG”). RVUs, which measure physician work value, are used to determine CMS payment for a given procedure or encounter.

The work value for the most common EMG code (95886, EMG, each extremity, complete) was increased by nearly 20 percent, and the value for code 95887 (non-extremity, which is used for testing face or trunk) increased by nearly 50 percent. The decision will help mitigate the deep pay cuts that went in effect in January 2013.

“We consider that a huge win because we have been telling CMS all along that they had very much undervalued those two codes,” said Marc R. Nuwer, MD, PhD, professor of neurology at the University of California, Los Angeles David Geffen School of Medicine.

In a disappointing move, however, CMS declined to increase RVUs for nerve conduction studies, despite an independent panel's recommendation to do so.

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The ongoing threats to payment for neurological services come as CMS looks for ways to reduce health care spending. Neurologists' victories in two of its three recent payment battles used different approaches.

The cuts to EEG payment were published in the CMS proposed physician fee schedule when it was issued in July. That prompted the Academy to mount a campaign in conjunction with the American Medical Association and other medical societies whose members were also affected by CMS' proposed strategy.

More than 2,000 Academy members supported a letter sent by AAN President Timothy A. Pedley, MD, during the CMS comment period. The Academy partnered with patient advocacy groups, including the Epilepsy Foundation and American Epilepsy Society, to show CMS how the cuts would affect patient care. And it worked with state neurological societies to deliver a consistent message to CMS.



“There was a lot of pressure on CMS, and we were definitely happy to see that they backed off on that proposal,” Becker said. In the final rule, however, CMS said that while it is not instituting the cuts this year, the idea may resurface in the future.

By contrast, the 2013 cuts to the EMG and nerve conduction work values were issued as a final rule in November 2012 without an earlier proposal or a comment period that would have allowed the Academy and its members to protest them. Thus, the Academy joined with three other medical societies to convince CMS to convene a refinement panel — a group of independent medical advisors — to review the work values.

Academy leaders, including two former Medical Economics and Management Committee chairs — Dr. Nuwer and Neil A. Busis, MD, chief of neurology at University of Pittsburgh Medical Center Shadyside — worked to hone an argument that could be delivered to the refinement panel in about five minutes via conference call.

The refinement panel agreed with the Academy's position and recommended that CMS should increase the work values for two EMG add-on codes. In its final rule for 2014 payment, CMS concurred.

“It is very difficult to get a refinement panel convened, it is very difficult to get a refinement panel to agree with you, and it is very difficult — apparently — to get CMS to agree with a refinement panel's recommendations,” Dr. Busis said. “So this victory is actually quite astonishing.”

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Why the CMS rejected the refinement panel's recommendation that the work values for nerve conduction studies also be increased is somewhat of a mystery.

“For some reason, CMS agreed with our arguments on EMG, and although we gave pretty much the same arguments on nerve conduction, it made no movement there,” Becker said. “None of the codes increased at all.”

Dr. Nuwer thinks nerve conduction studies were more vulnerable to CMS' position for two reasons.

“They are trying to squeeze money out of every place they are spending significant amounts of money, and there is a large amount of money being spent on nerve conduction studies relative to other kinds of neurodiagnostic tests,” he said. “And there are small pockets of fraud and abuse around the country where providers — typically not neurologists, but others — are abusing the use of these codes. These things together led to a perfect storm of problems that these codes ran into.”

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The most important takeaway from the CMS 2014 payment rulemaking is that physician income will continue to be threatened. With health care spending moving toward 20 percent of the US gross domestic product, CMS will continue to aggressively seek ways to lower payments.

“There are many other specialties who are in the same boat, so we shouldn't feel that CMS is picking on neurology or picking on nerve conduction studies,” Dr. Nuwer said. “CMS believes it has the responsibility to reduce spending and it's their right to make somewhat arbitrary decisions.”

Neurologists must protect their practices by using information to make smart decisions, Dr. Busis said. “When there is ratcheting down, you have to be very careful,” he said. “You have to analyze what you do, what impact it has on you financially, and decide whether you want to keep on doing it that way or not.”

For example, it is important to recognize when an insurer's payment for a certain code is so low that a neurologist will actually lose money on providing that service. In years past, the neurology practice might have been able to make up for that loss in another area, but that may no longer be the case.

While private payers generally follow CMS payment policies, some make exceptions. Dr. Busis pointed out that certain codes that CMS no longer uses are still in the Current Procedural Terminology (CPT) codebook, and some private insurers may allow physicians to use those codes.

“If your practice is primarily consulting, find out which insurers still pay for consults and you might decide to contract only with them,” he said.

An important note, however, is that the old nerve conduction codes with higher work values are no longer in the CPT book, which means they cannot be used. “No matter what contract you have with an insurer, it is illegal to use the old nerve conduction codes,” Dr. Busis said.

Meanwhile, the CMS decision to back away from its proposal for EEG practice expenses and its previous decision regarding EMG work values shows that well-organized physician campaigns can influence payment policy. That means that neurologists must actively engage in the political process, Dr. Nuwer said.

He encourages neurologists to get to know their Congressional representatives and to actively support the Academy's legislative agenda.

“Together, those two are probably the most effective ways of influencing the ways in which the future will unfold,” he said.

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•. Medicare Physician Fee Schedule (2014):
    •. AAN Capitol Hill Report:
      •. AAN: Frequently asked questions about the 2014 Medicare Physician Fee Schedule:
        •. Neurology Today archive on related health policy issues:
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