• Washington Committee Report

    Authors: Katie O. Orrico
    Alison Dye

    The CNS and AANS Washington Committee continues to make progress in advancing organized neurosurgery's legislative and regulatory agenda.  Recent activities are highlighted below.

    Lawmakers Release "Dear Colleague" Letter to CMS Regarding Prior Authorization
    On Aug. 9, Reps. Phil Roe, MD (R-Tenn., and Ami Bera, MD (D-Calif.), released a "Dear Colleague" letter urging their congressional colleagues to join them in sending a letter to Centers for Medicare & Medicaid Services (CMS) Administrator, Seema Verma, MPH, asking CMS to provide guidance to Medicare Advantage (MA) plans regarding the use of prior authorization (PA). The use of prior authorization by health plans has gotten out of control, and the Washington Committee has identified this as a priority topic. Finding a solution is complicated, however, since the individual states regulate most health plans. While the federal government has limited power to address prior authorization abuses in these plans, it does have the power to regulate Medicare Advantage (MA) plans. Since most health plans participate in MA, efforts by Medicare to rein-in these plans may have a spill-over effect in the state-regulated plan practices.

    House Ways and Means Red Tape Relief Project Status Report
    As a part of its effort to modernize and improve the Medicare program for American seniors and the providers that serve them, the House Ways and Means Committee launched the Medicare Red Tape Relief Project. This initiative seeks to identify opportunities to reduce legislative and regulatory burdens on Medicare providers, improving the efficiency and quality of the Medicare program for seniors and individuals with disabilities.  Last summer, the AANS and CNS submitted multiple recommendations on topics including:

    • Rescind Medicare Appropriate Use Criteria (AUC) for Imaging
    • Prior Authorization reform in Medicare Advantage
    • Suspend Medicare Global Surgery Data Collection
    • Improve Medicare Quality Payment Program

    The committee has continued working on this project throughout the past year, and organized neurosurgery has been part of the ongoing conversations.  In this regard, representing the Alliance of Specialty Medicine, Katie O. Orrico, Esq., director of the Washington Office, participated in two roundtable discussion sessions with members of the committee, focusing primarily on prior authorization reform. Responding to our concerns, the committee plans to request that CMS "standardize reporting and billing authorization requirements." Click here for a copy of the status report.

    House Passes Bill to Repeal the Medical Device Tax
    On July 24, the U.S. House of Representatives passed H.R. 184, the Protect Medical Innovation Act. The bipartisan vote was 283-132, with 57 Democrats joining 226 Republicans to advance the measure. Attention now turns to the Senate. While temporarily suspended for two years from 2018-19, the Affordable Care Act's 2.3 percent medical device excise tax may adversely affect medical innovation and patient care. Because America has a long tradition of excellence and innovation in patient care, and because neurosurgeons have been on the cutting edge of these advancements, the CNS and AANS have advocated for the repeal of this tax. In the run-up to the vote, the Washington Office staff worked with our industry partners and patient advocacy groups to encourage members of Congress to vote to repeal the tax. On July 23, we participated in a Twitter event using the hashtag RepealDeviceTax to draw attention to the vote. At one point, this effort was the number 5th highest trending conversation on Twitter.

    House Completes Action on Comprehensive Opioid Abuse Legislation
    After months of development and deliberation, the U.S. House of Representatives completed its efforts to address the opioid epidemic by passing more than 60 bills. On June 22, the House passed H.R. 6, the Substance Use Disorder Prevention that Promotes Opioid Recovery and Treatment (SUPPORT) for Patients and Communities Act by a 396-14 vote. H.R. 6 is a comprehensive package that includes the majority of the bills previously passed by the House.  The package contains policies impacting Medicare, Medicaid, public health and public safety programs that are intended to curb abuse, improve access to substance abuse treatment, and support law enforcement efforts. Other bills direct federal agencies to produce studies, reports and guidelines related to opioid use, abuse, and treatment among other matters. Attention now turns to the U.S. Senate, which has yet to act on opioid-related legislation.

    CMS Releases Proposed 2019 Medicare Physician Fee Schedule Rule
    On July 12, CMS released the 2019 Medicare Physician Fee Schedule proposed rule. Overall, CMS estimates that the proposed changes result in a net one percent increase in payments to neurosurgeons, due primarily to the impact of changes in malpractice relative value units. The biggest - and most controversial change - a sweeping new plan for evaluation and management (E/M) visit documentation requirements and a corresponding proposal to collapse payment for E/M visit levels 2 through 5 into a single blended payment amount, of $135 for new patient office visits and $93 for established patients. Fortunately, CMS did not recommend any changes in payments for 10- and 90-day global surgery services, however, in 2019, the agency will continue with its global surgery data collection initiative.  This program requires neurosurgeons in Florida, Kentucky, Louisiana, Nevada, New Jersey, North Dakota, Ohio, Oregon, and Rhode Island are required to report post-operative visit information furnished during the global period for certain procedures using CPT code 99024. In the document, CMS proposes to continue to ramp-up requirements for the third year of the Merit-Based Incentive Program (MIPS), during which 2019 performance will determine whether clinicians are subject to up to a 7 percent cut in Medicare payments in 2020. At the same time, CMS proposes to maintain certain flexibilities, particularly for small practices.

    Click here for a summary of the payment provisions of the proposed rule and here for a CMS fact sheet. For a detailed summary of the quality provisions, click here and here for the agency's Quality Payment Program (QPP) fact sheet on the proposed rule.

    CPT Corrects Significant Error for Reporting Decompression with Interbody FusionFollowing vigorous multi-specialty advocacy led by organized neurosurgery, in the May 2018 CPT Assistant publication, the American Medical Association (AMA) has corrected the erroneous October 2018 instruction regarding the use of the decompressive laminectomy CPT code 63047 at the same level as interbody fusion codes 22630 or 22633. The correction appropriately states that codes 22633 and 63047 may be reported for the same interspace when additional work is required to complete a decompression at the same spinal level. The CNS and AANS have always maintained that the CPT coding descriptions for these codes allow for reporting 63047 at the same level as 22633 or 22630 when work for decompression of neural elements is required in addition to the work required to perform the interbody fusion. The need for decompression for clinical scenarios such as neurogenic claudication alongside the need for interbody fusion, such as instability, must be accurately documented in the operative note.

    The May 2018 CPT Assistant publication notes that a -59 modifier should be added to 63047 when used with the 22633 or 22630 for non-Medicare patients. Medicare continues to apply a separate National Correct Coding Initiative (NCCI) edit that prevents reporting of these codes at the same interspace. The NCCI edit is inconsistent with the precise definition and spirit of these codes and runs directly counter to the May 2018 CPT Assistant publication. The CNS and AANS continue to object to the NCCI edit and are actively working to have it rescinded.

    AMA Releases Opioid Task Force Progress Report
    In 2014, the American Medical Association (AMA) Opioid Task Force convened to coordinate efforts that were underway within organized medicine to help end the nation's opioid epidemic. Together, the Task Force identified six recommendations focused on the actions that physicians could take - and the Task Force was committed to measure progress on each recommendation. On Aug. 9, AMA released a status report title "AMA Opioid Task Force Helping Guide Physicians' Progress to End the Nation's Opioid Epidemic," which is aimed at showing what the Task Force organizations have accomplished. CNS executive committee member, Jennifer A. Sweet, MD, continues to represent organized neurosurgery on this task force.

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