AAOS Now

Published 2/1/2014
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Matthew J. Twetten

AAOS, AAHKS Advocacy Efforts Help Mitigate CMS RVU Changes

Changes in work RVUs for TKA, THA could have been worse

Each year, physicians both anticipate and dread the release of the Medicare Physician Fee Schedule final rule. In addition to covering rules and regulations proposed for implementation during the next calendar year, the rule also includes Relative Value Units (RVUs) for every procedure with a Current Procedural Terminology (CPT®) code in the current fee schedule. Changes to the RVUs can have a significant impact—on both Medicare payments and payments by private payers who base reimbursements on a percentage of the Medicare fee schedule.

The 2014 Medicare Physician Fee Schedule final rule was released by the Centers for Medicare & Medicaid Services (CMS) on Nov. 27, 2013, and went into effect on Jan. 1, 2014. For many orthopaedic surgeons, the most significant changes in RVUs applied to total hip arthroplasty (THA) and total knee arthroplasty (TKA). The work RVUs for both procedures were reduced—never good news—but education and advocacy efforts by the AAOS and the American Association of Hip and Knee Surgeons (AAHKS) were effective in preventing even deeper cuts.

For the THA CPT code 27130 (Arthroplasty, acetabular and proximal femoral prosthetic replacement, with or without autograft or allograft), the work RVU was changed from 21.79 to 20.72, a decrease of 5 percent. For the TKA CPT code 27447 (Arthroplasty, knee, condyle and plateau; medial AND lateral compartments with or without patella resurfacing), the work RVU was changed from 23.25 to 20.72, a decrease of 12 percent.

It could have been worse
The reductions in the THA and TKA work RVUs are dramatic and will have significant impact for many surgeons. In turn, Medicare patients might also be affected as these patients face the potential of less access to these procedures. Implementation of the new values could be a significant setback for the collective health of Medicare beneficiaries and likely will have unintended consequences for society, based on recent studies showing the cost-effectiveness of TKA.

Despite the reductions imposed by CMS, the changes could have been considerably worse. Dedicated AAOS and AAHKS volunteers spent more than a year meeting with agency representatives and preparing materials designed to make a case for averting drastic cuts. These efforts began in 2012 and required a significant investment of both time and money by the AAOS and AAHKS.

The review conducted by the American Medical Association’s Multi-Specialty Relative Value Update Committee (RUC) in January 2013 set the stage. AAOS and AAHKS RUC advisors and AAOS and AAHKS leadership had been holding weekly meetings, both via conference calls and in-person, even before the review.

Participants in these initial meetings included the then-current presidents of the two organizations—John R. Tongue, MD, (AAOS) and Thomas Parker (Tad) Vail, MD, (AAHKS)—as well as William R. Creevy, MD, AAOS RUC advisor; John P. Heiner, MD, AAOS RUC alternate advisor; R. Dale Blasier, MD, chair of the AAOS Coding, Coverage and Reimbursement Committee; David A. Halsey, MD, AAHKS RUC advisor; Mark Froimson, MD, AAHKS RUC alternate advisor; Brian S. Parsley, MD, current AAHKS first vice-president; and Carlos J. Lavernia, MD, AAHKS past president. They also included outside advisors for both the AAOS and AAHKS, and staff from both organizations.

These efforts centered around preparing recommendations for the RUC meeting and were based on data derived from the surveys of hip and knee surgeons conducted by the AAOS and AAHKS. At the RUC meeting, AAOS and AAHKS made the following recommendations:

  • no change in work RVUs for THA
  • a 4 percent decrease in work RVUs for TKA

However, the RUC rejected these recommendations and proposed significant cuts in the work RVUs for both TKA and THA. The RUC recommended a work RVU of 19.60 for both 27130 and 27447. This would have meant an 11 percent decrease for THA and a 19 percent decrease for TKA. The AAOS and AAHKS then made it clear that they intended to contest the RUCs recommendations.

The RUC’s recommended values set a significant hurdle for the AAOS and the AAHKS in making their case to maintain current values for the procedures. As a result, the two organizations began a concentrated campaign, working diligently through CMS and other venues, to effect a change.

CMS meetings
After the 2013 AAOS Annual Meeting, AAOS President Joshua J. Jacobs, MD, along with AAHKS President Thomas K. Fehring, MD, others in the AAOS and AAHKS leadership ranks, AAOS staff, and outside counsel for the organizations met with CMS officials three times—in April, June, and August.

The societies argued that the survey methodology used at the RUC is not a valid statistical measurement and is likely to produce flawed data. They pointed out that independent reviews of survey times compared to other sources verify the flaws in using survey data. They also noted that health economists and other experts also object to the reliance on survey data; even Congress, in draft legislation to replace the sustainable growth rate formula, has directed CMS to investigate more reliable ways to measure time.

Indeed, data collected by CMS on anesthesia time for these procedures indicate that procedure times for THA and TKA have not significantly changed between 2005 and 2012. These data provided additional evidence that the survey results were misleading or incorrect. Based on this, AAOS and AAHKS argued that CMS should not take drastic action.

“Medicare should not cut rates for hip and knee replacement surgery without giving doctors and their patients a full explanation, and without a fair comment opportunity,” Dr. Fehring noted. “With the number of seniors who need this surgery and who are staying in the workforce longer, these procedures are vital for maintaining quality of life.”

Congressional meetings
In addition to the meetings with CMS, Dr. Jacobs met with several members of Congress to discuss the issue and the concerns of the orthopaedic community. Rep. Tom Price, MD, of Georgia, was especially helpful and a great champion on the issue.

As part of the congressional outreach, AAOS and AAHKS worked with both Republican and Democratic members of Congress to contact CMS administrator Marilyn Tavenner and other CMS officials, asking them to reconsider the recommended reductions.

“We believe doctors who perform these procedures should have an opportunity to examine CMS’s recommendations and underlying data and offer their analysis and comments before any rate changes go into effect,” the letter stated. “When considering rate changes, it is important to keep in mind that Medicare payments for hip and knee replacement procedures have not kept up with inflation. In real dollars, the payment rate has decreased 20 percent over the last 10 years.”

Patients also sent thousands of letters and emails to their legislators and Administrator Tavenner.

Results
The decision by CMS to deviate from the RUC’s recommended values, in and of itself, was not that unusual. In recent years, CMS has rejected about 25 percent of the RUC’s recommendations. However, when CMS has rejected the recommendations, it did so in order to impose even lower values. The decision in this case to increase the values was highly unusual and a significant surprise.

AAOS leadership was very pleased with the action. Dr. Jacobs stated, “Although we are disappointed that procedures we know provide tremendous value to the individual patient and to society were devalued, and that CMS did not use the values recommended by AAOS and AAHKS, we are pleased that CMS responded to our extensive regulatory and legislative advocacy efforts to alter the RUC’s recommendation of far deeper cuts.

“We are also grateful to all the AAOS and AAHKS volunteers who participated in the efforts, which were considerable,” he continued. “The action taken by CMS would not have been possible without the extraordinary efforts of so many dedicated orthopaedic surgeons on behalf of their colleagues. AAOS and AAHKS continue to strongly believe that our recommended values are the correct RVUs for these procedures.”

Next steps
The AAOS, in coordination with AAHKS, submitted extensive comments to CMS on this final rule and will continue to advocate to CMS throughout the year in the hope that these devaluations might be reversed in the 2015 Medicare Physician Fee Schedule. Based on the current precedent, such hopes may not be as unlikely as they might appear. The fact that CMS implemented higher values than the RUC recommended sets a precedent for the agency to listen and respond to reasoned, compelling arguments on the value of these services.

Matthew Twetten is the senior manager of policy and medical affairs in the AAOS office of government relations and can be reached at twetten@aaos.org

Other changes in the 2014 Fee Schedule
Additional changes to orthopaedic codes in the 2014 Medicare Physician Fee Schedule final rule include the following:

CPT code 27236—Open treatment of femoral fracture, proximal end, neck, internal fixation or prosthetic replacement. The work RVU remains the same at 17.60.

  • CPT code 27446—Arthroplasty, knee, condyle and plateau; medial OR lateral compartment. The work RVU has been changed from 16.38 to 17.48, an increase of 6.7 percent.
  • CPT code 23333—Removal foreign body, shoulder, deep. This is a new code for the removal of a foreign body in the shoulder, separate from the removal of a shoulder prosthesis, with a work RVU of 6.00. Removal of a shoulder prosthesis is now covered by the following two additional new CPT codes:
    • CPT code 23334—Removal shoulder prosthesis, single component. This new code has a work RVU of 15.50.
    • CPT code 23335—Removal shoulder prosthesis, both components. This new code has a work RVU of 19.00.
  • CPT code 24160—Removal of elbow prosthesis, both components. This is a new code with a work RVU of 18.63.
  • CPT code 24164—Removal of radial head implant/prosthesis. The work RVU for this code has been increased from 6.43 to 10.00.
  • CPT code 63047—Spinal laminectomy. This code was reviewed and its work RVU remains unchanged at 15.37.
  • CPT code 63048—Spinal laminectomy, each additional level. This code was reviewed and its work RVU remains unchanged at 3.47.