Keeping Our Eyes on the Prize-Reimbursement Equity ASHA Argues for Professional “Work” Category in Medicare Relative Value Units Bottom Line
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Bottom Line  |   March 01, 2005
Keeping Our Eyes on the Prize-Reimbursement Equity
Author Notes
  • Marat Moore, managing editor of The ASHA Leader, can be reached at mmoore@asha.org.
    Marat Moore, managing editor of The ASHA Leader, can be reached at mmoore@asha.org.×
Article Information
Practice Management / Regulatory, Legislative & Advocacy / ASHA News & Member Stories / Bottom Line
Bottom Line   |   March 01, 2005
Keeping Our Eyes on the Prize-Reimbursement Equity
The ASHA Leader, March 2005, Vol. 10, 1-37. doi:10.1044/leader.BML.10042005.1
The ASHA Leader, March 2005, Vol. 10, 1-37. doi:10.1044/leader.BML.10042005.1
Medicare reimbursement is under review this year as the Centers for Medicare and Medicaid Services (CMS) begin an assessment of Current Procedural Terminology (CPT™) codes for the first time since 2000.
Recognizing the significant impact of these codes upon the valuation of audiology and speech-language pathology services, ASHA and its expert panel of professionals on the Health Care Economics Committee (HCEC) began nearly two years ago to research and advocate to CMS and committees of the American Medical Association to change how “relative value units” are assigned to our health care services. ASHA is recognized by the American Medical Association to represent audiology and speech-language pathology in the CPT coding process.
Medicare currently does not use one key element of the reimbursement formula-the consideration of audiologists and SLPs in the physician work component-when valuing our clinical services. Instead, the relative value units (RVUs) assigned to many audiology and speech-language pathology services are based only on “practice expense”-reflecting the direct cost per minute for the time that clinicians spend with patients.
“ASHA’s goal is to expand the criteria used to determine Medicare reimbursement by adding the category of professional or ‘physician work’-which would recognize the skill, intensity, stress and risk of the procedures,” said Robert Fifer, an audiologist and member of the HCEC who serves as ASHA’s advisor to the American Medical Association’s Relative Value Update (RUC) Committee. Fifer also serves as alternate co-chair of the AMA’s Health Care Professionals Advisory Committee.
“This is an extremely important issue not only for audiology and speech-language pathology but also for other nonphysician health care disciplines,” he said.
“CMS is planning to eliminate the temporary pool of money now used for reimbursement of services that are not categorized as ‘physician work.’ If we don’t act to ensure that our services are appropriately valued before the pool is abolished, our reimbursement could drop significantly.”
Recognizing the impact of this issue on the professions, ASHA began nearly two years ago to research the issue and prepare for CMS’s 2005 CPT code review. With the process underway, ASHA recently submitted lengthy comments to CMS and initiated meetings with officials at the agency as well as physician members of the AMA’s RUC group. In February, Fifer formally presented ASHA’s arguments in support of the RVU “work” concept to the AMA’s RUC Health Care Professionals Advisory Committee meeting.
“Practice” Expense Falls Short
The reimbursement formula under Medicare includes three components: physician work, practice expense, and malpractice expense. The combination of these three factors comprises a total relative value unit (RVU) that is multiplied by the Medicare conversion factor for the year to determine the reimbursement rate of each procedure code under the Medicare Physician Fee schedule, published annually by CMS.
Since 1992, when the RVU system for determining Medicare fees was introduced, audiology and speech-language pathology services were valued based only on practice expense.
“Our professions are reimbursed for practice expense and not physician work primarily because we have not been defined in one of the physician categories within the Medicare statute,” Fifer said.
“This means that, for reimbursement purposes, we’re considered ancillary support personnel who assist the physician in the same way that a nurse or a technician assists the physician in performing various procedures.”
Under the reimbursement rules established jointly by the AMA and Medicare, the only factors considered for reimbursement of practice expenses are the median number of minutes required of an individual for service delivery, depreciation of capital equipment greater than $500, and the cost of disposable supplies.
“Work” Expense Would Recognize Value
In contrast, “work” is a scaled value factor that is compared or contrasted to the work RVUs of other CPT codes. The work-based RVUs utilize the skill, intensity, stress and risk of the procedures and are compared to reference CPT work values.
“Using a hypothetical example, repair of an eyelid requires about the same amount of time as transection of the carotid artery in the cavernous sinus of the brain,” Fifer explained. “But the latter procedure has an RVU work value that is approximately five times greater than an eyelid repair.”
By definition, “physician work” entails elements of history taking, examination/evaluation, clinical judgment, technical expertise, professional skill, and decision-making regarding patient management.
“As professional autonomy has grown for audiologists and SLPs in recent years with regard to their practice activities, we fulfill more elements of this definition than in years past,” noted Fifer.
“This is one of the major reasons that we are pursuing the authorization of reimbursement that recognizes ‘work’ as an element of the reimbursement formula.”
Funds in Jeopardy
Audiologists and SLPs are now reimbursed mainly from the “nonphysician work pool,” a pool of money created by Medicare as a temporary reimbursement mechanism for service areas that also include oncology services, radiology services, and cardiology laboratory procedures.
The nonphysician work pool was intended to be in existence only until Medicare could determine another reimbursement formula that would be appropriate and equitable for each of the service areas.
“Because the nonphysician work pool is expected to be abolished in the near future, ASHA’s representatives to the AMA coding committees are looking at alternatives to the current reimbursement formula,” Fifer said.
Given current practice patterns in audiology and speech-language pathology, Fifer said the physician work formula seems to be “the most logical choice to provide a stable, appropriate and equitable reimbursement formula.” Another advantage, he added, is that the AMA and Medicare are very familiar with that reimbursement formula.
Without replacement with an appropriate reimbursement formula, the professions could be in trouble.
“If the nonphysician work pool goes away without an equitable formula to take its place, a possibility exists that our reimbursement levels may decrease by as much as 45 percent,” Fifer said.
Advocacy Builds for Change
With more than 110,000 members and the HCEC’s expertise, ASHA has intensified its advocacy over the last six months because of the likely elimination of the nonphysician work pool.
HCEC members held discussions with AMA staff and members of the Relative Value Update Committee (RUC) and the Health Care Professionals Advisory Committee to lay the foundation for a transition to “work” from practice expense valuation.
In addition, preliminary discussions have been held with CMS representatives who are major players in the coding process and in the determination of reimbursement values. This topic has been presented at the last two Health Care Professionals Advisory Committee meetings for open discussion.
“Our primary goal is to stabilize the methodology and reimbursement formula for our CPT codes that are now valued as practice expense,” Fifer said.
“Along with this primary goal is a desire to ensure that any conversion away from the nonphysician pool produces a result that protects our current levels of reimbursement and offers the possibility of improving reimbursement for certain codes by means of scaling comparisons to reference codes.”
Discussion with physician members of the relevant AMA committees will continue “as long as necessary to ensure that any conversion is done in an appropriate and orderly manner,” he said.
If the AMA RUC endorses conversion from practice expense to work RVUs, then the methodologies of the conversion will need to be taken under consideration and advisement.
“If and when we are successful in converting our procedures, we’ll provide information to ASHA members about appropriate coding and documentation requirements associate with the new reimbursement formula,” Fifer said.
For more information on ASHA’s efforts, contact Steven White, director of health care economics and advocacy, by e-mail at swhite@asha.org or by phone at 800-498-2071, ext. 4126.
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March 2005
Volume 10, Issue 4