By Jenny Lower
A restructuring of the billing codes used by the Centers for Medicare and Medicaid Services (CMS) has caused drastic cuts in reimbursement rates for a range of breast intervention procedures, including stereotactic biopsy. The cuts went into effect January 1, 2014, but are still undergoing review.
In an article written for the Journal of the American College of Radiology (JACR), Ezequiel Silva III, MD, notes that the total cuts amount to a 24% reduction to the professional component and a 17% reduction to the technical component. Without higher reimbursements, Silva says, many physicians and hospitals may be hard pressed to make these services available, leading to reduced access to care for many patients—particularly women in rural environments.
“This disease affects women in the prime of their lives. These are 45-year-old mothers of three children. It is a big deal,” Silva said.
The cuts originated in the standard 5-year review conducted by the Relative Value Scale Update Committee (RUC) of the American Medical Association to identify potentially misvalued services. The 75% Reported Together screen, designed to catch possible coding redundancies, captured several breast intervention procedures, which involved separate codes for the surgical and imaging guidance components. Those codes were subsequently restructured into 14 bundled codes with resulting deep cuts in reimbursement rates.
Under the new guidelines, stereotactic biopsies alone have seen the professional component rate for physicians fall 45%. In hospitals, ultrasound reimbursements have been reduced 50%. For ultrasound biopsy, that’s barely enough to cover the cost of the one-time use, vacuum-assisted device itself, according to the ACR. Radiologists who primarily make their living on breast intervention procedures are likely to be among the hardest hit, but breast surgeons and radiation oncologists may be affected as well. Some vendors are concerned physicians and hospitals may not be able to afford their equipment.
The services won’t disappear. But “if the payment reductions are so significant that physicians are unable to provide the service, or facilities are unable to provide the equipment necessary, then your downstream consequence is decreased access,” Silva said. Most women will say they prefer to be treated in their community, but for women in remote areas where care options are already limited, the only solution may be to travel. A worst-case scenario could see the return of more invasive open biopsies if percutaneous biopsies are unavailable.
Silva lays out three possible ways for Congress to intervene. The first step is that “someone in Congress needs to bring to the floor legislation that will restore the payment rates to 2013 levels—which may themselves be too low,” Silva said. He has heard complaints from practitioners already struggling to keep their doors open at 2013 reimbursement rates. The 2014 cuts only exacerbate the problem.
Second, he would like to see a cap in place to limit the percentage decrease to a given code in a particular year, to dampen the year-to-year shock for practitioners.
Third, he wants to see Congress reevaluate the Practice Expense per hour for radiology, which is based on weak data from a 2005 survey conducted by the AMA. Conducting a new, statistically valid survey could increase that value to more appropriate levels. Such budget-neutral steps could ensure that precise, preferred treatment options like stereotactic biopsy remain widely available, Silva says.
“If you’re a woman and you have an indeterminate calcification in your breast, that’s a very stressful experience. As medical professionals, we owe it to those women to make that experience as tolerable as possible,” he noted.