Vera H. Rigolin, MD, FASE

Most of us choose medicine as a career for altruistic reasons and for the love of science. Payment for our services rarely enters our minds when we are in the early phases of choosing our professions. As we become established and confront the realities and challenges of modern medicine, we begin to appreciate the importance of fair and equitable reimbursement for the services we provide. Our clinics, hospitals, and other healthcare services cannot survive without appropriate financial support. Innovation and creation of new treatments cannot occur without adequate funding. Advocacy is therefore critically important for our field to continue to provide the best health care possible to our patients.

Although many Americans receive their healthcare from non-Medicare sources, the majority of the healthcare payment system for imaging services has its origins in Medicare. Established Medicare rates currently serve as the standard to which other payers determine their payment models. How does Medicare determine payment for physician and hospital services?

Let’s start by reviewing the different clinical settings for which Medicare provides reimbursement and by defining some of the key terms.

The Centers for Medicare and Medicaid Services (CMS) is the government agency that administers the Medicare and Medicaid programs. CMS develops the fee schedules for physicians and other services such as ambulance, clinical laboratory, and durable medical equipment. The Medicare Physician Fee Schedule (PFS) determines the reimbursement for physician services in the non-hospital setting. In the case of echocardiography, the PFS will determine payment for echo interpretation and for the technical fees. Medicare pays physicians using a Resource-Based Relative Value Scale (RBRVS). This payment mechanism is based on assigning relative weights to physician services. The payment is then calculated through a conversion factor to determine the Relative Value Unit (RVU). Services such as echocardiography have two components – the professional component (RVUs related to the work the physician performs to interpret the echo) and the technical component (RVUs for non-physician work such as staff time, equipment costs, room fees, etc.). The physician interpreting the echo receives payment determined by the professional RVUs and the hospital receives payment determined by the technical RVUs (unless the physician owns and operates the echo equipment – in that case, the physician receives both the professional and technical RVUs).

Payment to hospitals for Medicare services differ depending on whether the patient receiving the service is an inpatient or outpatient. The payment system for a Medicare inpatient is based in the patient’s Diagnosis Related Group (DRG). The DRG system provides a fixed, prospectively determined payment based on the patient’s diagnosis. This type of payment system incentivizes hospitals to provide efficient and less costly care.

The fee schedule for payment of outpatient hospital services is determined by the Hospital Outpatient Prospective Payment System (HOPPS) . Under HOPPS, procedures are classified into groups based on clinical similarity and resource use. These groups are called Ambulatory Payment Classifications (APCs) . A procedure’s billing code will determine which APC it belongs to in this payment system.

Procedural billing codes are known as Current Procedural Terminology (CPT) codes . These codes are used to identify medical services payable under PFS and HOPPS. These codes are used to determine the amount of reimbursement to health care providers by insurers.

CPT codes are developed, maintained and revised by the American Medical Association (AMA). The AMA/Specialty Society Relative Value Scale Update Committee (RUC) is an expert panel formed by the AMA to make relative payment value recommendations to CMS. The RUC is responsible for developing relative value recommendations to CMS for new or revised CPT codes and revising RVUs for existing CPT codes on an annual basis.

The AMA House of Delegates (HOD) is the principal policy-making body of the AMA. This forum represents the views and interests of physician members from more than 170 societies. These delegates are responsible for establishing policies on health, medical, professional, and governance matters. ASE first achieved full delegate status on the HOD in 2013. The AMA provides a powerful voice in Congress, the courts, and federal agencies. Full delegate status provides ASE with a vote on important AMA policy within the HOD.

The issues recently considered by the HOD are vast. Of particular interest to ASE are:

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  MIPS and MACRA

  
  
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  Site of Service Parity Policy

  
  
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  The Appropriate Use Criteria Mandate

  
  
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  MOC

  
  
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  EHR/data standardization interoperable

  
  
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  Immigration ban

  
  
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  Drug shortages

  
  
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  Prior authorizations

Full delegate status also provides ASE with Advisor status before the AMA’s Current Procedural Terminology (CPT) Editorial Panel and the AMA/Specialty Society RVS Update Committee (RUC). Without CPT/RUC Advisor status, ASE is excluded from both processes except when invited by the American College of Cardiology (ACC).

Having attained full Advisor status within the CPT and RUC has contributed to some of ASE’s more recent and substantial advocacy successes by allowing ASE to directly participate in the Medicare reimbursement code change review and valuation processes. Thanks to the strong participation of Dr. Michael Main (chair of ASE’s Advocacy committee), Dr. Geoffrey Rose, and the rest of ASE’s Advocacy team, ASE’s Advisor status has resulted in the following successes:

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  Creation of new interventional TEE, strain, and perfusion codes.

  
  
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  Supporting the value of CPT code 93306, as well as CPT codes 93307 and 93308, and stress echocardiography codes 93350 and 93351.

  
  
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  In November, CMS finalized the RUC’s recommendation increasing the physician wRVUs for 93306 from 1.30 to 1.50 , and maintaining the current values for remaining TTE and stress echocardiography codes beginning January 1, 2018.

ASE is committed to advocating for fair payment for cardiovascular ultrasound services. The success of the advocacy efforts requires the hard work of the Advocacy committee, ASE staff, and legal representation as well as maintenance of Delegate status in the AMA’s HOD. ASE’s delegate status is due for renewal in 2018. In order to maintain delegate status, ASE must demonstrate that 1,000 of ASE’s physician eligible (U.S.-based) membership must also be members of the AMA. Societies have lost their Delegate status as a result of failing to meet this requirement. ASE is working hard to ensure your voice is heard on issues related to legislative and regulatory issues, and on coding and reimbursement.

Help ASE by joining the AMA NOW to assure ASE maintains its Delegate Status and can continue to be a strong advocate for cardiovascular ultrasound!

Vera H. Rigolin, MD, FASE, is a cardiologist at Northwestern Memorial Hospital, Professor of Medicine at Northwestern University’s Feinberg School of Medicine, and is the current president of ASE. She specializes in echocardiography, valvular heart disease, and women’s heart health. She speaks fluent Portuguese, and has collaborated in the translation of four of ASE’s guideline webinars into Portuguese.