By now, I assume that you are aware that the Centers for Medicare & Medicaid Services (CMS) in the rule published in November reduced the payments for NCS by greater than 50 percent, and cut reimbursements for EMG as well. About 50 percent of my time is in the EMG lab, and both I and the AAN are aware of the disastrous nature of these cuts. Intraoperative monitoring codes also have problems in the final rule but for different reasons.
While I initially felt that neurology was somehow singled out, it was not. Other specialties also experienced drastic cuts like radiation oncology. Gl is having their codes reevaluated and faces similar cuts in the next cycle.
How did this happen? CMS is directed by statute to bundle services. About three years ago, they indicated that EMG and NCS codes should be bundled. The AAN and the AANEM spent many hours trying to figure out how to bundle codes. The codes accepted by the CPT committee are awkward. We are then required to survey these codes and present them to another committee, the RUC, to justify the RVU values assigned, which obviously translate to payment. The RUC accepted reasonable numbers for the codes. However, without notice or opportunity to comment, the final rule reduced the recommended values to an even greater extent.
What are the implications? These changes come with little notice. Most private practices survive on these services. Evaluation and management (E/M) services are not sufficiently recognized, particularly for the complex and chronic diseases we care for as neurologists. Academic departments also are severely impacted. Neurophysiology revenues keep the department viable in the mission of education, research, and care to the underserved. I have heard from neurologists who are considering a drastic change in practice–including closing the practice. Small practices in rural areas are at particular risk. What are we doing about the pay cut? We are leaving no stone unturned. We are contacting CMS about the code valuations and pointing out that the methodology applied does not recognize the intensity of the codes. This in part is a political process. We have asked all of you to write to CMS to explain the impact of these cuts to the Medicare population. We are enlisting help from Congress to put pressure on CMS. We also are going to the public and, in particular, patient groups and asking them to speak up on the need for access to these services.
While we are not mitigating our efforts at all, looking at the past response of CMS to similar efforts, the chances for a change in the code values, particularly in the short term, is small. We continue to work on improved recognition for E/M services performed by neurologists. Our chance of success here is greater. Multiple bills have included language to include neurology in the primary care bonus. The political time line is measured in years. At some point we will be included in improved payments. The cost pressures on health care are enormous and will continue to lead to changes to the payment for individual services and changes in systems of care. The efforts of the AAN already have avoided reductions in other areas. We will continue to aggressively work on the behalf of the specialty.
What can you do? Increasingly, the payments for and policies surrounding health care represent a political process. It is important that you become engaged and contact your congressional delegation and educate your patients. The AAN cannot do this alone.
Bruce Sigsbee, MD, FAAN