Daily News Boston CHEST 2024

October 6-9, 2024

Reimbursement challenges ahead in proposed CMS physician fee schedule

Kevin L. Kovitz, MD, FCCP
Kevin L. Kovitz, MD, FCCP

Many pulmonology practices are facing a steep decline in revenue in 2019, according to a series of presentations in a Monday session. The 2019 physician fee schedule proposed by the Centers for Medicare & Medicaid Services (CMS) could slash reimbursement. The impact will depend largely on the proportion of Level 4 and Level 5 visits compared to lower level codes. The higher the proportion of high-level codes, the greater financial hit.

“We are all sitting on the edge of our seats waiting to see what CMS ultimately does with the final rule,” said Kevin L. Kovitz, MD, FCCP, professor of medicine and director of interventional pulmonology at the University of Illinois College of Medicine.

Dr. Kovitz moderated a look at Reimbursement Challenges of the Proposed CMS Final Rule on Monday. The public comment period for the proposed final rule closed in September, and the final rule is expected later in October.

The problem for providers is CMS’ plan to collapse the current five codes for new and return visits down to two codes. The top three level codes will be eliminated entirely while reimbursement for what is now a Level 2 code will be increased somewhat.

CMS’ goals seem reasonable enough, said Scott Manaker, MD, PhD, FCCP, professor of medicine at the Hospital of the University of Pennsylvania. The agency’s stated purpose was to reduce provider administrative burdens, reduce the need for office visit audits, and reduce the need for record keeping while remaining budget neutral.

The mechanism CMS chose to implement those goals, a flat rate payment regardless of the severity or complexity of the patient, leaves much to be desired. As news of the new fee schedule spread, 170 medical societies and associations voiced their objections to CMS during the public comment period.

Dr. Manaker said his institution expects to lose about $6 million in revenue for 2019 on an annual operating budget of $550 million and 750 faculty. The problem: about 90% of pulmonology billings are for Level 5 codes. Their Level 5 billing rate has remained stable over several years.

“This proposed fee schedule is lunacy, not to mention the chaos because we will handle Medicare one way and private insurers another way,” he said.

The Cleveland Clinic ran its own analysis of the potential impact of the proposed fee schedule. Thomas Gildea, MD, MS, head of bronchology, said the institution expects to lose about $3,800 for every 100 Medicare patients it sees next year, an overall decline in reimbursement of 22.1%.

Many specialties will be hit harder. Pulmonary hypertension expects to lose 26%. Lung transplantation is looking at a 34.9% decline in Medicare reimbursement.

“This is bad news for us,” he said, “far worse than the 2% decline predicted by CMS.”

The picture is more complicated for private practice.

Michael E. Nelson, MD, FCCP, is part of a five practitioner practice, Shawnee Mission Pulmonary Consultants. There are no interventionalists and all practitioners see sleep patients. The practice expects just a 0.09% loss over 2018 predicted collections because it has fewer high-level billings.

Kim D. French, MHSA, CAPPM, FCCP, executive director of Suburban Lung Associates, expects the large practice to see a loss of just under $500,000 compared to 2018. Interventional pulmonology will take the biggest hit, a loss of 18.9%, while sleep shows a 1.5% gain.

“Most of us are probably coding those 99204s and 22214s very appropriately,” she said. “This is a huge decrease in dollars that will have real implications in patient care.”