Gregory N. Nicola

MACRA: background, opportunities and challenges for the neurointerventional specialist

The legislative branch of government took many by surprise when it announced the Medicare Access and CHIP Reauthorization Act of 2015. Once the Act was passed, President Obama quickly signed this bipartisan, bicameral effort into law. A foundational element of this legislation was the permanent repeal of the sustainable growth rate formula. Physicians and their patients were appropriately enthusiastic about this development. The Medicare Access and CHIP Reauthorization Act of 2015 included additional elements of considerable interest to neurointerventional specialists.

The RUC: a primer for neurointerventionalists.

The Relative Value Scale Update Committee (RUC) plays a critical role in determining physician payment. When the Centers for Medicare and Medicaid Services (CMS) transitioned to paying physicians based on the Resource-Based Relative Value Scale, the American Medical Association developed this unique multispecialty committee. Physicians at the RUC determine the resources required to provide physician services and recommend appropriate payment for those services. The RUC then submits its recommendations to CMS. Physicians have thus been important in determining relative value and hence payment for the services they provide.

Current procedural terminology; a primer.

In 1966, The American Medical Association (AMA) working with multiple major medical specialty societies developed an iterative coding system for describing medical procedures and services using uniform language, the Current Procedural Terminology (CPT) system. The current code set, CPT IV, forms the basis of reporting most of the services performed by healthcare providers, physicians and non-physicians as well as facilities allowing effective, reliable communication among physician and other providers, third parties and patients. This coding system and its maintenance has evolved significantly since its inception, and now goes well beyond its readily perceived role in reimbursement. Additional roles include administrative management, tracking new and investigational procedures, and evolving aspects of ‘pay for performance’. The system also allows for local, regional and national utilization comparisons for medical education and research. Neurointerventional specialists use CPT category I codes regularly—for example, 36 215 for first-order cerebrovascular angiography, 36 216 for second-order vessels, and 37 184 for acute stroke treatment by mechanical means. Additionally, physicians add relevant modifiers to the CPT codes, such as ‘−26’ to indicate ‘professional charge only,’ or ‘−59’ to indicate a distinct procedural service performed on the same day.

The Bundled Payments for Care Improvement Initiative

The Affordable Care Act enters its fifth year firmly entrenched in our national consciousness. One method that has entered the vernacular for achieving cost savings is accountable care. There are other approaches that are less well known. The Bundled Payments for Care Improvement Initiative has the potential to significantly impact neurointerventionalists. We review that initiative here.

The Burwell roadmap

In January 2015 the current Secretary of the Department of Health and Human Services (HHS) outlined a bold initiative to shape the delivery of healthcare through a set of strategies aimed at improving the quality of care and reducing the growth of healthcare costs. The strategies include increasing payment incentives tied to higher value care, increasing care coordination and integration, and increasing access to information to guide patients and clinicians. Significantly, the proposal includes specific goals for alternative payment models and value-based payments for the first time in the history of the Medicare program.

Accountable Care Organizations: what they mean for the country and for neurointerventionalists

The Affordable Care Act is celebrating its fifth anniversary and remains one of the most significant attempts to reform healthcare in US history. Prior to the federal legislation, Accountable Care Organizations had largely been part of an academic discussion about how to control rising healthcare costs, but have since become a fixture in our national healthcare landscape. A fundamental shift is underway in the relationship between healthcare delivery and payment models. Some elements of Accountable Care Organizations may remain unfamiliar to most healthcare providers, including neurointerventional specialists. In this paper we review the fundamental concepts behind and the current forms of Accountable Care Organizations, and discuss the challenges and opportunities they present for neurointerventionalists.

Diagnostic carotid and cerebral angiography: A historical summary of the evolving changes in coding and reimbursement in a complex procedure family

Carotid and cerebral angiography have been a mainstay of neurointerventional and neuroradiologic practice for years. Centers for Medicare and Medicaid Services (CMS) and Relative Value Scale Update Committee (RUC) initiatives have compelled the professional societies to bundle component codes under threat of unilateral CMS revision and revaluation. Code bundling usually results in a decrease in the professional Relative Value Unit (RVU) valuation, and thus the MD reimbursement. The year 2013 saw a dramatic revision to the Current Procedural Terminology (CPT) code set that defines carotid and cerebral procedures. This paper reviews the process that led to that code set being revised and estimates the impact on professional reimbursement. We show the current and previous carotid angiography CPT codes and use clinical examples to assess professional RVU valuation before and after code revision.

MACRA 2.0: are you ready for MIPS?

The annual cost of healthcare delivery in the USA now exceeds US

Affordable care 2014: a tale of two boards

3 trillion. Fee for service methodology is often implicated as a cause of this exceedingly high figure. The Affordable Care Act created the Center for Medicare and Medicaid Innovation (CMMI) to pilot test value based alternative payments for reimbursing physician services. In 2015, the Medicare Access and CHIP Reauthorization Act (MACRA) was passed into law. MACRA has dramatic implications for all US based healthcare providers. MACRA permanently repealed the Medicare Sustainable Growth Rate so as to stabilize physician part B Medicare payments, consolidated pre-existing federal performance programs into the Merit based Incentive Payments System (MIPS), and legislatively mandated new approaches to paying clinicians. Neurointerventionalists will predominantly participate in MIPS. MIPS unifies, updates, and streamlines previously existing federal performance programs, thereby reducing onerous redundancies and overall administrative burden, while consolidating performance based payment adjustments. While MIPS may be perceived as a straightforward continuation of fee for service methodology with performance modifiers, MIPS is better viewed as a stepping stone toward eventually adopting alternative payment models in later years. In October 2016, the Centers for Medicare and Medicaid Services (CMS) released a final rule for MACRA implementation, providing greater clarity regarding 2017 requirements. The final rule provides a range of options for easing MIPS reporting requirements in the first performance year. Nonetheless, taking the newly offered ‘minimum possible’ approach toward meeting the requirements will still have negative consequences for providers.

The episode, the PTAC, cost, and the neurointerventionalist

The Patient Protection and Affordable Care Act (ACA) became law on 23 March 2010. As part of the law, two independent boards were established. The Patient-Centered Outcomes Research Institute embodies national aspirations for employing comparative effectiveness research in healthcare decision-making, and the Independent Payment Advisory Board is focused on the need for a group of impartial experts to establish anticipatable growth rates for Medicare. Approximately 4 years after the bill was passed into law, these independent boards are at very different points in their life cycles. This article provides a status update.