It’s possible that sometime early in 2019, about 1,000 randomly selected surgeons who perform total knee arthroplasty (TKA) and/or total hip arthroplasty (THA) will receive a potentially dense and time-consuming survey from the American Academy of Orthopaedic Surgeons (AAOS), and that another 1,000 or so will receive the same survey from the American Association of Hip and Knee Surgeons (AAHKS).
If this survey is sent, it’s not one to ignore. It could determine how much TKA and THA surgeons are paid, not just by Medicare, but by many or all other payers, for TKA and THA procedures starting in 2021.
More likely, there will be no survey.
That won’t mean that there is no problem. “AAOS and other societies with procedures on the CMS list from the 2019 MPFS* final rule have indicated to the RUC (AMA’s Relative Value Scale Update Committee) that the societies do not believe the identified procedures require surveys,” said William Creevy, M.D., the AAOS RUC advisor, in response to our query.
* MPFS = Medicare Physician Fee Schedule, referred to hereinafter as the “PFS.”
Why are THA and TKA payments under threat?
The answer, in a word, is: “Anthem.”
As we previously reported, the Centers for Medicare and Medicaid Services (CMS) decided to review seven Current Procedural Terminology (CPT) codes, including 27130 (TKA) and 27447 (THA) for whether their Relative Value Units (RVUs) are too high. The seven procedures below, taken from page 169 of the 2,379-page PDF version of the final rule for the 2019 PFS, are:
- 27130 Total hip arthroplasty
- 27447 Total knee arthroplasty
- 43239 Egd biopsy single/multiple
- 45385 Colonoscopy w/lesion removal
- 70450 CT head w/o contrast
- 93000 Electrocardiogram complete
- 93306 TTE [transthoracic echocardiogram]w/doppler complete
CMS said it was acting on an anonymous “public” comment posted to the Federal Registerunder a Medicare rule which allows the public to submit views at any time on Medicare.
“Anonymous”, it turns out, is Anthony Mader, Vice President, Public Policy for Anthem.
Anthem Declares a Price War
“Anthem believes there is systematic overvaluation of work for the Berenson-Eggers Type of Service (BETOS) categories of Major Procedures, Other Procedures, Test Interpretations, and Imaging Interpretations” (that is, specialists’ RVUs), says Mader’s letter.
Put simply: Anthem wants CMS to cut reimbursements for these seven codes, then slash and burn through the RVUs for specialist codes across the entire PFS.
The entire letter is available online.
Anthem ignored three requests for an interview, then said, after our fourth email, “We aren’t commenting beyond what was stated publicly in our letter.”
