Life Sciences

Cardiologists, oncologists, other specialty customers affected by unheralded Medicare cut

Medicare & Reimbursement Advisor Weekly, November 20, 2009

If you have a product prescribed by specialty physicians, consider this: Next year’s Medicare physician pay schedule will likely hurt your specialty provider customers, particularly those in rural communities.

As of January 1, 2010, the Centers for Medicare & Medicaid Services (CMS) plans to eliminate a series of five-digit CPT codes that specialist physicians, such as cardiologists, oncologists, and surgeons use to bill for medical or surgical consults. These consults occur at the request of a practitioner who wants a specialist’s opinion regarding his or her patient.

“When these doctors find out about this, they are going to go ballistic,” says Larry deGhetaldi, MD, administrator of the Palo Alto Medical Foundation, a multi-specialty group practice with 900 physicians in Santa Cruz, CA. He adds that if it weren’t for the complexity and anxiety over health reform, “this would have been the major freak-out issue.”

Under current CMS rules, the CPT code for consultation calls for reimbursement is between $20 and $50 higher than for a comparable office visit. But by eliminating the CPT codes, those specialists will be forced to bill under a different payment code bracket, which covers for a simple office visit.

The rule change could have an impact on some specialists’ willingness to be available for specialty referral care, either in the hospital or in their office practices, says Ted Mazer, MD, a San Diego–area otolaryngologist.

“The potential impact on already endangered ER call panels should have been considered as well. The devaluation of the consultants’ services may adversely impact access in both city and rural settings,” Mazer says, especially in areas where there is already a shortage of some specialists.

When this change takes effect, Mazer worries that the confusion in what codes Medicare will accept will cause delays in payment, resulting in cash flow problems for specialty physicians as well.

The policy change has come about, in part, because of a desire of the Obama administration to increase reimbursement to primary care physicians, who are increasingly in short supply. But such redistribution may tend to worsen the schism between those groups and specialists.

“Patients in certain parts of the country who undergo a routine hospital admission will have 10 consults,” deGhetaldi says. “If they force this new patient code, that will control some of these costs.”