Reframing Medicare Physician Payment Policy for 2019: A Look at

On July 12, 2018, the Centers for Medicare and Medicaid Services (CMS) released the proposed

2019 Medicare physician fee schedule and quality payment program, combining these 2 rules

for the first time. This occurred in a milieu of changing regulations that have been challenging

for interventional pain management specialists. The Affordable Care Act (ACA) continuous to be

amended by multiple administrative changes. This July 12th rule proposes substantial payment

changes for evaluation and management (E&M) services, with documentation requirements, and

blending of Level II to V CPT codes for E&M into a single payment. In addition, various changes in

the quality payment program with liberalization of some metrics have been published. Recognizing

that there are differing impacts based on specialty and practice type, as a whole interventional

pain management specialists would likely see favorable reimbursement trends for E&M services

as a result of this proposal. Moreover, in comparison with recent CMS final ruling, this proposed

rule has relatively limited changes in procedural reimbursement performed in a facility or in-office

setting.

CMS, in the new rule, has proposed an overhaul of the E&M documentation and coding system

ostensibly to reduce the amount of time physicians are required to spend inputting information into

patients’ records. The new proposed rule blends Level II to V codes for E&M services into a single

payment of $93 for office outpatient visits for established patients and $135 for new patient visits.

This will also have an effect with blended payments for services provided in hospital outpatients.

CMS also has provided additional codes to increase the reimbursement when prolonged services are

provided with total reimbursement coming to Level V payments. Interventional pain management-

centered care has been identified as a specialty with complexity inherent to E&M associated with

these services.

Among the procedural payments, there exist significant discrepancies for the services performed

in hospitals, ambulatory surgery centers (ASCs), and offices. A particularly egregious example

is peripheral neurolytic blocks, which is reimbursed at 1,800% higher in hospital outpatient

department (HOPD) settings as compared with procedures done in the office. The majority of

hospital based procedures have faced relatively small cuts as compared with office based practice.

The only significant change noted is for spinal cord stimulator implant leads when performed in

office setting with 19.2% increase. However, epidural codes, which have been initiated with a

lower payment, continue to face small reductions for physician portion.

This review describes the effects of the proposed policy on interventional pain management

reimbursement for E&M services, procedural services by physicians and procedures performed in

office settings.

Key words: Physician payment policy, physician fee schedule, Medicare, Merit-Based Incentive

Payment System, interventional pain management, regulatory tsunami, Medicare Access and CHIP

Reauthorization Act of 2015

Pain Physician 2018: 21:415-432

Health Policy

Reframing Medicare Physician Payment Policy

for 2019: A Look at Proposed Policy

From:

Pain Management Center

of Paducah, Paducah, KY;

Spine

Pain Diagnostics Associates,

Niagara, WI;

Millennium Pain

Center, Bloomington, IL, and

University of Illinois, Urbana-

Champaign, IL;

LSU Health

Science Center, New Orleans,

LA; and

Massachusetts General

Hospital and Harvard Medical

School, Boston, MA

Additional Author Affiliation

Information on P. 428.

Address Correspondence:

Laxmaiah Manchikanti, MD

2831 Lone Oak Road

Paducah, KY 42003

E-mail: [email protected]

Disclaimer: There was no

external funding in the

preparation of this manuscript.

Conflict of interest: Dr.

Benyamin is a consultant for

Medtronic. Dr. Kaye is a speaker

for Depomed, Inc. and Merck..

Dr. Hirsch is a consultant for

Medtronic.

Manuscript received: 08-15-2018

Revised manuscript received:

09-04-2018

Accepted for publication:

09-06-2018

Free full manuscript:

www.painphysicianjournal.com

Laxmaiah Manchikanti, MD

, Vijay Singh, MD

, Ramsin M. Benyamin, MD

Alan D. Kaye, MD, PhD

, Vidyasagar Pampati, MSc

, and Joshua A. Hirsch, MD

www.painphysicianjournal.com

Pain Physician 2018; 21:415-432 • ISSN 1533-3159

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416 www.painphysicianjournal.com

Reframing Medicare Physician Payment Policy for 2019

and intensity, whereas changes in service utilization

were not associated with a statistically significant

change (23). The data also showed that changes in

disease prevalence of instance were essentially associ

ated with spending reductions of 2.4% or $28.2 billion

(23). Even then, disability continues to escalate, along

with opioid related deaths, which continue to increase

at epidemic rates (24-26). It was also postulated that

a nominal decrease in health care cost based on price

reductions and cost calculation methodology of services

with site-of-service differentials by Medicare and oth

ers, and multiple policy changes, may have led to the

unintended consequences of limiting access to medi

cally needed services (2-4,27,28).

In a press release from July 2018, in the form of

a letter to physicians from CMS Administrator, Seema

Verma, the administration understandings of the is

sues facing provider communities and Medicare were

described (29). Administrator Verma highlighted the

following:

 Years of eduction, training, and hard work, as well

as the expertise of physicians, are not utilized ap

propriately, but instead, they are being forced to

spend far too much of their time on burdensome

and often mindless administrative tasks.

 Wasteful tasks imposed on physicians have been

draining energy and taking time away from pa

tients, from reporting on measures that demand

that physicians follow complicated and redundant

processes, to documenting lines of text that don’t

add value to patient’s medical record, to hunting

down records and faxes from other physicians and

sifting through them.

 The systems have taken the most brilliant students

and put them to work clicking through screens

and copying and pasting, with 42% of physicians

reporting burnout.

 Doctor/patient relationship has been deteriorating

and patients are not being put first.

 Physicians should be able to deliver care to pa

tients, not sitting at a computer screen.

Administrator Verma blamed Washington for many

of the frustrations with the current system, as policies

that have been put forth as solutions either have not

worked or have moved health care in the opposite di

rection. In fact, she stated that electronic health records

that should make it easier for physicians to record notes

and achieve interoperability. Amazingly, the govern

ment spent $30 billion to encourage their uptake, turn-

he Centers for Medicare and Medicaid Services

(CMS) released its proposed 2019 Medicare

Physician Fee Schedule on July 12, 2018, with

the comment period ending September 10, 2018 (1). As

opposed to prior iterations, the 2019 Medicare physician

fee schedule (MPFS) and quality payment program

(QPP) proposed rule is the first year that the 2 rules

have been combined. This rule also is accompanied by

multiple fact sheets including ones on changes to the

quality payment program and physician fee schedule

proposals for 2019. In many ways, these changes reflect

the philosophy of the Trump administration. This is in

contrast to the 2017 proposed rule at which time the

Obama administration had declared the success of

the Patient Protection and Affordable Care Act (ACA)

with significant progress towards solving longstanding

challenges facing the US health care system related

to access, affordability, and quality of care (2-8). As

we have described in the past, reducing health care

expenditures with increased access to affordable

insurance coverage and improvement in quality have

been the cornerstones of multiple legislative efforts and

regulations including the ACA (4-18). Despite the fact

that there are clear examples of program success, the

effectiveness of ACA in achieving some of its primary

goals has been questioned (5,8). There has been a net

increase in the number of individuals with insurance;

a portion of which is attributable to the expansion of

Medicaid. Moreover there likely has been a reduction

in costs; however, with diminished access for many

who were previously insured and concerningly without

corresponding improvement in the quality of care

(4,5,8).

National health expenditures (NHEs) have grown

with expenditures reaching $3.3 trillion in 2016, which

is equivalent a 17.9% share of the gross domestic

product (GDP) (19). Medicare spending also reached a

historic $672.1 billion with a share of 20.36% of total

NHEs, while Medicaid spending grew almost as high as

Medicare to $565.5 billion in 2016, and a 17.1% share

of total NHE (19). The Trump administration started

with plans to repeal the ACA, which have not material

ized even with multiple legislative attempts through

Congress leaving it as the law of the land (20,21). The

statistics showing expenditures in the United States

reveal that the US spent $87.6 billion on back and neck

pain with an additional $95.9 billion on musculoskel

etal disorders in 2013 (22). Further, the same authors

also showed that the major reason for the increase in

expenditures was related to changes in service price

ing this tool into a serious distraction from patient care

due to the inability to exchange records between sys

tems and the increasing requirements for information

that must be documented. Administrator Verma prom

ised that CMS is committed to turning the tide and has

launched “Patients Over Paperwork” initiative, under

which they have been working to reduce the burden

of unnecessary rules and requirements. CMS indicates

that is has thus proposed an overhaul of the evaluation

and management (E&M) documentation and coding

system ostensibly to dramatically reduce the amount of

time physicians have to spend in putting unnecessary

information into patient’s records. Administrator Verma

also described multiple other changes that are reflected

in this proposed rule including a major reduction of the

documentation burden for E&M office visit code, .new

payments for physician services that are not part of a

face-to-face office visit and some easements in the qual

ity payment program

The proposed policy favorably affects interven

tional pain management’s reimbursement for E&M ser-

vices, procedural services by physicians and procedures

performed in office settings.

Background

Medicare establishes a physician fee schedule for

services furnished by physicians and other practitioners

in all sites of services, including office visits, surgical pro

cedures, diagnostic tests, therapy services, and multiple

specified preventive services. Payments are based on the

relative resources typically used to furnish the service.

Relative value units (RVUs) are applied to each service

for physician work, practice expense, and malpractice.

These RVUs become payment rates through application

of a conversion factor. Payment rates are calculated to in

clude an overall payment update specified by the statute.

The impact of the Medicare physician fee schedule

is enormous for interventional pain physicians. The

Medicare fee schedule affects not only fee-for-service

Medicare, but also Medicare Advantage Plans, a large

number of Medicaid plans, and a significant proportion

of private payers. Since 2016, interventional pain man

agement has suffered significant losses in multiple areas

of payments, not only for physician payments, but also

facility payments for in-office procedures and ambula

tory surgery centers. Further, the opioid epidemic has

also become a focus affecting interventional techniques

in that interventional techniques might appropriately

be considered in lieu of prescriptions opioids (24-26,30-

40). Manchikanti et al (2) demonstrated significant

declines in payment rates in 2017, which continued

through 2018, despite multiple efforts by American

Society of Interventional Pain Physicians (ASIPP) and

others to avoid these reductions. This is likely resulting

in reductions in utilization of interventional techniques

as shown in Appendix Table 1 and Appendix Figs. 1-4

(33-39). Opioid prescriptions are down but deaths

continue to increase concurrent with a decline in in

terventional techniques as shown in Appendix Figs. 5

and 6 (24-32).

Even prior to the proposed rule, interventional

techniques have been facing a multitude of issues de

spite demonstration of clinical and cost effectiveness

due to improper evidence synthesis (41-58). Based on

the available data, CMS is proposing updated pricing

recommendations for supply and equipment items cur

rently used as direct practice expense (PE) inputs. These

data were derived from market research resources and

methodologies including field surveys, aggregate data

bases, vendor resources, market scans, market analysis,

physician substantiation, and statistical analysis. CMS

is proposing to update supply and equipment pricing

over a 4-year phase-in.

Physician Payment uPdate

The proposed rule updates physician payment

schedule conversion factor from $35.9996 to $36.0463,

reflecting a statutory update of 0.25%, offset by a

budget neutrality adjustment of -0.12%, resulting in a

0.13% update.

Evaluation and Management Services

Payments

CMS proposed to collapse payment for office and

outpatient visits to a single blended payment for office

visits, Level 2 to 5 for new patients (CPT 99202-99205)

with a single payment of $134.45 and for established

patient office visits with a single payment for Levels

2-5 (CPT 99212-99215) into a single payment of $92 as

shown in Table 1.

In addition, new codes would be created to pro

vide additional payments to office visits of $5, $14 and

$67, with multiple procedure adjustment with reduc

tion when an E&M visit is furnished in combination

with a procedure on the same day (Table 2). Physicians

will be allowed to choose their method of documenta

tion, among the following options:

 1995 or 1997 E&M guidelines for history, physical

examination, and medical decision making (cur

rent framework for decision making, which is the

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Reframing Medicare Physician Payment Policy for 2019

current framework for documentation)

 Medical decision making only.

 Physician time spent face-to-face with patients.

It seems that some physicians will continue to

document and report among the 5 levels of codes. CMS

will only require documentation to support the medical

necessity of the visit and to support a Level 2 CPT visit

code. In order to report an established office visit to

Medicare, physicians need to document medical neces

sity and then one of the following:

 Two of the 3 components:

1) Problem-focused history that does not include

a review of systems or a past, family or social

history;

2) A limited examination of the affected body

area or organ system; and

3) Straightforward medical decision making mea

sured by minimal problems, review, and risk; or

 Time personally spent by billing practitioner face-

to-face with the patient.

However, CMS is soliciting comments on what time

disproportionately care for patients with complex needs

would face a fee cut for Levels 4 and 5 visits, despite the

add-on payment. Further, physicians in nonprocedural

specialties whose revenue derives largely from these vis

its as shown in Appendix Fig. 7 could find this cut unten-

able. Figures 1 and 2 compare the interventional pain

management, pain management, and parent specialties

compared with internal medicine and overall specialties.

As illustrated earlier, interventional pain management

would see an increase with added benefit of reduced

documentation, facilitating increased patient time.

Table 1. Proposed blended payment schedule for office and outpatient based evaluation and management visits.

Physician Office

Payments

Hospital Outpatient Payments

Established Patients 2018

2019

Proposed

2018 2019 Proposed

Physician Facility Total Physician Facility Total

Level 1 – CPT 99211 $21.96 $24.15 $9.36

$113.68

$123.04 $9.73

$115.76

$125.49

Level 2 – CPT 99212 $44.64

$91.92

$25.92 $139.60

$65.60 $181.36

Level 3 – CPT 99213 $74.16 $52.20 $165.88

Level 4 – CPT 99214 $109.44 $79.92 $193.60

Level 5 – CPT 99215 $147.60 $113.04 $226.72

New Patients

Level 1 – CPT 99201 $45.36 $43.26 $27.36

$113.68

$141.04 $25.59

$115.76

$141.35

Level 2 – CPT 99202 $76.32

$134.45

$51.48 $165.16

$102.37 $218.13

Level 3 – CPT 99203 $109.80 $78.12 $191.80

Level 4 – CPT 99204 $167.40 $131.76 $245.44

Level 5 – CPT 99205 $210.60 $172.08 $285.76

Table 2. Proposed additional payment codes in 2019 physician payment rule.

• Proposing ~$5 add-on payment to recognize additional resources to address inherent complexity in E&M visits associated with primary care

services.

• Proposing ~$14 add-on payment to recognize additional resources to address inherent visit complexity in E&M visits associated with certain

non-procedural based care.

• Proposing ~$67 add-on payment for a 30 minute prolonged E&M visit.

should be required if this is the documentation selec-

tion with multiple options being considered. One op-

tion being 10 minutes (CPT defined typical time) or 16

minutes which is a weighted average of all established

office visits.

An impact analysis with additional payment accu

racy adjustments was performed by CMS as shown in

Table 3. For 2019, multiple specialties may face a reduc

tion. For some specialties, it is rather significant and it

is thus easy to understand their concern. Obstetrics and

gynecology will be the major beneficiary with overall

4% increase, followed by nurse practitioners of 3%.

Interventional pain management will see less than 3%

increases. Anesthesiology and physical medicine and

rehabilitation specialties will see minimal changes to

overall payments.

Song and Goodson (59) analyzed the CMS proposal

to reform office visit payments. Overall they had a nega

tive opinion about collapsing of the codes and also the

resultant adverse consequences. As shown in Appendix

Fig. 7, they postulated that these changes may benefit

by removing physicians’ incentive to spend time with

patients who have complex needs. Thus, physicians who

Specialty

Allowed

Charges

(in

millions)

Estimated

Potential

Impact of

Valuing Levels

2-5 Together,

with Additional

Adjustments

Nephrology $2,285

Minimal change to

overall payment

Neurosurgery $812

Nuclear Medicine $50

Ophthalmology $5,542

Oral/Maxillofacial Surgery $57

Orthopedic Surgery $3,815

Other $30

Pathology $1,151

Pediatrics $64

Physical Medicine $1,120

Plastic Surgery $387

Radiology $4,898

Thoracic Surgery $360

Vascular Surgery $1,132

Allergy/Immunology $240

Less than 3%

estimated decrease

in overall payment

Audiologist $67

Hematology/Oncology $1,813

Neurology $1,565

Otolaryngology $1,220

Pulmonary Disease $1,767

Radiation Oncology and

Radiation Therapy Centers

$1,776

Rheumatology $559 -3%

Dermatology $3,525 -4%

Podiatry $2,022 -4%

TOTAL $93,486 0%

Table 3 Specialty-specific impacts including payment accuracy adjustments.

Specialty

Allowed

Charges

(in

millions)

Estimated

Potential

Impact of

Valuing Levels

2-5 Together,

with Additional

Adjustments

Obstetrics/Gynecology $664 4%

Nurse Practitioner $3,586 3%

Obstetrics/Gynecology $664

Less than 3%

estimated increase

in overall payment

Nurse practitioner $3,586

Hand Surgery $202

Interventional Pain Management $839

Optometry $1,276

Physician Assistant $2,253

Psychiatry $1,260

Anesthesiology $1,995

Minimal change to

overall payment

Cardiac Surgery $313

Cardiology

Chiropractor $789

Colon and Rectal Surgery $168

Critical Care $334

Emergency Medicine $3,196

Endocrinology $482

Family Practice $6,382

Gastroenterology $1,807

General Practice $461

General Surgery $2,182

Geriatrics $214

Infectious Disease $663

Internal Medicine $11,173

Interventional Radiology $362

Multispecialty Clinic/Other

Physicians

$141

Other Evaluation and Management Proposals

1. When physicians report an E&M service and a pro-

cedure on the same date, CMS proposes to imple-

ment a 50% multiple procedure payment reduc-

tion to the lower paid of the 2 services. However,

this policy is not consistent with current valuation

of procedures commonly performed with office

visits, as duplicative resources have already been

removed from the underlying procedures. It ap

pears CMS proposed this policy to offset payment

increases to dermatology and other specialties that

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Reframing Medicare Physician Payment Policy for 2019

often report lower level office visit codes in con-

junction with minor procedures.

2. In addition, CMS will add $5 to each office visit per

formed for primary care purposes via a new code

GPC1X visit complexity inherent to E&M associated

with primary medical care services. In addition, rel

evant to interventional pain management, CMS

identified multiple specialties including interven

tional pain management that often report higher

level office visits and noted that potential reduction

in payment. To offset this loss, CMS proposes to add

$14 to each office visits performed by the specialists

in the following specialties via a new code GCGOX

visit complexity inherent to E&M (Table 2). The fol

lowing specialties have been identified:

 Allergy/immunology

 Cardiology

 Endocrinology

 Hematology/oncology

 Interventional pain management-centered care

 Neurology

 Obstetrics/gynecology

 Otolaryngology

 Rheumatology

 Urology

A new prolonged service code will be implemented

to add on to any office visit lasting more than 30 min

utes beyond the office visit (i.e., hour-long visits in total.

It is reported by:

 Code GPR01, prolonged evaluation and man

agement or psychotherapy services(s). with a

payment rates of $67 (Table 2).

An interventional pain management physician

currently reporting 99205 and spending more than 60

minutes with a patient would be paid $211. Under the

proposed new method, the interventional pain physi

cian would report 99202-99205, depending on their

documentation selection ($134), plus GCG0X ($14), plus

GPR01 ($67), for a combined payment of $215.

CMS will implement new codes and payment for re

mote monitoring and inter-professional consultations.

3. Medicare would pay physicians for their time when

they reach out to beneficiaries via telephone or

other telecommunication devices to decide wheth

er an office visit or other service is needed. CMS

also proposes to pay for the time it takes physicians

to review a video or image sent by a patient seek

ing care or diagnosis for an ailment.

Fig. 1 2016 Medicare E&M services by level of service – new patient visits.

Fig. 2. 2016 Medicare E&M services by level of service – established patient visits.

Practice Expense Relative Values

Based on the Protecting Access to Medicare Act

of 2014 (PAMA), CMS initiated a market research to

update the direct PE inputs for supply and equipment

pricing for calendar year (CY) 2019.

Proposed Additional Calculation for

Evaluation and Management Services

CMS determines the proportion of indirect PE al-

located to a service by calculating a PE per hour based

upon the mix of specialties that bill for a service. How

ever, a wide range of specialties bill for E&M services

and the change into one payment level will have an ef

fect on PE per hour for many specialities. To address this

issue, CMS is proposing to create a single PE per hour

value for E&M visits of $136.34, based on an average

of the PE per hour across all specialties that bill E&M

codes, weighted by the volume of those specialties al

lowed charge for E&M services.

creation of a Bundled ePisode of

are for management and counseling

reatment for suBstance use disorders

Due to the available evidence suggesting that

routine counseling, either associated with medication-

assisted treatment (MAT) or on its own, can increase the

effectiveness of treatment for substance use disorder,

the federal guidelines for opioid treatment programs

describe that MAT and wraparound psychological and

support service can include the following services (60):

• Physical examination and assessment

• Psychological assessment

• Treatment planning

• Counseling

• Medication management

• Drug administration

• Comprehensive care management and supportive

services

• Care coordination

• Management of care transition

• Individual and family support services

• Health promotion

CMS now believes that making a separate payment

for a bundled episode of care for management and

counseling for substance use disorders could be effec

tive in preventing the need for more acute services (61).

Medicare pays for one-third of opioid related hospital

stays, and Medicare has seen the largest annual increase

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Reframing Medicare Physician Payment Policy for 2019

in the number of these stays over the past 2 decades.

CMS is requesting comments on whether the counsel

ing portion and other MAT components could also be

provided by qualified practitioners “incident” to the

services of the billing physician who would administer

or prescribe any necessary medications and manage the

overall care, as well as supervise any other counselors

participating in the treatment.

Professional liaBility insurance

elative values

CMS is seeking specific comments on ways to

improve how specialties in the state-level raw rate fil

ings data are cross walked for categorization into CMS

specialty codes in order to develop the specialty-level

risk factors and the professional liability insurance (PLI)

RVUs. At present CMS is proposing to add 28 codes

identified as low-volume services to the list of codes

for anticipated specialty assignment. These codes are

reported with the -26 modifier and were submitted by

the RUC. In the addendum for the CY2019 malpractice

risk factors and premium amounts by specialty, CMS

cross walked non-MD-DO specialties to the lowest

MD-DO risk factor specialty, allergy immunology. The

RUC also has consistently maintained that a risk factor

linked to a physician specialty is too high for many of

the non-physician health care professions.

In addition, cardiothoracic surgery and neurosur

gery, specialties with high PLI costs, are proposed to

receive positive impacts to payments related to their

insurance costs for 2019.

gloBal surgery data collection

The Medicare Access and CHIP Reauthorization Act

of 2015 (MACRA) required CMS to implement a process

to collect data on post-operative visits and use these

data to assess the accuracy of global surgical package

valuation.

CMS currently bundles payments for postoperative

care within 10 or 90 days after many surgical proce

dures. Historically, CMS has not collected data on how

many postoperative visits are actually performed dur

ing the global period. In the year 2017 FFS final rule,

CMS adapted a policy to collect postoperative visit

data (62). Consequently, CMS required practitioners in

groups with 10 or more practitioners in 9 states includ

ing Florida, Kentucky, Louisiana, Nevada, New Jersey,

North Dakota, Ohio, Oregon, and Rhode Island to use

the no pay CPT code 99024 for the postoperative fol

low-up visit, normally included in the surgical package,

to indicate that an E&M service was performed during a

postoperative period for reasons related to the original

procedure to report postoperative visits. However, this

has not affected practitioners who only practice with

fewer than 10 practitioners. There have been multiple

data reporting utilizing CPT 99024 in anesthesiology.

The proportion of practitioners reporting CPT code

99024 in anesthesiology is 29%, pain management is

40%, and interventional pain management is 33%. Fur

ther, these were variable for 10-day and 90-day global

period. In the future, CMS may add or increase physi

cian payment work value based on this data.

2019 Potentially misvalued codes list

CMS continues to propose a list of potentially misval-

ued codes for review by the RUC and possible adjustment.

Historically, the RUC and CMS has identified 2,086 services

through 20 different screening criteria for further review

by the RUC since 2006 (63-66). The RUCs efforts for 2009 to

2018 have resulted in $5 billion for redistribution within

the Medicare Physician Payment Schedule.

Potentially misvalued codes are identified in the

following categories:

• Codes that have experienced the fastest growth

• Codes that have experienced substantial changes

in practice expense

• Codes that describe technologies or surveys within

an appropriate time period (such as 3 years) after the

relative values are initially established for such codes

• Codes which are multiple codes that are frequently

billed in conjunction with furnishing a single service

• Codes with low relative values, particularly those

that are often billed multiple times for a single

treatment

• Codes that have not been subject to review since

implementation of the fee schedule

• Codes that account for the majority of spending

under the fee-for-service (FFS)

• Codes for services that have experienced a sub

stantial change in the hospital length of stay or

procedure time

• Codes for which there may be a change in the typi

cal site of service since the code was last valued

• Codes for which there is significant difference in

payment for the same service between different

sites of service

• Codes for which there may be anomalies in relative

values within a family of codes

• Codes for services when there may be efficiencies

when a service is furnished at the same time as

other services

• Codes with higher intraservice work per unit of

time

• Codes with high PE RVUs

• Codes with high cost supplies

• Codes as determined appropriate by the secretary

Apart from CMS identifying the misvalued codes,

the public and stakeholders, including insurers, may

nominate potentially misvalued codes for review by

submitting the code with supporting documentation

by February 10 of each year.

Payment for interventional Pain

anagement Procedures

In the proposed rule, the physician payment sched-

ule conversion factor is updated to $36.0463 from the

previous factor of $35.9996. This is a reflection of the

statutory update of 0.25%. However, this is offset by

the budget neutrality adjustment of 0.12% and so the

actual update result is only 0.13%

The physician payment schedule is mostly without

significant changes in payment rates for procedures,

without major changes for more commonly performed

procedures, while some procedures have seen signifi

cant increases; consequently, it is a mixed bag. Table 4

shows the 2019 proposed physician payment rates

comparing them to the 2018 final rates. The schedule

shows the rates for facility and non-facility; facility rates

when a physician performs the procedure in an ASC or

hospital; whereas, non-facility rates include the facility

expense portion of the office. An extended schedule

is available on the ASIPP website under Physician Fee

Schedules at http://www.asipp.org/Fee-Schedules.html.

Based on the available literature (28,33-39), an

overwhelming majority of interventional techniques

are performed in outpatient settings, either in physi

cians’ offices, hospital outpatient departments (HOP-

Ds), or ambulatory surgery centers (ASCs). In 2012, the

Medicare Payment Advisory Commission (MedPAC)

recommended that if the same service can be safely

performed in different settings, a prudent purchaser

should not pay more for that service in one setting

than in another (27,67). The Office of Inspector General

(OIG) also has expressed a similar approach (68); how

ever, because of hospital acquisition of practices and

increased levels of payments which is costing more for

Medicare. More and more procedures are performed in

an HOPD setting, essentially in an office setting which

is most likely similar to offices utilized outside, but paid

at 300% more than in-office procedures and over 80%

more than in ASCs. Further, for some procedures there

is such a dramatic difference that hospitals are paid at

2,000% as shown in Table 5 (1,68).Thus, the same pro

cedures are provided in an office is reimbursed at a rate

of $14-$20 with continued reductions in 2019, which

were initiated in 2017. These rates are inadequate for

these procedures which must be performed in sterile

fashion following the guidance set by the Centers for

Disease Control and Prevention (CDC).

With the continued decline in reimbursement ini

tiated in 2017, percutaneous adhesiolysis (CPT 62263

and 62264) continue to be the subject of comments

in the past and continue to face declines. Once again,

the fee schedule shows a 0.9% to 2.4% reduction for

non-facility settings and a reduction of 1.5% to 4.9%

for facility setting. CPT 62263 involving multiple per

cutaneous epidural adhesiolysis sessions, 2 or 3 days,

is performed very infrequently or rarely. However, CPT

62264 is commonly performed (38), though its utiliza

tion is declining rapidly as shown in Appendix Fig. 3.

and Appendix Table 2. The reimbursement is reduced

0.9% in a non-facility setting and 1.5% in a facility set

ting. Even though there is no significant difference for

the facility portion of the work involved to perform the

procedure in a non-facility setting, there is a significant

difference in reimbursement of $426.43 versus $597.65.

The saga related to epidural injections with and

without fluoroscopy which started in 2017 continues.

Overall, the reimbursement changed with an increase

of 0.1% to 0.8% for non-facility services; whereas,

it declined by 1.6% to 2.1% when the procedure is

performed in a facility setting. The reimbursement

rates continue to be inadequate with elimination of

separate payment for fluoroscopy, leading potentially

to a shift of procedures to the more highly reimbursed

transforaminals rather than interlaminars. Inter

laminars have declined significantly over the past few

years though there are other confounding factors at

play with regards to this migration (Appendix Fig. 2

and Appendix Table 3) (34,37). Ironically, there are

meaningful increases for continuous epidural injec

tions which are never performed in chronic pain man-

agement settings and carry different codes when they

are performed in obstetric anesthesia.

There are significant reductions for electronic

analysis of programmable pump (CPT 62367), electronic

analysis of programmable pump with reprogramming

(CPT 62368) with 8.1% and 6.8% reductions for non-

facility performance, whereas, these reductions are

2.8% and 4% in a facility setting.

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424 www.painphysicianjournal.com

Reframing Medicare Physician Payment Policy for 2019

Table 4. 2019 proposed physician payment rates compared to 2018 rates.

CPT Description

2018 (CF=35.9996)

2019 Proposed

(CF: 36.0463)

% of change from

2018

Non-

Facility

(Office)

Facility

(ASC/

HOPD)

Non-

Facility

(Office)

Facility

(ASC/

HOPD)

Non-

Facility

(Office)

Facility

(ASC/

HOPD)

20526 Injection, therapeutic, carpal tunnel $79.56 $59.76 $79.30 $59.84 -0.3% 0.1%

20550 tendon sheath, ligament injection $54.36 $40.68 $53.35 $40.01 -1.9% -1.6%

20551 Tendon origin/insertion $62.28 $44.28 $53.71 $40.73 -13.8% -8.0%

20552 Single or multiple trigger point(s), 1 or 2 muscle group(s) $56.52 $39.24 $55.87 $38.57 -1.1% -1.7%

20553 Single or multiple trigger point(s), 3 or more muscle groups $65.16 $44.64 $64.88 $44.34 -0.4% -0.7%

20600 Small joint injection $49.32 $36.72 $47.58 $35.69 -3.5% -2.8%

20605 Intermediate joint injection $51.84 $38.88 $50.46 $37.85 -2.7% -2.7%

20610 Major joint injection $61.92 $47.88 $61.28 $47.94 -1.0% 0.1%

22510 Vertebroplasty (Thoracic) $1,727.62 $453.24 $1,816.73 $454.90 5.2% 0.4%

22511 Vertebroplasty (Lumbar) $1,705.66 $423.72 $1,797.27 $426.07 5.4% 0.6%

22512 Vertebroplasty - Additional $978.47 $216.72 $933.24 $217.00 -4.6% 0.1%

22513 Percut kyphoplasty, thor $7,328.08 $541.43 $7,090.67 $541.06 -3.2% -0.1%

22514 Percut kyphoplasty, thor $7,293.52 $503.99 $7,063.99 $503.57 -3.1% -0.1%

22515 Percut kyphoplasty, Additional $4,415.35 $233.64 $4,106.76 $234.30 -7.0% 0.3%

22534 Percut kyphoplasty, lumbar $379.08 $382.45 0.9%

22869 Insj stablj dev w/o dcmprn $551.81 $471.49 -14.6%

22870 Insj stablj dev w/o dcmprn add-on $142.56 $128.32 -10.0%

27093 Injection procedure for HIP arthrography – without anesthesia $191.88 $72.72 $207.99 $72.45 8.4% -0.4%

27095 Injection procedure for HIP arthrography – with anesthesia $252.00 $86.40 $277.20 $86.51 10.0% 0.1%

27096 Injection procedure for Sacroiliac joint, arthrography $163.08 $86.40 $162.57 $85.07 -0.3% -1.5%

27279 Arthrodesis sacroiliac joint $725.61 $719.99 -0.8%

62263 Percutaneous epidural adhesiolysis - 2 or 3 days $612.35 $329.40 $597.65 $313.24 -2.4% -4.9%

62264 Percutaneous epidural adhesiolysis – 1 day $430.20 $245.88 $426.43 $242.23 -0.9% -1.5%

62268 Percutaneous aspiration, spinal cord cyst or syrinx $267.84 $266.38 -0.5%

62270 Spinal puncture, diagnostic $162.36 $81.00 $153.92 $80.74 -5.2% -0.3%

62272 Spinal puncture, therapeutic $208.08 $86.76 $202.58 $87.23 -2.6% 0.5%

62273 Epidural, blood patch $178.20 $117.36 $176.27 $116.07 -1.1% -1.1%

62284 Injection procedure myelography $194.76 $91.08 $203.66 $91.56 4.6% 0.5%

62287 Disc decompression $595.43 $592.24 -0.5%

62290 Diskography each level: lumbar $334.08 $175.32 $344.60 $172.30 3.2% -1.7%

62291 Diskography each level: C/T $331.92 $173.52 $330.91 $165.45 -0.3% -4.6%

62320 Cervical or Thoracic interlaminar epidural; without fluoro $170.28 $103.32 $165.45 $100.93 -2.8% -2.3%

62321 Cervical or Thoracic interlaminar epidural; with fluoro $253.80 $110.88 $254.13 $108.50 0.1% -2.1%

62322

Lumbar or sacral (caudal) interlaminar epidural

injection(s); without fluoro

$159.84 $89.64 $155.00 $87.59 -3.0% -2.3%

62323

Lumbar or sacral (caudal) interlaminar epidural

injection(s); with fluoro

$250.56 $102.60 $252.68 $100.93 0.8% -1.6%

62324

Cervical or thoracic continuous interlaminar epidural

Injection(s),; without fluoro

$149.04 $93.60 $148.51 $93.72 -0.4% 0.1%

62325

Cervical or thoracic continuous interlaminar epidural

Injection(s),; with fluoro

$225.72 $108.00 $238.99 $110.66 5.9% 2.5%

Table 4 (cont.). 2019 proposed physician payment rates compared to 2018 rates.

CPT Description

2018 (CF=35.9996)

2019 Proposed

(CF: 36.0463)

% of change from

2018

Non-

Facility

(Office)

Facility

(ASC/

HOPD)

Non-

Facility

(Office)

Facility

(ASC/

HOPD)

Non-

Facility

(Office)

Facility

(ASC/

HOPD)

62326

Lumbar or sacral (caudal) continuous interlaminar epidural

Injection(s),; Without fluoro

$156.96 $92.88 $153.20 $91.56 -2.4% -1.4%

62327

Lumbar or sacral (caudal) continuous interlaminar epidural

Injection(s),; With fluoro

$230.04 $98.64 $238.27 $99.49 3.6% 0.9%

62350

Tunneled intrathecal or epidural catheter for long-term

medication administration via an external pump or

implantable reservoir; w/o laminectomy

$414.36 $410.21 -1.0%

62355

Removal or previously implanted intrathecal or epidural

catheter

$278.28 $277.20 -0.4%

62360

Implant or replacement of device for intrathecal or epidural

drug infusion; subcutaneous reservoir

$323.64 $328.74 1.6%

62361

Implantation or replacement of device for epidural drug

infusion; non-programmable pump

$448.56 $454.90 1.4%

62362 Implant spine infusion pump $398.52 $395.07 -0.9%

62365 Remove spine infusion device $307.80 $306.75 -0.3%

62367 Electronic analysis of programmable pump $43.56 $26.28 $40.01 $25.23 -8.1% -4.0%

62368

Electronic analysis of programmable pump with

reprogramming

$58.68 $36.36 $54.79 $35.33 -6.6% -2.8%

63650

Implant neuroelectrodes (NA=National price is Not

Available)

$1,353.23 $425.88 $1,613.43 $418.50 19.2% -1.7%

63655

Implant neuroelectrodes (NA=National price is Not

Available)

$866.51 $877.37 1.3%

63661 Remove spine eltrd perq aray $602.27 $335.88 $620.36 $332.71 3.0% -0.9%

63662 Remove spine eltrd plate $875.87 $888.54 1.4%

63663 Remove spine eltrd perq aray $809.63 $467.27 $824.74 $459.23 1.9% -1.7%

63664 Remove spine eltrd plate $911.87 $919.90 0.9%

63685 Implant neuroreceiver $376.92 $372.00 -1.3%

63688 Revise/remove neuroreceiver $387.36 $384.61 -0.7%

64400

Injection, anesthetic agent; Trigeminal nerve, any division

or branch

$134.64 $74.52 $138.78 $74.62 3.1% 0.1%

64402 Facial nerve $144.72 $85.68 $155.00 $88.31 7.1% 3.1%

64405 Greater occipital nerve $105.48 $65.88 $85.43 $54.43 -19.0% -17.4%

64408 Vagus nerve $119.16 $88.92 $116.43 $85.43 -2.3% -3.9%

64410 Phrenic nerve $158.40 $87.12 $161.49 $87.95 2.0% 1.0%

64413 Cervical plexus $130.68 $84.24 $129.77 $84.35 -0.7% 0.1%

64415 Brachial plexus $121.32 $67.32 $122.56 $67.77 1.0% 0.7%

64417 Axillary nerve $132.84 $72.72 $136.98 $73.17 3.1% 0.6%

64418 Suprascapular nerve $120.24 $64.08 $97.33 $58.76 -19.1% -8.3%

64420 Intercostal, single $114.48 $69.48 $113.91 $69.57 -0.5% 0.1%

64421 Intercostal, multiple, regional block $154.80 $95.04 $158.24 $93.72 2.2% -1.4%

64425 Ilioinguinal, Iliohypogastric $137.52 $96.84 $140.58 $97.33 2.2% 0.5%

64430 Pudendal nerve $140.76 $83.16 $147.79 $82.19 5.0% -1.2%

64445 Sciatic nerve $140.76 $75.24 $141.66 $75.34 0.6% 0.1%

64450 Other peripheral nerve or branch $82.08 $46.80 $77.86 $45.42 -5.1% -3.0%

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426 www.painphysicianjournal.com

Reframing Medicare Physician Payment Policy for 2019

Table 4 (cont.). 2019 proposed physician payment rates compared to 2018 rates.

CPT Description

2018 (CF=35.9996)

2019 Proposed

(CF: 36.0463)

% of change from

2018

Non-

Facility

(Office)

Facility

(ASC/

HOPD)

Non-

Facility

(Office)

Facility

(ASC/

HOPD)

Non-

Facility

(Office)

Facility

(ASC/

HOPD)

64479 Cervical transforaminal epidural injections $240.48 $136.08 $247.28 $133.37 2.8% -2.0%

64480 Cervical transforaminal epidural injections add-on $115.92 $65.16 $121.84 $64.52 5.1% -1.0%

64483 L/S transforaminal epidural injections $223.20 $115.92 $229.98 $113.91 3.0% -1.7%

64484 L/S transforaminal epidural injections add-on $94.32 $53.64 $98.41 $52.27 4.3% -2.6%

64490 C/T facet joint injections, 1st Level (Old 64470) $193.68 $109.44 $190.32 $107.06 -1.7% -2.2%

64491 C/T facet joint injections, 2nd Level (Old 64472) $95.40 $62.28 $95.16 $61.28 -0.2% -1.6%

64492 C/T facet joint injections, 3rd Level $96.12 $63.00 $95.52 $62.00 -0.6% -1.6%

64493 Paravertebral facet joint or facet joint nerve; L/S, 1st Level $175.68 $93.60 $174.46 $91.92 -0.7% -1.8%

64494 Paravertebral facet joint or facet joint nerve; L/S, 2nd Level $88.20 $53.64 $87.95 $52.27 -0.3% -2.6%

64495 Paravertebral facet joint or facet joint nerve; L/S, 3rd Level $88.20 $54.36 $87.59 $52.99 -0.7% -2.5%

64505 Injection, anesthetic agent; sphenopalatine ganglion $112.32 $93.60 $121.12 $96.60 7.8% 3.2%

64510

Injection, anesthetic agent; Stellate ganglion (cervical

sympathetic)

$130.32 $75.96 $133.37 $75.34 2.3% -0.8%

64520

Injection, anesthetic agent; lumbar or thoracic

(paravertebral sympathetic)

$191.88 $83.52 $205.82 $83.99 7.3% 0.6%

64530

Injection, anesthetic agent; celiac plexus, with or without

radiologic monitoring

$192.96 $93.96 $202.58 $93.36 5.0% -0.6%

64600

Destruction by neurolytic agent, trigeminal nerve;

supraorbital, infraorbital, mental, or inferior alveolar branch

$416.52 $234.00 $439.76 $237.91 5.6% 1.7%

64605

Destruction by neurolytic agent, trigeminal nerve; second

and third division branches at foramen ovale

$559.07 $351.00 $585.03 $353.25 4.6% 0.6%

64610

Destruction by neurolytic agent, trigeminal nerve; second

and third division branches at foramen ovale under

radiologic monitoring

$762.83 $509.39 $803.11 $518.71 5.3% 1.8%

64612

Chemodenervation of muscle(s); muscle(s) innervated by

facial nerve (eg, for blepharospasm, hemifacial spasm)

$137.16 $121.32 $139.14 $122.56 1.4% 1.0%

64620 Destruction by neurolytic agent, intercostal nerve $210.24 $177.84 $208.35 $176.63 -0.9% -0.7%

64630 Destruction by neurolytic agent; pudendal nerve $236.16 $197.64 $242.59 $195.73 2.7% -1.0%

64633 Destroy cerv/thor facet jnt $429.12 $232.56 $418.14 $227.09 -2.6% -2.4%

64634 Destroy c/th facet jnt addl $192.96 $70.56 $187.80 $69.57 -2.7% -1.4%

64635 Destroy lumb/sac facet jnt $424.44 $229.32 $415.25 $224.93 -2.2% -1.9%

64636 Destroy l/s facet jnt addl $175.32 $61.56 $170.86 $59.84 -2.5% -2.8%

64640

Destruction by neurolytic agent; other peripheral nerve or

branch

$135.72 $96.12 $136.26 $95.52 0.4% -0.6%

64680

Destruction by neurolytic agent, with or without radiologic

monitoring; celiac plexus

$309.96 $168.84 $324.42 $166.17 4.7% -1.6%

It appears that CMS has recognized the importance

of implanting of neuroelectrodes by increasing the

reimbursement for non-facility setting by 19.2%; how

ever, at the same time it reduces physician reimburse-

ment by 1.7%.

Facet joint nerve blocks and facet joint neuro-

lytic procedures are facing reductions in the range of

1.5% to 3%; however, increases for nerve blocks and

sympathetic blocks, especially in non-facility setting is

appreciable.

Table 5 Schedule of facility 2019 proposed payments for soft tissue and intraarticular injections in multiple settings.

Office

Overhead

ASC HOPD

% of HOPD over

Office Overhead

20600 Small joint injection $11.90 $21.97 $248.68 1991%

20605

Intermediate joint injection $12.62 $23.41 $248.68 1871%

20550 tendon sheath, ligament injection $13.34 $23.41 $248.68 1765%

20551 Tendon origin/insertion $12.98 $24.13 $248.68 1816%

20552 Trigger point(s), 1 or 2 muscle group(s) $17.30 $30.25 $248.68 1337%

20553 Trigger point(s), 3 or more muscle groups $20.55 $35.29 $248.68 1110%

20526 Injection, therapeutic, carpal tunnel $19.47 $39.25 $248.68 1178%

64640

Destruction by neurolytic agent; other peripheral

nerve or branch

$40.64 $87.86 $772.30 1800%

Finally, CMS continues to provide inadequate

reimbursement for peripheral neurolytic procedures

(CPT 64640) of $136.26 for non-facility and physician

reimbursement of $95.52. These procedures require

blockade of multiple nerves with expensive equip

ment; however, CMS continues to consider this as a

single procedure and thus reimburses inadequately.

This procedure should be reimbursed similar to other

radiofrequency neurotomy procedures such as facet

joint neurotomy (CPT 64633-64637). There is substantial

evidence showing the effectiveness of peripheral nerve

blocks in managing chronic knee pain, hip pain, among

multitude of other conditions. The code is often uti

lized to report sacroiliac joint neurotomy procedures.

Thus, reflecting the HOPD rates, these reimbursement

patterns must be addressed and increased. The proce

dure also carries an extremely low reimbursement in

ASC settings. Similarly, though not to the same extent,

another procedure the neurolytic block of pudendal

nerves (CPT 64630) also carries a low reimbursement of

$242.59 in a non-facility setting and $195.73 in a facility

setting. The neurolytic procedure of intercostal nerve

also faces the same path with $208.35 for non-facility

setting and $176.63 for facility setting. Consequently, it

is time for CMS while making so many changes to make

the appropriate changes for the future.

recognizing communication technology-

Based services

CMS is proposing to pay separately for 2 newly de-

fined physicians’ services furnished using communica-

tion technology including brief communication in tech-

nology-based service i.e., virtual check-in (HCPCS code

GVCI1) and remote evaluation of recorded video and/or

images submitted by the patient (HCPCS code GRAS1).

This is expected to increase efficiency for practitioners

and convenience for beneficiaries. Both services of brief

communication technology-based service and remote

evaluation of recorded video and/or images may be

used to assess the patient visit needs.

In addition, CMS also has proposed to pay sepa

rately for new coding describing chronic care remote

physiologic monitoring (CPT codes 990X0, 990X1, and

994X9) and interprofessional internet consultation with

multiple CPT codes 994X6, 994X0, 99446, 99447, 99448,

and 99449.

discontinuation of functional status

ePorting requirements for outPatient

heraPy

The proposed payment rule for 2019 will discon-

tinue the functional status reporting requirements

for services furnished on or after January 1, 2019 for

outpatient therapy. Since January 1, 2013, as required

by the Middle Class Tax Relief and Jobs Creation Act of

2012, all providers of outpatient therapy services have

been required to include functional status information

on claims for therapy services. The data was collected

using a non-payable HCPCS G-codes and modifiers to

describe a patient’s functional limitation and severity

at periodic intervals during outpatient therapy services.

Since the Bipartisan Budget Act of 2018 repealed the

therapy caps, these requirements served no purpose.

quality Payment Program

The proposed changes to quality payment pro-

gram (QPP) aim to reduce clinician burden, focus on

outcomes, and promote intraoperability of electronic

health records by removing Merit-based Incentive Pay

ment System (MIPS) process-based quality measures

Reframing Medicare Physician Payment Policy for 2019

www.painphysicianjournal.com 429

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428 www.painphysicianjournal.com

references

1. Department of Health and Human Ser-

vices, Centers for Medicare & Medicaid

Services. 42 CFR Parts 405, 410, 414, 414,

415 and 495. [CMS–1693–P] Medicare

Program; Revisions to Payment Policies

Under the Physician Fee Schedule and

Other Revisions to Part B for CY 2019;

Medicare Shared Savings Program Re-

quirements; Quality Payment Program;

and Medicaid Promoting Interoperabili-

ty Program. Proposed rule. July 27, 2018.

2. Manchikanti L, Kaye AD, Hirsch JA.

Proposed Medicare physician payment

schedule for 2017: Impact on interven-

tional pain management practices. Pain

Physician 2016; 19:E935-E955.

3. Manchikanti L, Singh V, Hirsch JA. Fa-

cility payments for interventional pain

management procedures: Impact of

proposed rules. Pain Physician 2016;

19:E957-E984.

4. Obama B. United States health care re-

form: Progress to date and next steps.

JAMA 2016; 316:525-532.

5. Manchikanti L, Helm S 2nd, Benya-

min RM, Hirsch JA. A critical analysis

of Obamacare: Affordable care or insur-

ance for many and coverage for few?

Pain Physician 2017; 20:111-138.

6. Manchikanti L, Hirsch JA. Repeal and re-

place of Affordable Care: A complex, but

not an impossible task. Pain Physician

2016; 19:E1109-E1113.

7. Bauchner H. The Affordable Care Act

and the future of US health care. JAMA

2016; 316:492-493.

8. Cannon MF. Is Obamacare harming

quality? (Part 1). Health Affairs Blog, Jan-

uary 4, 2018.

www.healthaffairs.org/do/10.1377/

hblog20180103.261091/full/

9. Hirsch JA, Leslie-Mazwi TM, Barr RM,

McGinty G, Nicola GN, Silva E 3rd,

Manchikanti L. The bundled payments

for care improvement initiative. J Neu-

rointerv Surg 2016; 8:547-548.

10. Hirsch JA, Nicola G, McGinty G, Liu RW,

Barr RM, Chittle MD, Manchikanti L.

ICD-10: History and context. AJNR Am

J Neuroradiol 2016; 37:596-599.

11. Manchikanti L, Hammer M, Benyamin

RM, Hirsch JA. Physician Quality Re-

porting System (PQRS) for intervention-

al pain management practices: Chal-

lenges and opportunities. Pain Physician

2016; 19:E15-E32.

12. Hirsch JA, Harvey HB, Barr RM, Dono-

van WD, Duszak R Jr, Nicola GN, Schae-

fer PW, Manchikanti L. Sustainable

growth rate repealed, MACRA revealed:

Historical context and analysis of recent

changes in Medicare physician payment

methodologies. AJNR Am J Neuroradiol

2016; 37:210-214.

13. Hirsch JA, Leslie-Mazwi TM, Barr

RM, McGinty G, Nicola GN, Patel AB,

Manchikanti L. The Burwell roadmap. J

Neurointerv Surg 2016; 8:544-546.

14. Hirsch JA, Leslie-Mazwi TM, Nicola GN,

Bhargavan-Chatfield M, Seidenwurm

DJ, Silva E, Manchikanti L. PQRS and

the MACRA: Value-based payments have

moved from concept to reality. AJNR Am

J Neuroradiol 2016; 37:2195-200.

15. Manchikanti L, Helm S 2nd, Benya-

min RM, Hirsch JA. Merit-Based In-

centive Payment System (MIPS): Harsh

choices for interventional pain manage-

ment physicians. Pain Physician 2016;

19:E917-E934.

16. Hirsch JA, Leslie-Mazwi TM, Patel AB,

Rabinov JD, Gonzalex RG, Barr RM, Nic-

ola GN, Klucznik RP, Prestigiacomo CJ,

Manchikanti L. MACRA: Background,

opportunities and challenges for the

neurointerventional specialist. J Neuroin-

terv Surg 2016; 8:868-874.

17. Hirsch JA, Rosenkrantz AB, Ansari SA,

Manchikanti L, Nicola GN. MACRA 2.0:

Are you ready for MIPS? J Neurointerv

Surg 2017; 9:714-716.

18. Golding LP, Nicola GN, Ansari SA,

Rosenkrantz AB, Silva Iii E, Manchikanti

L, Hirsch JA. MACRA 2.5: the legislation

moves forward. J Neurointerv Surg 2018

Jul 4. [Epub ahead of print].

19. Hartman M, Martin AB, Espinosa N,

Catlin A, The National Health Expendi-

ture Accounts Team. National health care

spending in 2016: Spending and enroll-

ment growth slow after initial coverage

expansions. Health Aff (Millwood) 2018;

37:150-160.

20. Hirsch JA, Rosenkrantz AB, Nicola GN,

Harvey HB, Duszak R Jr, Silva E 3rd, Barr

RM, Klucznik RP, Brook AL, Manchikanti

L. Contextualizing the first-round failure

of the AHCA: Down but not out. J Neuro-

interv Surg 2017; 9:595-600.

21. Hirsch JA, Rosenkrantz AB, Allen B,

Nicola GN, Klucznik RP, Manchikanti L.

AHCA meets BCRA; timeline, context,

and future directions. J Neurointerv Surg

2018; 10:205-208.

22. Dieleman JL, Baral R, Birger M, Bui AL,

Bulchis A, Chapin A, Hamavid H, Horst

C, Johnson EK, Joseph J, Lavado R, Lom-

sadze L, Reynolds A, Squires E, Campbell

M, DeCenso B, Dicker D, Flaxman AD,

Gabert R, Highfill T, Naghavi M, Night-

ingale N, Templin T, Tobias MI, Vos T,

Murray CJ.. US spending on personal

health care and public health, 1996-

2013. JAMA 2016; 316:2627-2646.

23. Dieleman JL, Squires E, Bui AL, Camp-

bell M, Chapin A, Hamavid H, Horst

C, Li Z, Matyasz T, Reynolds A, Sadat

N, Schneider MT, Murray CJL. Factors

associated with increase in US health

care spending, 1996-2013. JAMA 2017;

318:1668-1678.

24. Manchikanti L, Kaye AM, Knezevic

NN, McAnally H, Trescot AM, Blank S,

Pampati V, Abdi S, Grider JS, Kaye AD,

Manchikanti KN, Cordner HJ, Gharibo

CG, Harned ME, Albers SL, Atluri S,

Aydin SM, Bakshi S, Barkin R, Benyamin

RM, Boswell MV, Buenaventura RM,

Calodney AK, Cedeno DL, Datta S, Deer

TR, Fellows B, Galan V, Grami V, Hansen

H, Helm S 2nd, Justiz R, Koyyalagunta

D, Malla Y, Navani A, Nouri K, Pasupule-

ti R, Sehgal N, Silverman SM, Simopou-

los TT, Singh V, Slavin KV, Solanki DR,

Staats PS, Vallejo R, Wargo BW, Wata-

nabe A, Hirsch JA. Responsible, safe,

and effective prescription of opioids for

chronic non-cancer pain: American So-

ciety of Interventional Pain Physicians

(ASIPP) guidelines. Pain Physician 2017;

20:S3-S92.

25. National Institute on Drug Abuse. Over-

dose death rates. September 2017.

www.drugabuse.gov/related-topics/

trends-statistics/overdose-death-rates

26. Manchikanti L, Sanapati J, Benyamin

RM, Atluri S, Kaye AD, Hirsch JA. Re-

framing the prevention strategies of the

opioid crisis: focusing on prescription

opioids, fentanyl, and heroin epidemic.

Pain Physician 2018; 21:309-326.

27. Manchikanti L, Benyamin RM, Falco

FJE, Hirsch JA. Recommendations of the

Medicare Payment Advisory Commis-

sion (MedPAC) on the health care deliv-

ery system: The impact of interventional

pain management in 2014 and beyond.

Pain Physician 2013; 16:419-440.

28. Manchikanti L, Pampati V, Hirsch JA.

Cost calculation methodology exac-

erbates site-of-services differential by

10- to 18-fold for soft tissue and joint

injections in hospital outpatient depart-

ments. IPM Reports 2017; 1:183-189.

29. Letter to Doctors from CMS Admin-

istrator Seema Verna, Department of

Health & Human Services, Centers for

Medicare and Medicaid Services.

and overhauling the MIPS. Quality payment program is

a subject of a separate manuscript.

conclusion

The proposed fee schedule includes seismic shifts

for E/M services, which is garnering significant atten

tion in the medical community. Interventional pain

management continues to face many challenges in the

present environment. It is important for IPM specialists

to understand the multitude of changes in the regula

tions including the proposed fee schedule so as to pre-

serve interventional pain management into the future.

Acknowledgments

The authors wish to thank Bert Fellows, MA, Direc-

tor Emeritus of Psychological Services, Pain Manage-

ment Center of Paducah, for manuscript review, and

Tonie M. Hatton and Diane E. Neihoff, transcriptionists,

for their assistance in the preparation of this manu

script. We would like to thank the editorial board of

Pain Physician for its review and criticism in improving

the manuscript.

Author Affiliations

Dr. Manchikanti is Medical Director of the Pain

Management Center of Paducah, Paducah, KY, and

Clinical Professor, Anesthesiology and Perioperative

Medicine, University of Louisville, Louisville, KY, and

Professor of Anesthesiology-Research, Department

of Anesthesiology, School of Medicine, LSU Health

Sciences Center, New Orleans, LA.

Dr. Singh is Medical Director, Spine Pain Diag

nostics Associates, Niagara, WI

Dr. Benyamin is Medical Director, Millennium

Pain Center, Bloomington, IL, and Clinical Assistant

Professor of Surgery, College of Medicine, University

of Illinois, Urbana-Champaign, IL.

Dr. Kaye is Professor, Program Director, and

Chair, Department of Anesthesiology, and Professor,

Department of Pharmacology, LSU Health Science

Center, New Orleans, LA.

Vidyasagar Pampati is a Statistician at the Pain

Management Center of Paducah, Paducah, KY.

Dr. Hirsch is Vice Chief of Interventional Care,

Chief of NeuroInterventional Spine, Service Line

Chief of Interventional Radiology, Director Inter

ventional and Endovascular Neuroradiology, Massa-

chusetts General Hospital; and Associate Professor,

Harvard Medical School, Boston, MA.

aPPendix

To access complete article with live links to Appendix Tables and Figures:

http://www.painphysicianjournal.com/current

Click Here for All Appendix Tables and Figures

Reframing Medicare Physician Payment Policy for 2019

Pain Physician: September/October 2018: 21:415-432

430 www.painphysicianjournal.com

www.painphysicianjournal.com 431

30. H.R. 5804. Post-Surgical Injections as an

Opioid Alternative Act. Introduced May

15, 2018.

31. National Institute on Drug Abuse. Over-

dose death rates. August 2018

www.drugabuse.gov/related-topics/

trends-statistics/overdose-death-rates

32. IQVIA Institute for Human Data Science

Study. Medicine use and spending in

the U.S. A review of 2017 and outlook for

2022. April 2018.

www.iqvia.com/institute/reports/med-

icine-use-and-spending-in-the-us-re-

view-of-2017-outlook-to-2022

33. Manchikanti L, Pampati V, Hirsch JA.

Utilization of interventional techniques

in managing chronic pain in Medicare

population from 2000 to 2014: An analy-

sis of patterns of utilization. Pain Physi-

cian 2016; 19:E531-E546.

34. Manchikanti L, Soin A, Mann DP, Bak-

shi S, Pampati V, Hirsch JA. Reversal of

growth of utilization of interventional

techniques in managing chronic pain

in Medicare population post Affordable

Care Act. Pain Physician 2017; 20:551-567.

35. Manchikanti L, Pampati V, Hirsch JA.

Retrospective cohort study of usage

patterns of epidural injections for spi-

nal pain in the US fee-for-service Medi-

care population from 2000 to 2014. BMJ

Open 2016; 6:e013042.

36. Manchikanti L, Hirsch JA, Pampati V,

Boswell MV. Utilization of facet joint

and sacroiliac joint interventions in

Medicare population from 2000 to 2014:

Explosive growth continues! Curr Pain

Headache Rep 2016; 20:58.

37. Manchikanti L, Soin A, Mann DP, Bak-

shi S, Pampai V, Hirsch JA. Comparative

analysis of utilization of epidural proce-

dures in managing chronic pain in the

Medicare population: Pre and post Af-

fordable Care Act. Spine (Phila Pa 1976)

2018; [Epub ahead of print].

38. Manchikanti L, Pampati V, Benyamin

RM, Hirsch JA. Declining utilization of

percutaneous epidural adhesiolysis in

Medicare population: Evidence-based

or over-regulated? IPM Reports 2018;

2:9-18.

39. Manchikanti M, Manchikanti L, Kaye

AD, Pampati V, Hirsch JA. Usage pat-

terns of sacroiliac joint injections – A

comparative evaluation of pre and post

Affordable Care Act in Medicare popula-

tion. IPM Reports 2018; in press. HOLLY

ADD PAGE NUMBERS

40. H.R. 6138. ASC Payment Transparency

Act of 2018. June 19, 2018.

41. Chou R, Hashimoto R, Friedly J, Fu R,

Dana T, Sullivan S, Bougatsos C, Jarvik

J. Pain Management Injection Therapies

for Low Back Pain. Technology Assess-

ment Report ESIB0813. (Prepared by the

Pacific Northwest Evidence-based Prac-

tice Center under Contract No. HHSA

290-2012-00014-I.) Rockville, MD:

Agency for Healthcare Research and

Quality; July 10, 2015.

www.cms.gov/medicare/coverage/de-

terminationprocess/downloads/id98ta.

pdf

42. Manchikanti L, Knezevic NN, Boswell

MV, Kaye AD, Hirsch JA. Epidural injec-

tions for lumbar radiculopathy and spi-

nal stenosis: A comparative systematic

review and meta-analysis. Pain Physician

2016; E365-E410.

43. Grider JS, Manchikanti L, Carayan-

nopoulos A, Sharma ML, Balog CC,

Harned ME, Grami V, Justiz R, Nouri

KH, Hayek SM, Vallejo R, Christo PJ. Ef-

fectiveness of spinal cord stimulation in

chronic spinal pain: A systematic review.

Pain Physician 2016; 19:E33-E54.

44. Helm II S, Racz GB, Gerdesmeyer L,

Justiz L, Hayek SM, Kaplan ED, El Ter-

any MA, Knezevic NN. Percutaneous

and endoscopic adhesiolysis in manag-

ing low back and lower extremity pain:

A systematic review and meta-analysis.

Pain Physician 2016; 19:E245-E282.

45. Farber SH, Han JL, Elsamadicy AA, Hus-

saini Q, Yang S, Pagadala P, Parente B,

Xie J, Lad SP. Long-term cost utility of

spinal cord stimulation in patients with

failed back surgery syndrome. Pain Phy-

sician 2017; 20:E797-E805.

46. Cho JH, Lee JH, Song KS, Hong JY,

Joo YS, Lee DH, Hwang CJ, Lee CS.

Treatment outcomes for patients with

failed back surgery. Pain Physician 2017;

20:E29-E43.

47. Helm II S, Simopoulos TT, Stojanovic M,

Abdi S, El Terany MA. Effectiveness of

thermal annular procedures in treating

discogenic low back pain. Pain Physician

2017; 20:447-470.

48. Manchikanti L, Helm S 2nd, Pampati V,

Racz GB. Cost utility analysis of percu-

taneous adhesiolysis in managing pain

of post-lumbar surgery syndrome and

lumbar central spinal stenosis. Pain

Pract 2015; 15:414-422.

49. Manchikanti L, Pampati V, Kaye AD,

Hirsch JA. Cost utility analysis of cervi-

cal therapeutic medial branch blocks in

managing chronic neck pain. Int J Med

Sci 2017; 14:1307-1316.

50. Manchikanti L, Pampati V, Kaye AD,

Hirsch JA. Therapeutic lumbar facet

joint nerve blocks in the treatment of

chronic low back pain: Cost utility analy-

sis based on a randomized controlled

trial. Korean J Pain 2018; 31:27-38.

51. Boswell MV, Manchikanti L. Appropri-

ate design and methodologic quality as-

sessment, clinically relevant outcomes

are essential to determine the role

of epidural corticosteroid injections.

Commentary RE: Chou R, Hashimoto

R, Friedly J, Fu R, Bougatsos C, Dana

T, Sullivan SD, Jarvik J. Epidural corti-

costeroid injections for radiculopathy

and spinal stenosis: A systematic review

and meta-analysis. Ann Intern Med 2015;

163:373-381. Evid Based Med 2016; 21:89.

52. Manchikanti L, Boswell MV, Kaye AD,

Helm II S, Hirsch JA. Therapeutic role of

placebo: Evolution of a new paradigm

in understanding research and clinical

practice. Pain Physician 2017; 20:363-386.

53. Manchikanti L, Hirsch JA, Falco FJ, Bo-

swell MV. Management of lumbar zyg-

apophysial (facet) joint pain. World J Or-

thop 2016; 7:315-337.

54. Levine AB, Parrent AG, MacDougall KW.

Stimulation of the spinal cord and dor-

sal nerve roots for chronic groin, pel-

vic, and abdominal pain. Pain Physician

2016; 19:405-412.

55. Manchikanti L, Falco FJE, Pampati V,

Cash KA, Benyamin RM, Hirsch JA. Cost

utility analysis of caudal epidural injec-

tions in the treatment of lumbar disc

herniation, axial or discogenic low back

pain, central spinal stenosis, and post

lumbar surgery syndrome. Pain Physi-

cian 2013; 16:E129-E143.

56. Manchikanti L, Pampati V, Benyamin

RM, Hirsch JA. Cost utility analysis of

lumbar interlaminar epidural injections

in the treatment of lumbar disc hernia-

tion, central spinal stenosis, and axial or

discogenic low back pain. Pain Physician

2017; 20:219-228.

57. Manchikanti L, Hirsch JA, Kaye AD, Bo-

swell MV. Cervical zygapophysial (facet)

joint pain: Effectiveness of intervention-

al management strategies. Postgrad Med

2016; 128:54-68.

58. Manchikanti L, Manchikanti KN, Ghar-

ibo CG, Kaye AD. Efficacy of percuta-

neous adhesiolysis in the treatment of

lumbar post surgery syndrome. Anesth

Pain Med 2016; 6:e26172.

59. Song Z, Goodson JD. The CMS proposal

to reform office-visit payments. N Engl J

Med 2018 [Epub ahead of print].

60. King VL, Brooner RK, Peirce JM, Kolod-

ner K, Kidorf MS. A randomized trial of

Web-based videoconferencing for sub-

stance abuse counseling. J Subst Abuse

Treat 2014; 46:36-42.

61. Owens PL, Barrett ML, Weiss AJ, Wash-

ington RE, Kronick R. Hospital Inpatient

Utilization Related to Opioid Overuse

Among Adults 1993-2012. Statistical

Brief #177. Healthcare Cost and Utiliza-

tion Project (HCUP). August 2014. Agen-

cy for Healthcare Research and Quality,

Rockville, MD.

www.hcup-us.ahrq.gov/reports/stat-

briefs/sb177-Hospitalizations-for-Opi-

oid-Overuse.jsp

62. Department of Health and Human Ser-

vices, Centers for Medicare & Medicaid

Services. 42 CFR Parts 405, 410, 411, 414,

417, 422, 423, 424, 425, and 460. [CMS-

1654-CN2] Medicare Program; Revisions

to Payment Policies Under the Physi-

cian Fee Schedule and Other Revisions

to Part B for CY 2017; Medicare Advan-

tage Bid Pricing Data Release; Medicare

Advantage and Part D Medical Loss Ra-

tio Data Release; Medicare Advantage

Provider Network Requirements; Ex-

pansion of Medicare Diabetes Preven-

tion Program Model; Medicare Shared

Savings. Proposed Rule. November 18,

2016.

63. Hirsch JA, Leslie-Mazwi TM, Nicola GN,

Barr RM, Bello JA, Donovan WD, Tu R,

Alson MD, Manchikanti L. Current pro-

cedural terminology: A primer. J Neuro-

Intervent Surg 2015; 7:309-312.

64. Hirsch JA, Silva E 3rd, Nicola GN, Barr

RM, Bello JA, Manchikanti L, Donovan

WD. The RUC: A primer for neurointer-

ventionalists. J Neurointerv Surg 2014;

6:61-64.

65. Hirsch JA, Donovan WD, Leslie-Mazwi

TM, Nicola GN, Manchikanti L, Silva E

3rd. Component coding and the neu-

rointerventionalist: A tale with an end. J

Neurointerv Surg 2013; 5:615-619.

66. Donovan WD, Leslie-Mazwi TM, Silva E

3rd, Woo HH, Nicola GN, Barr RM, Bel-

lo JA, Tu R, Hirsch JA. Diagnostic carotid

and cerebral angiography: A historical

summary of the evolving changes in

coding and reimbursement in a com-

plex procedure family. J Neurointerv Surg

2014; 6:712-717.

67. Medicare Payment Advisory Commis-

sion. Report to the Congress. Medicare

Payment Policy. Washington, DC: Med-

PAC. March 2017.

http://medpac.gov/docs/default-source/

reports/mar17_entirereport.pdf

68. Department of Health and Human Ser-

vices, Centers for Medicare & Medic-

aid Services. 42 CFR Parts 416 and 419.

[CMS–1695–P] Medicare Program: Pro-

posed Changes to Hospital Outpatient

Prospective Payment and Ambulatory

Surgical Center Payment Systems and

Quality Reporting Programs; Requests

for Information on Promoting Interop-

erability and Electronic Health Care In-

formation, Price Transparency, and Le-

veraging Authority for the Competitive

Acquisition Program for Part B Drugs

and Biologicals for a Potential CMS In-

novation Center Model. Proposed Rule.

July 31, 2018.