2019 Medicare fee schedule rule possibly misvalued THA/TKA codes: 4 insights


CMS recently released the 2019 Medicare Physician Fee Schedule Final Rule and identified seven high-volume current procedural terminology codes as potentially misvalued, including the codes for total hip and total knee arthroplasty.

Here are four things to know:

1. CMS requested the American Medical Association's Relative Value Update Committee re-evaluate the work for these procedures.

2. An RUC subcommittee did not find reason to reevaluate the codes at a meeting in October.

3. The American Association of Hip and Knee Surgeons reviewed CMS-disclosed materials and found no valid indication that the work, complexity and effort of care physicians provide patients undergoing these procedures have changed since the codes were previously reviewed in 2013.

4. AAHKS argues physician-led quality initiatives have yielded substantial improvements in these procedures' value, and RUC should not review the codes at this time. Lowering the valuation of these codes, AAHKS contends, will add to the supply-side crisis and threaten patient access.

AAHKS President Craig J. Della Valle, MD, said, "Our members have worked very hard over the past decade to improve the quality of care they provide for patients undergoing hip and knee arthroplasty while simultaneously partnering with payers, including the federal government to lower costs. Given the high societal value that these procedures provide, penalizing the surgeon (whose compensation is a small fraction of the total cost of the episode of care in DRGs 469 and 470) for improvements in care seems unfair, misguided and may threaten access to care."

American Academy of Orthopaedic Surgeons President David A. Halsey, MD, said, "The AAOS strongly disagrees with the assumption that the seven high-volume CPT codes, including 27130 (total hip arthroplasty) and 27447 (total knee arthroplasty), are potentially misvalued. Since they were last revalued by the [RVU] and CMS in 2013, there hasn't been any evidence to suggest a change in physician work or practice expense.

The nature of the reevaluation request is also problematic, which was made by a large for-profit managed care health insurance company. CMS did not identify the source, nor did it make the full communication publicly available in the proposed rule. We are troubled by this lack of transparency and failure to disclose a potential conflict of interest.

Given these concerns, we do not believe that any further action is warranted and would advise against a review by the RUC and CMS. These procedures save the U.S. economy a combined $28 billion in lifetime societal savings, and any change to their RVUs could impair patient access to high quality orthopedic care."

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