How CMS' changes will affect spine surgeons in 2021 — Prior authorization, reimbursement cuts & more


Surgeons and specialists are bracing for another challenging year as further Medicare reimbursement cuts are planned, with commercial payers likely to follow suit. 

Orthopedic practices are struggling to play catch-up with patient backlogs caused by elective surgery bans enforced earlier in the year, while competition for operating room time and COVID-19 infection rates continue to rise across the country. 

Eight members of Congress sponsored a bill in November that would mitigate 2021 Medicare cuts by offering a relief payment to surgeons in 2021 and 2022, but it may be too little, too late for some. There are concerns that some practices may not survive a second elective surgery shutdown.

State and federal COVID-19 relief packages offered throughout the year could lead to additional cuts down the line, leaving smaller practices already operating on fine margins in particular distress.

While many surgeons believe that reimbursement cuts were inevitable, one of the biggest concerns is that the scope and magnitude of the cuts will limit access to care when patients need it most.

Here are four key CMS updates for spine surgeons in 2021:

1. About 300 musculoskeletal procedure codes will be removed from CMS' inpatient-only list over a three-year period, including 67 spine codes for 2021. In 2020, just six spinal procedures were removed from the inpatient-only list. 

CMS' changes will further encourage the shift of these procedures away from hospitals toward to outpatient surgery centers, which can perform them at lower costs. The changes would also make it easier for payers to deny inpatient admission costs and place a larger burden on surgeons to justify and meet inpatient criteria.

2. Under the Medicare Physician Fee Schedule, CMS finalized a conversion factor of $32.41, which is a decrease of $3.68 compared to the conversion factor for 2020. The 10 percent drop in the conversion factor and the resulting Medicare reimbursement cuts to many surgical specialties — coupled with rising overhead costs and reduced patient volumes due to the pandemic — will greatly affect surgical practices next year. The secondary effects of the reduced revenue will put off many expansion plans, hiring of new staff and investment in new technologies. 

3. Beginning July 1, 2021, CMS will require prior authorization for cervical fusion with disc removal as well as implanted spinal neurostimulators. The agency said it plans to use the prior authorization to ensure Medicare patients receive necessary care and reduce "unnecessary increases in the volume" of covered outpatient spine services.

4. While CMS' 2021 final rules spelled more bad news for surgeons, some spine device companies will benefit from the agency's transitional pass-through payment program, which provides additional payments for new devices that show a substantial clinical improvement over existing technologies.

Stryker's SpineJack was awarded TPT status as well as the new technology add-on payment, which provides additional payment in the hospital inpatient setting.

Vertos Medical's Mild lumbar spinal stenosis procedure will see its average ASC reimbursement increase 41 percent next year in recognition of the cost of the device associated with the procedure.

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