Government Shutdown Avoided, Medicare Cuts Remain
One of the most controversial aspects of the bill is the decision to allow a 2.8% Medicare physician payment cut to take effect on January 1, 2025. When adjusted for inflation, the reduction is estimated at 6.3%, according to the California Medical Association. Dr. Bruce A. Scott, President of the American Medical Association (AMA), expressed deep concern over declining reimbursement rates, warning Congress’s failure to address declining Medicare reimbursement rates for the fifth consecutive year would lead to physicians being forced to close their practices or leave the profession entirely, intensifying issues with patient access to healthcare. Similarly, Anders Gilberg, Senior Vice President of Government Affairs at the Medical Group Management Association (MGMA), called the bill a "huge congressional failure," emphasizing that the cuts will not only affect Medicare but also impact commercial contracts tied to Medicare rates and Medicaid reimbursements in states using Medicare as a benchmark.
The Medicare Payment Advisory Commission (MedPAC) recommended inflation-based updates to Medicare payments related to the Medicare Economic Index (MEI), but Congress failed to adopt these measures despite rising healthcare delivery costs which are expected to increase by 3.5% in 2025. In addition to the Medicare cuts, the final legislation omitted several other healthcare reforms that gained bipartisan support. Prior authorization reform, which aimed to simplify the insurance pre-approval process was excluded. The AMA criticized this omission, stating it represents a win for insurance companies at the expense of patients. Proposed regulations to increase oversight of pharmacy benefit managers and efforts to incorporate key drug pricing reforms were removed, despite strong bipartisan backing. Advocacy groups such as Patients for Affordable Drugs Now (P4ADNow) denounced this decision, citing missed opportunities to lower healthcare costs for consumers. The bill passed the House of Representatives with a vote of 366-34-1 and the Senate with a vote of 85-11. While the spending bill succeeded in avoiding a government shutdown, it fell short in addressing systemic issues within the healthcare sector. The omissions in long-term planning and essential reforms have left healthcare providers and advocacy groups concerned about the future of patient care and the financial viability of medical practices. Moving forward, substantial legislative action will be needed to secure a more sustainable and fair healthcare system. Status of ROCR Act Moving Forward Into 2025
In 2024, The American Society for Radiation Oncology (ASTRO) made significant progress advocating for the Radiation Oncology Case Rate (ROCR) Value Based Program Act (H.R. 8404), targeted at Medicare payment reform for radiation oncology. According to ASTRO, this bi-partisan legislation aims to “protect access to high value cancer treatments for patients across the country, enhance patient outcomes and reduce health disparities while generating savings for Medicare.” The ROCR Act was introduced in May by bipartisan lawmakers, representing ASTRO’s most significant legislative initiative for Medicare payment reform. Shortly after, nearly 100 ASTRO advocates, including 30 residents, attended Advocacy Day in Washington, D.C., where they engaged with over 100 congressional offices to seek co-sponsorship of the bill.
In July, over 60 organizations, including freestanding centers, hospitals, and specialty societies, endorsed the ROCR Act. This growing coalition highlighted the bill’s broad appeal. By August, all four major radiation oncology societies comprised of the American College of Radiation Oncology (ACRO), American College of Radiology (ACR), Association for Clinical Oncology (ASCO) and ASTRO) formally supported the bill. In September, additional groups endorsed the legislation during the ASTRO Annual Meeting. Sen. Thom Tillis (R-NC), a champion of the bill, addressed attendees, emphasizing its potential to reform Medicare payment for radiation therapy. His senior health aide, Garrett Daniel, outlined the legislative challenges ahead in a divided Congress. Congress faced a December 20 deadline to pass a government funding bill, which included other priorities like preventing Medicare physician payment cuts. However, this legislative vehicle did not include the ROCR Act due to limited legislative days and the transition to a new Congress. A critical hurdle is the Congressional Budget Office (CBO) “score”, or savings estimate for the ROCR Act, which remains pending. This analysis is essential to demonstrate the bill’s fiscal viability but is delayed due to a backlog of health-related legislation. Some radiation therapy manufacturers have raised issues about the treatment of adaptive radiation therapy under the ROCR Act. ASTRO is engaging with these stakeholders to find solutions, though an agreement has not yet been reached. ASTRO is prepared to reintroduce this bill in the 119th Congress in 2025, allowing more time to build bipartisan support, secure a favorable CBO score, and advance the bill through key health care committees. Discussions on Medicare payment reform gained momentum in late 2024 and are expected to accelerate in 2025, potentially creating a better environment for the ROCR Act to progress. Medicare Estimates Improper Payment Rates for 2024
The U.S. Department of Health and Human Services (HHS) released its 2024 Agency Financial Report, which details how HHS invested resources for the past fiscal year (October 1, 2023, through September 30, 2024). This report included a breakdown of proper and improper payments made by Medicare.
HHS reviewed a stratified random sample of Medicare Fee-For-Service (FFS) claims to determine if HHS properly paid claims under Medicare’s policies on coverage, coding and billing. For 2024 estimates, HHS sampled approximately 50,000 claims representative of the Medicare FFS claims processed from July 1, 2022, through June 30, 2023. Medicare FFS parts A and B paid an estimated 92.34 percent of total spending properly, amounting to $382.02 billion. The estimated improper payments are 7.66 percent, or $31.70 billion. Improper payments due to missing or insufficient documentation accounted for 5.21 percent ($21.56 billion) of total expenditures, representing 68.00 percent of all improper payments. Other error types included incorrect coding (10.02 percent) and lack of medical necessity (15.68 percent). Improper payments for Skilled Nursing Facility (SNF), hospital outpatient, Inpatient Rehabilitation Facility (IRF) and hospice claims were major contributing factors to the Medicare FFS estimate, accounting for 38.88 percent of all improper payments. While the factors contributing to improper payments are complex and vary by year, the primary causes continue to be insufficient documentation and medically unnecessary errors. HHS employs a multifaceted approach to combat improper payments in Medicare FFS. This includes implementing corrective action plans and interagency collaboration to address emerging risks. Additionally, HHS has devised preventative measures to address service areas at high-risk for improper payment like SNF, hospital outpatient, hospice and home health, aiming to curb improper payments through targeted actions. HHS mitigation strategies include automation, training, internal process and policy change, audits and predictive analytics. Clinical Examples for MR Safety Codes
Additional information has been released on the new magnetic resonance (MR) safety codes. Following is a general overview of the new codes, along with clinical example summaries. A previously published RCCS article entitled “MR Safety Codes” can be found in the October RCCS industry news and should be referenced for a full understanding of these new codes.
Effective January 1, 2025, six new CPT® codes have been established describing the work necessary to ensure patients with a device, implant or foreign body safely receive necessary diagnostic or interventional MR services. MR safety services are distinctly different from evaluation and management (E/M) codes, which are not specific to MR safety. An MR Safety Officer (MRSO), MR Technologist, Dosimetrist or Medical Physicist cannot report these services alone. These positions are considered clinical staff that work under the supervision of a physician or other QHP to provide MR safety services. The physician that interprets the MR examination may be different from the one providing the MR safety services. All MR safety codes can be reported independently for the same MR examination. Codes 76017 - 76019 are modifier 51 exempt; therefore, there is no reduction in reimbursement when reporting these services for the same MR examination. Five of the six codes may be reported regardless of whether the MR examination is performed. Code 76017, which represents safety services provided during the MR examination, is the exception.
Services Prior to the MR Date of Service (DOS) (76014, 76015, 76016)
76014 and 76015 are time-based codes which represent the technical component (TC) only. There is no physician work involved, and no modifier should be appended. These codes represent preparatory research performed by clinical staff and do not include independent decision making. For example, an MRI of the lumbar spine is ordered for a patient with a neurostimulator. The medical record does not include model information for the implanted leads. Certain lead models have anatomical exclusion zones over the implant. MR conditions for the implant are dependent on the lead model; therefore, clinical staff must use appropriate sources, such as a patient screening form, surgical reports or review of prior imaging and various databases, to determine MR conditional status of the implanted leads. This information is documented in the patient’s medical record to be accessed by the Radiologist and/or MRSO. Documentation should indicate the leads as either MR safe, MR conditional, or MR unsafe. 76016 represents a risk benefit analysis that requires independent decision making by the Physician or other Qualified Health Professional (QHP), who is responsible for the safe performance of the MR examination. For example, a pacemaker lacks MR conditional labeling and programming modes. A physician or other QHP performs a risk benefit analysis, including review of MR safety parameters for conformance with implanted-device safety instructions. If MR safety parameters do not conform with the implanted-device safety instructions, the physician or other QHP will consider alternative diagnostic tests for appropriateness and risk, and make recommendations for alternative tests, procedures, or MR requirements.
Services on the Same DOS of the MR (76017, 76018, 76019)
76017 represents real-time MR safety exam customization by or under the supervision of a physician or other QHP. For example, an MRI is ordered for a patient presenting with new seizures and weakness. The patient has a deep brain stimulator (DBS) for Parkinson disease. The DBS has MR conditions restricting scan time and energy deposition. MR conditions of the DBS, including scanner idle times to allow for device cooling, are met by a medical physicist who customizes and monitors the performance of the MR exam interactively. The medical physicist performs these services under the supervision of a Radiologist who reviews MR images and provides feedback to the Medical Physicist in real time to determine if any scan parameter adjustments or additional views are needed. The radiologist considers cutting additional views from protocol to avoid exceeding any total scan time restrictions of the DBS. Any limitations to the MR examination that are related to the DBS system affecting the diagnostic quality and interpretation of the MR examination should be documented in a written report. 76018 represents MR safety device programming in the MR suite by, or under the supervision of, a physician or other QHP. For example, a patient with a DBS has their device modified into an MR safe mode in the MR suite prior to the exam. The device programming is performed in a safe area away from the scanner, where the patient also gets their IV started before the MR examination begins. After the MR examination is completed, the device is turned back on in a safe area, where the patient also changes their clothes. 76019 represents work with the patient to immobilize or position a device to make it safer for the patient to have the MR exam. For example, an MRI of the brain is ordered for a patient with an auditory brainstem implant (ABI). The ABI has MR conditions for an internal magnet, which require the application of a head wrap to immobilize and secure the device. Because there is a risk to the patient and to the ABI when entering the MR field, this service requires a discussion with the patient prior to the start of the MR examination. Informed consent must be obtained from the patient before proceeding with the MR examination. The ABI is immobilized according to the implant manufacturer’s MR conditional instructions. The physician or QHP monitors the patient’s condition during positioning and introduction into the MR exam room. The patient is introduced and removed slowly from the MR examination. The examination is discontinued if the patient cannot tolerate the pain, after which the immobilization wrap is removed, and the ABI location is checked for any evidence of implant migration, malfunction, or tissue damage. The patient is provided with educational materials. Any implant positioning and immobilization precautions, as well as recommendations for future MR examinations are documented in a written report. OIG Report Reveals Improper Medicare Payments for Surgical Services
A report issued by the Office of Inspector General (OIG) revealed providers did not always follow Federal requirements when billing for surgical services, particularly co-surgery and assistant-at-surgery services. Under Medicare Part B, The Centers for Medicare and Medicaid Services (CMS) makes a reduction in payment for physicians who work together as co-surgeons during a surgical procedure, and those physicians who assist the primary physician during a surgical procedure. The focus of the OIG’s audit was to determine if these services followed Federal requirements, and how this impacted Medicare payments.
When two physicians work together to perform a surgical procedure on the same patient during the same operative session, Medicare considers this a co-surgery. When the procedure code has a co-surgery indicator of “1” (co-surgeons may be allowed with supporting documentation to establish medical necessity) or “2” (co-surgeons are permitted without submission of documentation if the two-specialty requirement is met) and medical necessity is met for two surgeons, co-surgeons can be coded and billed. Each physician must append a “62” modifier (two surgeons) to the procedure code, and under the Medicare Physician Fee Schedule (MPFS), each physician will receive a reduced payment equal to 62.5 percent of the MPFS for the billed procedure. When a physician acts as a surgical assistant to the primary physician during a surgical procedure, Medicare considers this an assistant-at-surgery. When the procedure code has an assistant-at-surgery indicator of “0” (payment restriction for assistants at surgery applies to this procedure unless supporting documentation is submitted to establish medical necessity) or “2” (payment restriction for assistants at surgery does not apply to this procedure. Assistant at surgery may be paid) and medical necessity is met for a physician assistant, assistant-at-surgery can be coded and billed. The physician assistant must append the appropriate assistant surgeon modifier “80” (assistant surgeon), “81” (minimum assistant surgeon) or “82” (assistant surgeon when qualified resident surgeon not available), and under the MPFS the assistant surgeon will receive a reduced payment equal to 16 percent of the established MPFS for the billed service. The HCPCS modifier “AS” can also be appended for cases in which a physician assistant, nurse practitioner or clinical nurse specialist acts as a surgical assistant. In these situations, the reduced payment equals 14 percent of the MPFS for the billed procedure. The audit consisted of 100 statistically sampled services, which covered a variety of surgical procedures, including services related to spinal fusions, knee replacements and endovascular repairs, among others. In addition, 127 corresponding services that were billed by providers with the same procedure code for the same beneficiary on the same day as the sampled services were reviewed. Of the 100 statistically sampled services, the OIG found 69 of these services did not comply with CMS requirements. Specifically, 49 were incorrectly billed without the co-surgery modifier; 14 were incorrectly billed with an assistant-at-surgery modifier; and 6 were incorrectly billed as duplicate services. Based on the results of the statistically sampled service errors, it is estimated that Medicare made $4.9 million in improper payments during the two-year audit period. Of the 127 corresponding services reviewed, 62 did not meet Federal requirements. Collectively, errors occurred primarily because CMS did not have adequate system controls in place to identify and prevent these payments. The OIG offered recommendations to CMS, including:
CMS agreed with the OIG recommendations and outlined actions it planned to take to address the issues found, particularly improvement of Medicare control systems.
FDA Approves Two Oncology Therapies for Lung/Pancreatic Cancers
The U.S. Food and Drug Administration (FDA) recently approved two oncology therapies for treatment of lung cancer and pancreatic cancer in specific patients. The agency approved durvalumab (brand name Imfinzi®, AstraZeneca) for use by adults with limited-stage small cell lung cancer whose disease did not progress after concurrent platinum-based chemotherapy and radiation therapy. This approval is based on results of a randomized phase 3 ADRIATIC trial, which included 730 patients. As an immune checkpoint inhibitor drug, durvalumab has been previously approved for use in extensive-stage small cell lung cancer, unresectable stage III non-small cell lung cancer, locally advanced or metastatic urothelial carcinoma, locally advanced or metastatic biliary tract cancer and endometrial cancer.
The FDA also granted accelerated approval to zenocutuzumab-zbco (brand name Bizengri®, Merus N.V.) for use in two indications. First, use in adults with advanced, unresectable or metastatic non-small cell lung cancer (NSCLC) who have a neuregulin 1 (NRG1) gene fusion, and whose disease progressed on or after prior systemic therapy. Second, use in patients with unresectable or metastatic pancreatic ductal adenocarcinoma (PDAC) who have NRG1 gene fusion1, and whose disease progressed on or after prior systemic therapy. These approvals are based on results of a multicenter, open label, multicohort eNRGy Study, which included 64 adults in the NRG1/NSCLC group and 30 patients in the NRG1/PDAC group. As a bispecific HER2 and HER3-directed antibody, this approval represents the first FDA approval of a systemic therapy for patients with NSCLC or PDAC, according to the FDA. OIG Announces “Incident-to” Audit
In November 2024, the Office of Inspector General (OIG) announced an audit of incident-to claims, with a report projected to be released in 2026. Medicare Part B covers physicians' services as well as services and supplies provided by a physician’s staff, including non-physician practitioners (NPPs), when those services meet the criteria for "incident-to" billing. "Incident-to" refers to services and supplies that are an integral part of a physician’s professional services and are provided during the course of diagnosing or treating a patient’s illness or injury.
To qualify as "incident-to," these services must be furnished under the direct supervision of the physician, meaning the physician must be physically present in the office suite and immediately available to provide assistance if needed. Such services are billed under the physician's National Provider Identifier (NPI) as if the physician personally performed them. Medicare reimburses incident-to services at the full rate specified by the Medicare Physician Fee Schedule. Previous work by the Office of Inspector General (OIG) emphasized the need for greater transparency in incident-to services to strengthen program integrity. This audit seeks to determine whether Medicare Part B payments for incident-to services complied with Medicare’s requirements.
All rights reserved. No part of this newsletter may be reproduced in any form whatsoever without written permission from the publisher. This newsletter may reflect coding information from the 2025 Physician’s Current Procedural Terminology (CPT® Manual). CPT is a registered trademark of the American Medical Association. CPT® five-digit codes, nomenclature and other data are copyright 2024 American Medical Association. All Rights Reserved. No fee schedules, basic units, relative values or related listings are included in CPT®. This product should not be considered a substitute for the codes, cross-references and exclusions located in the CPT® Manual. AMA does not directly or indirectly practice medicine or dispense medical services. AMA assumes no liability for the data contained herein or not contained herein.
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