Work RVU – CPT 77080, Axial Bone Density Studies – We request CMS to reconsider the Work RVU for DXA by conducting an independent assessment of the survey data presented by the American College of Radiology (ACR) and International Society of Clinical Densitometry societies.
In the final rule of 2006, CMS accepted the RUC working group recommendation to lower the RVU to .20. This recommendation came from a working group comprised of six members in which only one member was knowledgeable about DXA. We strongly believe the survey data listed below should be considered and the Work RVU be increased to .50 as detailed in the ISCD survey and/or at the very least increased to .30 as recommended by the ACR. ACR conducted a survey of 51 radiologists regarding the physician work component for DXA. The survey concluded that the Work RVU for DXA should remain at .30. Radiologist makes up 40% of physicians performing the DXA. ISCD surveyed 453 physicians currently performing DXA from multiple disciplines with results ranging from a low of .17 to a high of .76 with the median of .50. The multiple disciplines make up 60% of physicians performing DXA.
CMS reevaluate and exclude DXA testing 77080 & 77081 from the provisions of the DRA for the following reasons:
The proposed rule references the definition of imaging services under Section 5102(b)(1) of the Deficit Reduction Act (DRA). In addition, it sets out the criteria and analysis to determine which imaging services will be included in order to implement the DRA as well as those imaging services that are to be exempt from the DRA’s definition.
Under the DRA, imaging services are defined as “imaging and computer-assisted imaging services, including X-ray, ultrasound (including echocardiography), nuclear medicine (including PET), magnetic resonance imaging (MRI), computed tomography (CT), and fluoroscopy, but excluding diagnostic and screening mammography”. In the rule, CMS articulates the analysis that it will use to determine which CPT codes are to be included under the DRA definition, as well as those codes that are to be considered exempt from the law.
CMS states, “we believe that imaging services are those that provide visual information, thereby assisting in the diagnosis or treatment of illness or injury”. CMS notes the following procedures as examples of exceptions to the definition of imaging services under the Act: bronchoscopy with or without fluoroscopic guidance and upper gastrointestinal endoscopy with transendoscopic ultrasound-guided intramural or transmural fine needle aspiration/biopsy(s). CMS articulates the rational for these exceptions: “In these cases, we are unable to clearly distinguish imaging from non-imaging services because, for example, a specific procedure may or may not utilize an imaging modality, or the use of an imaging technology cannot be segregated from the performance of the main procedure.” (Emphasis added).
Therefore, applying this CMS analysis, CPT Code 77080 (DXA) should be excluded from the definition of imaging services in the diagnosis and treatment of osteoporosis. The DXA test uses equipment that produces a numerical value of bone mass (in units of gram/cm) which is compared to young normal controls to derive a T-score). This number is used to diagnose bone disease. Although the DXA equipment also generates an image, the image itself is not used to diagnose bone disease and therefore cannot be segregated from the main procedure, and should be excluded from the provision of the DRA.
Osteoporosis causes fractures in approximately half of women and one quarter of men. Over 20% of adults who sustain a hip fracture die within the following year and many more never regain independence. Annual direct health care costs for fracture care in the United States currently approximate $16.9 billion a year and are projected to exceed $25 billion by 2025. Despite the epidemic proportions of osteoporosis, the test used to diagnosis this preventable disease, and hailed by the Surgeon General in 2004, as “one of the most significant advances in the last quarter century,” is in danger of being eliminated from the woman’s health care arsenal by Medicare payment policies. The test, DXA (Dual Energy X-Ray Absorptiometry) (CPT code 77080), and a companion procedure, VFA (Vertebral Fracture Assessment) (CPT code 77082) are critical for the diagnosis of osteoporosis and monitoring the response to treatment. The 40% reduction in the Medicare Physician Fee Schedule reimbursement for DXA in the non-facility setting (implemented in 2007 with the Deficit Reduction Act) has already caused some physicians to discontinue offering this vital service. By 2010, DXA reimbursement will have dropped 75%. With reimbursement below operating costs in 2010, this essential preventive service will largely disappear from the non-facility environment as over 90% of physicians have indicated that they will stop performing DXA studies by 2010.
While CMS has an obligation to review all comments received during the rule making process, we call on Medicare to carefully consider the requests contained in this document, as this particular payment policy will undermine the agency’s preventive health care agenda as it relates to osteoporosis care. The Medicare Payment Advisory Committee (MedPAC) in their March 2007 report to Congress states; “The Commission is concerned that differences in the profitability across physician services create financial incentives for physicians to favor furnishing some procedures and services over other, less profitable ones. In this environment, beneficiary access to relatively undervalued services-and to the providers that perform them—may be threatened. Misvalued services should be identified and payments corrected…. Also, revisiting the RBRVS may be needed to explore the possibility of including other factors—in addition to input costs—in the pricing of individual services.”
Undervalued services create disincentives to provide such services to Medicare beneficiaries, thereby threatening access to important health care diagnostic and therapeutic interventions. We believe that the changes requested in our comment letter are necessary to support efforts to improve recognition of osteoporosis through increased DXA testing.