STOP PHOTOTHERAPY REIMBURSEMENT CUTS Proposed ...

STOP PHOTOTHERAPY REIMBURSEMENT CUTS
Proposed Medicare Physician Fee Schedule CY 2014
The National Psoriasis Foundation respectfully urges the Centers for Medicare and Medicaid Services (CMS) to reconsider the proposed
cuts to phototherapy treatment codes (96900, 96910, and 96912) included in the Proposed CY 2014 Medicare Physician Fee Schedule
(PFS) to ensure that these safe and cost-effective treatments remain accessible and available to the 7.5 million Americans who live with
psoriasis.
DESCRIPTION
2013
2014
RVUs 1 RVUs 2
Total Total
2014
Total RVUs payment in
% $ assuming
Difference
Payment
in $ with
34.023
CF
35.6653 CF 3 2013
% Payment
Difference
b/n 2013 &
2014-
2012 # of
Procedures
96900: Ultraviolet light therapy 0.58 0.65 -10.77% $20.69 $22.11 -6.46% 97,972
96910: Photochemotherapy
with uv-b 1.10 2.24 -50.89% $39.23 $76.21 -48.52% 383,029
96912: Photochemotherapy
with uv-a 1.10 2.87 -61.67% $39.23 $97.65 -59.82% 34,307
How Treatment Codes 96900, 96910, and 96912 are used: Phototherapy or light therapy, is a first-line
treatment for psoriasis and involves exposing the skin to ultraviolet light B (UVB) or ultraviolet light A
(UVA) on a regular basis under medical supervision. Phototherapy is one of the safest and most costeffective
therapies for psoriasis and may be the only therapy option for certain subsets of psoriasis patients,
i.e. children, pregnant women and immuno-suppressed patients. Both treatments work by penetrating the
skin and slowing the growth of affected skin cells.
Why is CMS proposing this change? Where CMS found reimbursements to be higher in a non-facility
setting than in a facility setting, non-facility practice expense relative value units (RVUs) were reduced to
align with the Medicare's Hospital Outpatient Prospective Payment System (OPPS) payment for the same
service. 4 In other words, non-facility RVUs were capped at the OPPS level. 5 RVUs are a calculation of
physician work, practice expense, and malpractice expense. For services with no work RVUs (including
phototherapy), CMS is proposing to compare the total non-facility PFS payment to the OPPS payment rates
directly since no PFS payment is made for these services when furnished in the facility setting.
CMS suggests that the unaligned payments are not the result of appropriate payment differentials between
the services furnished in different settings. Rather, they believe it is due to anomalies in the data they use
under the PFS and in the application of the resource-based practice expense (PE) methodology to the
particular services. 6
Flaw with CMS rationale: The rationale underlying the phototherapy cuts in the CY 2014 Physician Fee
Schedule is fundamentally flawed because the OPPS and ambulatory surgical center (ASC) fee setting does
not evaluate the costs of the resources that are used to provide services and fails to recognize the extent to
which a hospital or ASC may offset the costs of providing these services. OPPS and ASC fees are grouped
into Ambulatory Payment Classifications (APCs) which are intended to cover the costs of providing services
in those settings, but which may actually pay more or less than the costs incurred. Hospitals and ASCs are
able to offset the underpaid services with those that pay more than costs that are incurred, something
physicians are unable to do. There is no evidence that the fees OPPS or ASC fee schedule accurately reflect
the cost of providing services, and they certainly do not reflect the cost of providing services in the
physician’s office. Using APCs incomplete fees to value services that are performed 90.6% and 91.8% of

the time respectively (for codes 96910 and 96912) in a physician’s office is not in the best interest of
Medicare beneficiaries.
Likely Patient Impact: There is already a shortage of phototherapy units in the country, and these cuts
would likely lead to additional closures of phototherapy units and decreased availability of these treatments,
adversely affecting millions of patients. Should this treatment option disappear, many patients would be
forced to go without treatment or transition to a systemic therapy that includes biologics, which can cost
more than 10 times the expense of phototherapy treatments. (Phototherapy costs approximately $2,000-
$3,000 a year.) 7
1 See: http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched/PFS-Federal-Regulation-Notices-
Items/CMS-1600-P.html. Open the file entitled: http://www.cms.gov/Medicare/Medicare-Fee-for-Service-
Payment/PhysicianFeeSched/Downloads/CMS-1600-P-CY2014-PFS-Addenda.zip Open file entitled: Copy of Addendum B Relative Value
Units and Related Information Used In Determining Medicare Payments CY 2014 Proposed Rule. CY 2014 RVU values are calculated by
adding 1.09 to .01 = 1.10 RVUs.
2 See: http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched/PFS-Federal-Regulation-
Notices-Items/CMS-1590-FC.html?DLPage=1&DLSort=3&DLSortDir=descending Open file entitled: CY 2013 PFS Addenda:
http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched/Downloads/CMS-1590-FC-CY2013-
PFS-Addenda.zip Open file entitled: Addendum B FR 2013. CY 2013 RVU values are calculated by adding non-facility PE
RVUs and malpractice RVUs.
3 (To determine payment, relative values (RVUs) are multiplied by the conversion factor (CF). If the SGR cut is averted the
projected conversion factor would be based on 2013 rate and adjusted for budget neutrality at 35.6653.
https://amda.com/advocacy/feeschedule.cfm?printPage=1&
4 For a list of codes with reduced non-facility PE RVUs to align with OPPS See: http://www.cms.gov/Medicare/Medicare-Fee-for-Service-
Payment/PhysicianFeeSched/Downloads/CY-2014-PFS-Proposed-Rule-Codes-With-Reduced-Nonfacility-PE-RVUS.zip Open file entitled:
Copy of Codes With Reduced Nonfacility PE RVUs Due to Proposed OPPSASC Cap
5 See supplement document to the rule from the CMS webpage titled “CY2014 PFS Proposed Rule codes with Reduced
Nonfacility PE RVUs.”
6 http://www.gpo.gov/fdsys/pkg/FR-2013-07-19/pdf/2013-16547.pdf. See FR pages 43296-43298 and 43302-43304
7 Beyer V, Wolverton SE, Recent Trends in Systemic Psoriasis Treatment Costs. Arch Dermatol. 2010; 146(1):46-54