Kathy Francisco & Mark Gittleman, MD

Medicare regulations and policies change annually.  In 2014, the Centers for Medicare & Medicaid Services issued several changes impacting reimbursement for procedures related to the diagnosis and treatment of breast cancer. In particular, the changes signal a growing shift towards bundled payments – packaging multiple components of a procedure into a single CPT code – that will affect overall reimbursement to healthcare providers.

Kathy Francisco of The Pinnacle Health Group, one of the nation’s leading reimbursement consulting groups, and breast surgeon Mark Gittleman, MD, discuss these changes and the impact they have on hospitals, individual practitioners and – most importantly – patients.

What have been the major reimbursement changes in 2014 for physicians who offer brachytherapy?

Kathy Francisco: This year, there were no significant changes for brachytherapy. However, there were major changes to breast biopsy procedures, including new CPT codes that providers (physicians and hospitals) must report this year.  Medicare implemented new ‘packaging’ guidelines that bundle procedures together.  For radiation oncology, there were no significant packaging changes this year but packaging and CPT code changes are expected to be implemented in 2015 and these will have impact on radiation oncology.

Mark Gittleman, MD:  The overall trend seems to be decreased reimbursement, which is partially due to bundling. When you bundle multiple procedures into a single code, reimbursement tends to be less than the sum of the parts was before.  Image-guided breast biopsy codes were cut quite significantly; reimbursement for vacuum-assisted biopsies, for instance, decreased by more than 30 percent. In contrast, brachytherapy device placement decreased by just 8 percent, which is modest, especially considering its profitability compared to other procedures.

How does reimbursement for the radiation delivery portion of brachytherapy compare to other radiation options for early-stage breast cancer in the hospital setting and freestanding center?

KF: Brachytherapy procedures provide appropriate and adequate reimbursement for both the radiation oncologist and the surgeon. Other treatment modalities are radiation oncology focused only and the surgeon receives no reimbursement, nor are they involved in the patient care. Brachytherapy also offers fewer treatment visits for patients, making for a great patient option, especially for working women.

For hospital-based radiation oncology departments, strut-based brachytherapy offers the greatest reimbursement, with an average Medicare reimbursement of $16,000. This is compared to $13,500 for standard whole breast radiation, $7,000 for hypofractionated whole breast irradiation (HF-WBI), and $1,200 for intraoperative radiation therapy (IORT). In the freestanding environment, average Medicare reimbursement for standard whole breast radiation is the same (approximately $13,500), while strut-based brachytherapy ($8,400) compares favorably to other accelerated courses of treatment, including HF-WBI ($7,000) and IORT ($1,000).

How does brachytherapy reimbursement compare to other procedures performed by surgeons in the private practice setting, such as biopsies, lumpectomies and mastectomies?

MG: Reimbursement is extremely favorable for brachytherapy device placement. It takes approximately 15 minutes to place a catheter in the office, which is roughly the same amount of time required for an ultrasound-guided percutaneous biopsy – and yet reimbursement for the two procedures is drastically different. There are very few procedures that are comparable in time or effort that have the same margin as brachytherapy device placement; the revenues are even greater than for mastectomies.

Economic considerations don’t drive treatment decisions, but they are certainly a factor to consider in offering any type of treatment – especially for surgeons in private practice. When surgeons started offering brachytherapy more than 10 years ago, there was no reimbursement; we were doing it because we felt it was the best clinical option for certain patients. As physicians, the first question we must always ask ourselves is, “Is this treatment clinically appropriate?” When that answer is yes, the next question is, “Can I afford to offer it?” And when it comes to brachytherapy, the answer is, “How can I afford not to?” For many patients, brachytherapy is the best clinical option available, and we’re fortunate this clinical decision is supported with such favorable reimbursement.

With all the reimbursement changes, how were the total RVUs for the surgical portion of brachytherapy affected? What has happened to the radiation delivery portion of the RVUs?

KF: There are insignificant changes in RVUs associated with radiation oncology procedures in 2014. Code edits and changes are expected in 2015 that may have impact on radiation therapy delivery, however, brachytherapy is not expected to see any significant changes in 2015.

What impact do you think these reimbursement changes will have on patient care?

KF: It is difficult to imagine that health care services are offered based upon reimbursement by Medicare and private plans, however, with the reductions over the past few years, this has become a reality. Physicians who were able, in the past, to purchase expensive equipment and offer procedures in the office setting are not able to afford the equipment due to reimbursement reductions or unexpected future changes. Hospitals have suffered budget cuts due to reimbursement reductions across the board, so patients are affected when equipment is not available at every hospital. Clearly, reductions and unexpected changes will have impact on patients being offered procedures and access to new technologies, so patients will have to become more educated and more demanding about treatment options that may not be presented by hospitals or physicians in the future.

MG: Fortunately, I don’t think any surgeon will let an 8 percent decrease in reimbursement keep them from offering brachytherapy. The changes to image-guided biopsy reimbursement may lead some surgeons to use a 14-gauge biopsy device under ultrasound guidance, where appropriate, instead of a vacuum-assisted device, but that’s an appropriate option in certain instances which will not affect quality of care.

As surgeons, we need to provide the most appropriate patient care, which is our primary focus. However, we must also be able to provide that care from an economic point of view. When you have two clinically equivalent options, that’s when economics come into play. In the case of brachytherapy, when it’s clearly the best clinical choice for the patient and the economics are favorable, it’s an easy decision to offer that treatment.

Ms. Francisco is a managing partner of The Pinnacle Health Group, Inc. She has over twenty years of managerial experience focused in reimbursement, payer relations and state and federal governmental affairs. Her areas of expertise include strategic and tactical reimbursement coverage and coding, policy development and implementation, sales and marketing support and legislative policy development. For more information, visit www.thepinnaclehealthgroup.com.

Dr. Gittleman has been practicing general surgery for over 30 years. In 1995, he dedicated his practice exclusively to the surgery and disease of the breast. In addition to being a Board Certified Surgeon he is also certified in breast ultrasound and stereotactic interventional breast procedures by the American Society of Breast Surgeons. Dr. Gittleman is also a principal clinical investigator in a number of clinical trials regarding the diagnosis and treatment of breast cancer.