PRACTICE RESOURCES > Regulation/AUA Positions, Letters, and Talking Points > HCFA Regarding 2001 Proposed Fee Schedule


HCFA Regarding 2001 Proposed Fee Schedule

September 15, 2000

Ms. Nancy-Ann Min DeParle
Administrator
Health Care Financing Administration
Department of Health and Human Services
Attn: HCFA-1120-P
P.O. Box 8013
Baltimore, MD 21244-8013


Re: HCFA-1120-P—Medicare Program; Revisions to Payment Policies Under the Physician Fee Schedule for Calendar Year 2001.

Dear Ms. DeParle:

On behalf of the American Urological Association (AUA), representing 9,200 American urologists, I am pleased to submit comments on the Health Care Financing Administration's (HCFA) proposed changes to the physician fee schedule for 2001.

I. Resource-based Practice Expense Relative Value Units (RVUs)

As participants in the process of refining resource-based practice expense RVUs, the AUA appreciates the complexity of deriving resource-based values using the currently-available data. We offer the following suggestions for HCFA's consideration as the refinement process moves forward.

  1. Lewin Group Recommendations on Edits and Trims to Socioeconomic Monitoring System (SMS) Survey Data

    As part of its contract to evaluate SMS data for validity and reliability, The Lewin Group recommended that HCFA revise edits and trims to SMS survey data on practice expenses and hours worked to exclude data that fall outside the acceptable ranges (for example, three standard deviations from the geometric mean). Although HCFA chose not to follow this recommendation at this time, we would like to reiterate our belief that using median values is another way to resolve this issue.

    Because outliers have little effect on the median, it is a better estimate of the center of the sample of data than the mean. Therefore—to arrive at the fairest possible relative ranking of practice expenses per hour among medical specialties—we believe HCFA should consider using median values rather than the mean when calculating practice expense pools.

  2. Direct Patient Care Hours

    We understand that HCFA uses SMS data on average physician time spent in patient care activities to yield the hourly expense value for each specialty. For urology, the 1994 to 1996 SMS data indicate that urologists spend an average of 55 to 58 hours per week in patient care activities.

    However, many have questioned HCFA's assumption that physicians incur expense evenly over the entire time they are involved in patient care activities, and argue that the time a physician's office is open really serves as the best denominator for determining the hourly expense rate. In a Gallup mail survey of urology practice managers conducted in April, 2000, the AUA asked "For each separate location that your urology practice operates, please provide the hours per week the office is open." Based on 162 responses to this question, the average number of hours per week that urology full-time offices are open is 40.8. Therefore, we urge HCFA to calculate the practice expense pool for urology based on this more accurate measure of the period of time that urologists incur expenses.

  3. Recommendations from Relative Value Scale Update Committee's (RUC) Practice Expense Advisory Committee (PEAC) on BPH Heat Therapy Procedures

    We applaud HCFA for its proposal to accept PEAC-reviewed and RUC-approved values for the purposes of calculating non-facility (in-office) relative value units (RVUs) for the following heat therapy procedures that treat benign prostatic hyperplasia (BPH):

    • CPT® code 52647 - Non-contact laser coagulation of prostate, including control of postoperative bleeding, complete (vasectomy, meatotomy, cystourethroscopy, urethral calibration and/or dilation, and internal urethrotomy are included) (ILC)
    • CPT® code 53850 - Transurethral destruction of prostate tissue; by microwave thermotherapy (TUMT)
    • CPT® code 53852 - Transurethral destruction of prostate tissue; by radiofrequency thermotherapy (TUNA)

    Medicare payments that reflect the actual resource intensity of performing these procedures in the office setting are important for these new technologies. Otherwise, there could never be a true assessment of effectiveness and cost of these procedures compared to traditional BPH surgery.

    Although inadvertent exclusion of one of the supply inputs for TUMT led to a calculation error in the proposed rule, we appreciate that HCFA staff worked with us to reconcile this error in a timely manner. Upon reviewing the raw data inputs forwarded to us by HCFA staff, all expenses appear to now be properly included in the calculation of the practice expense payment.

  4. Calculation of Physician Practice Expense Pools/Zero Work Pool

    In our January 3, 2000 comments to HCFA regarding the final rule implementing changes to the physician fee schedule for calendar year 2000, we requested that HCFA take the technical component portion of the following urologic procedures out of the zero work pool and instead calculate their RVUs using the resource-based method.

    Table I. Urologic Procedures to Remove from Zero Work Pool

    CPT® Code

    Description Percent Performed by Urologists

    51725

    Simple cystometrogram 84%

    51726

    Complex cystometrogram 86%

    51736

    Simple uroflowmetry 89%

    51741

    Complex uroflowmetry 94%

    51772

    Urethra pressure profile studies, any technique 59%

    51784

    Electromyography studies of anal or urethral sphincter, other than needle, any technique 68%

    51785

    Needle electromyography studies of anal or urethral sphincter, any technique 83%

    51792

    Stimulus evoked response 66%

    51795

    Voiding pressure studies; bladder voiding pressure, any technique 84%

    51797

    Voiding pressure studies; intra-abdominal voiding pressure 84%

    54240

    Penile plethysmography 46%

    54250

    Nocturnal penile tumescence and/or rigidity test 46%


    We reasoned that because these procedures are performed mostly by urologists, calculating their values based on urology's practice expense per hour would be more appropriate than placing them in the zero work pool. However, we received no indication from HCFA on whether these procedures were taken out of the zero work pool. Therefore, we once again request that HCFA calculate the practice expense values for these codes as part of the urology pool.

II. Cost of Complying with Regulations

Physician offices today must comply with numerous complex rules and regulations, often at a substantial cost to the practice. Because compliance constitutes a legitimate and considerable expense for physician practices, we believe that HCFA should identify a way to incorporate the cost of compliance into physician practice expense payments or into the annual updates to the physician fee schedule. While the annual updates currently take into account the estimated percentage increase in expenditures for physicians' services resulting from changes in law or regulations, this does not include the cost to physicians of complying with these laws and regulations.

III. Geographic Practice Cost Index Changes

The AUA is concerned that HCFA's method of calculating geographic adjusters for Puerto Rico (PR) underestimates office rental expenses incurred by physicians in PR. The proposed geographic adjuster for PR in 2002 is .712, which is well below any other practice expense geographic adjuster. We find this hard to believe given that San Juan and other large Puerto Rican cities and suburban areas have rent costs similar to that of any other major cities in the United States.

Because of the large amount of poverty in PR, (Puerto Rico's per capita income of $8,509 is less than one third the U.S. average, and about one half that of Mississippi, the poorest state) the HUD proxy rental data is inordinately low to reflect the poorer population. This creates a cavernous gap between the Puerto Rican HUD rental data and the actual typical office rent paid by physicians, which roughly matches the cost of rent physicians pay in other major U.S. cities. Therefore, we believe the HUD proxy data inappropriately drags down PR's actual rental costs because the price of HUD rental units must conform to a population that is significantly poorer.

We join with the AMA to request that HCFA issue a contract to study rental costs in PR to determine whether the current index is equitable. If the HUD rental proxy is found to be inadequate in PR, further studies should be conducted to determine if similar problems exist in other areas with high poverty rates.

IV. New Codes for 2001

The AUA disagrees with the RUC's recent decision to combine the following two CPT® codes for cryosurgical ablation of the prostate into one code:

We are also concerned about the methodology the RUC employed in valuing the procedure. We have discussed this concern with HCFA staff and now have plans to send the cryosurgery codes through the RUC a second time or to request review by a HCFA refinement panel. We request that these codes be put on the agenda for HCFA's next refinement panel meeting.

V. HCFA's Impact Tables

In showing impacts by specialty, rounding impacts to whole percentages does not allow a specialty to accurately assess how much it is impacted by particular regulatory changes. Therefore, we request that HCFA show impacts by specialty rounded to a tenth of a percentage point to make the information more useful. In addition, we urge HCFA to include an additional impact table showing changes for each of the four years of the practice expense transition.

VI. Inaccurate Work RVUs in Addendum B of the Proposed Rule

The following urology services have inaccurate work values published in addendum B of the proposed rule:

CPT® code

Descriptor Work value published in addendum B Actual work value

50240

Nephrectomy, partial 22%

50541

Laparoscopy, surgical; ablation of renal cysts 16%

50840

Replacement of all or part of ureter by bowel segment, including bowel anastomosis 20%

50945

Laparoscopy, surgical, ureterolithotomy 17%

52276

Cystourethroscopy with direct vision internal urethrotomy 5%

53220

Excision or fulguration of carcinoma of urethra 7%


We request that HCFA fix this error before publication of the final rule to ensure that these procedures are paid at the correct rate in 2001.

Thank you for considering our comments. If you have any questions, please contact Robin Hudson, Manager of Regulatory Affairs, at 410-689-3762 or govaffairs@AUAnet.org.

Sincerely,


Irwin N. Frank, MD, F.A.C.S.
President
American Urological Association
 

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