Proposed APCs could prevent women from receiving some breast procedures
Proposed APCs could prevent women from receiving some breast procedures
HCFA should make changes, experts say
Outpatient Reimbursement Management has learned that the proposed ambulatory payment classifications (APCs) may prevent many Medicare women from being able to choose some of the most advanced surgical procedures, as debate continues over the government's upcoming rate system for surgery centers.
At press time in early August, a similar APC system for hospital outpatient services was to be published at any time.
Three breast diagnostic procedures will be reimbursed at a lower rate under the proposed APCs. Some new, minimally invasive procedures, meanwhile, essentially will be unavailable to elderly women because their higher equipment costs are not recognized in the proposed APCs, according to directors at several surgery centers.
U.S. Rep. Nancy L. Johnson (R-CT) expressed her concern about the new APCs in a letter to Nancy-Ann Min DeParle, administrator of the Baltimore-based Health Care Financing Administration (HCFA).
"I am concerned that aging women will be denied access to medical advancements," Johnson wrote in the July 17 letter. "Interestingly, under the proposed rule, men will have access to two new minimally invasive procedures for benign prostatic hypertrophy, with a proposed increase in reimbursement that is reasonable and customary for a range of treatment options." (See story on impact to other surgeries, p. 67.)
HCFA officials have addressed these and other concerns about APCs by extending the 60-day comment period on the surgery center regulations. Facilities now have until Sept. 10 at 5 p.m. to contact HCFA with suggestions and opinions about the proposed regulations for ambulatory surgery centers (ASCs). (For information on how to submit comments or access the original document, see story, p. 67.)
"The APCs might prevent women from having biopsies done with new instruments, and these new instruments are an improvement," says Beth A. Boyd, RN, clinical director and educational coordinator for The Breast Center in Marietta, GA. The Breast Center is a private surgical practice that specializes in breast procedures, including ultrasound, stereotactic biopsy, and mammography.
"Overall, to me it's unfortunate," says Maxine Brinkman, MHA, director of women's health services for Mercy Health Network in Mason City, IA. Brinkman also is the immediate past president of the National Association of Professionals in Women's Health in Chicago.
"It's a step backward and is subjecting women to less technically good procedures," Brinkman says.
Will private payers cut payments?
An even more frightening possibility is that commercial payers will follow suit and base their payment structures on Medicare's APCs, says Jerry Henderson, executive director of SurgiCenter of Baltimore in Owings Mills, MD. The multispecialty center performs about 11,000 procedures a year, including breast procedures.
"The impact could be horrendous," Henderson says. "Breast procedures have taken a pretty big hit, and it will have a larger impact on freestanding surgery centers than on hospitals."
At the center of the controversy are the proposed reimbursement rates for breast biopsy diagnostic procedures. Currently these are reimbursed under these three CPT codes:
· 19100: Breast biopsy; core - $314;
· 19101: Breast biopsy; incisional - $422;
· 19125: Excision of breast lesion identified by preoperative placement of radiological marker - $482.
The new APC group definition lists CPT 19100 as APC 122, defined as a Level II needle biopsy, aspiration, and the reimbursement rate is $186, a decrease of $128 from the current payment rate.
The CPT codes 19101 and 19125 are grouped under the APC 197 as an incision/excision breast procedure, and the reimbursement for these is $411. It's an $11 decrease from CPT 19101 and a $71 decrease from CPT 19125.
Newest technology left out of APCs
The reduction in reimbursement is only part of the problem. The bigger issue, ASC directors say, is that the proposed codes do not address new breast biopsy procedures.
For example, until 1994, most stereotactic breast biopsies in outpatient settings involved using a core needle biopsy. The gold standard was an open excisional biopsy performed in a hospital operating room. The latter procedure requires general anesthesia, and the woman needs longer recovery time. It also leaves some internal and external scarring, Boyd says.
Then manufacturers introduced the stereotactic biopsy procedure with vacuum-assisted biopsy device. The new stereotactic technology allows digital imaging on a computer during the biopsy. It is minimally invasive, so it doesn't cause as much scarring, and the woman does not need general anesthesia. The woman can drive herself to and from the outpatient facility, and the whole procedure and recovery may take two hours, Boyd says.
"It's a very big difference," Boyd explains. "You don't have operating room time, or preoperative laboratory time to pay for, so it benefits the insurance companies to work with this too."
Although the stereotactic biopsy, using a vacuum-assisted biopsy device, costs more than the traditional stereotactic core needle biopsy, it is a much better diagnostic tool because it allows the surgeon to remove larger tissue samples and an entire area of abnormality in the breast, instead of only a small tissue sample, Boyd adds.
The Biopsys Mammotome Breast Biopsy System, manufactured in 1994, is now marketed by Ethicon Endo-Surgery in Cincinnati. It was the first vacuum-assisted biopsy device, Boyd says. Norwalk, CT-based United States Surgical Corp. has recently introduced the MIBB (Minimally Invasive Breast Biopsy), which also is a vacuum-assisted breast biopsy device used with stereotactic imaging.
Both devices use new technology that allows larger tissue samples and removal of the lesion through a 4 mm incision, Boyd says.
United States Surgical Corp. also manufactures the ABBI (Advanced Breast Biopsy Instrumentation), another new stereotactic breast biopsy technology that would be adversely affected by the APCs, says Kathryn Barry, senior director of health policy and reimbursement for the company.
The MIBB was introduced this year, and the ABBI was introduced in 1996, which means they were not included in cost data HCFA collected in its 1994 ASC survey, Barry says.
HCFA's outdated methodology
"We are concerned they are using an outdated methodology that doesn't keep pace with advancements of technology that are piloting a shift to ambulatory care," Barry says.
The ABBI, which uses a disposable product, costs more than the proposed APC reimbursement of $411, Barry says. Add in the cost of the surgeon, facility, and staff time, and the cost of the new stereotactic breast biopsy will exceed Medicare's reimbursement rate.
"So this creates two perverse incentives: There are ASCs with this technology, but they won't schedule Medicare patients for the procedure, so Medicare women will be denied access to the technology," Barry says. "Or physicians will be motivated to send their patients to a hospital because the procedure is reimbursed more there."
Ironically, while Medicare's low reimbursement level might deny older women stereotactic technology, other government agencies are paying for it, Brinkman notes. The Atlanta- based Centers for Disease Control has included stereotactic procedures for low-income women in its Breast and Cervical Cancer Early Detection Program, which is funded by the National Institutes of Health in Washington, DC.
Hysteroscopy rate drops
Henderson points out that women also are being short-changed with HCFA's proposed reimbursement for surgical hysteroscopy, which is under APC code 550 and corresponds to CPT code 56356, which is for hysteroscopy, surgical, with endometrial ablation. The procedure allows a surgeon to destroy the endometrial lining of a woman's uterus, instead of performing a hysterectomy.
The procedure traditionally has been done in a hospital setting, where the reimbursement rate is more than $2,000 in many states, Henderson says.
The proposed APC code 550 would reimburse the procedure in an outpatient setting at $610. Surgeons now have the option of using new technology that uses a heated balloon to destroy the endometrial lining, which is safer and quicker, but requires a disposable instrument that costs about $650, Henderson says.
"So before you have the first minute of surgery, the first staff person, and the first suture, you're already behind," he says. (For more information on the APCs, see also the APG Corner, p. 70. For information on the surgeries added to the list and rates of current ones being reduced, see Outpatient Reimbursement Management, July 1998, p. 49. Also, for HCFA's discussion of APCs, see ORM, August 1998, p. 62.)
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