Question: I have heard and read that Medicare is reducing fees in 2021. How does that affect acupuncture reimbursement? Is there anything we can do to block or prevent this reduction?
Yes, this will affect your reimbursements and it is imperative that the profession block this change.
Relative Value Units
Many factors can affect reimbursement of health care services, including acupuncture. These factors include, but are not limited to the value of each specific service under the Medicare protocols of relative value units (RVU).
In medical billing, patients or insurance companies submit claims to assist in reimbursement. This reimbursement is dependent on RVUs. It is critical to Medicare, Medicaid and commercial health insurance reimbursements.
Relative value units are measurements or comparisons among all the CPT codes based on the relative worth or value of one code to another. For example, 97810 has a current relative value of 1.05 and 97811 has a value of 0.80. In simplest terms, this means the value of the second set is roughly 75 percent of what the primary set is valued at. Every CPT codes has a RVU and based on what is paid or allowed for one code, you can ascertain what another code would be valued at based on the RVU differences. For instance, massage 97124 has a RVU of 0.83, which means it is approximately 3 percent higher in value than 97811.
The RVU Conversion Factor
Medicare currently uses a conversion factor of approximately $37; this amount is multiplied by the RVU to establish the rate or fee. This is just the start of the calculation, as variations consider factors such as the geographic location where the service is provided. For example, rural areas will generally be at lower rates than an urban location (the same as real estate).
Factors that make a direct difference in the RVU conversion are the work performed, cost of maintaining the practice, and liability expenses. Acupuncture has a higher RVU for the initial set, whether manual or electroacupuncture, than all but a few physical medicine codes. This is partly due to the invasive use of needles, the expertise required and the commensurate liability.
Understanding How It Impacts Reimbursement
Many, if not all payers use at least some of the elements of Medicare rates and reimbursement to aid in establishing their reimbursement levels. Many states, for their workers' compensation fee schedules and other state-mandated rates, have a direct correlation to Medicare rates. Many acupuncturists are now aware of this acutely, as the Veterans Administration system for payment of acupuncture providers is directly per the Medicare fee schedule.
The 2021 Cuts
As we go to press with this article in December 2020, Medicare is scheduled to make a significant reduction in Medicare rates in 2021. CMS has proposed finalized changes to increase the reimbursement for the outpatient / office physician evaluation and management (E/M) CPT codes in CY 2021 (as proposed by the AMA), which will result in an approximately 8 percent cut in payment for outpatient acupuncture, chiropractic, PT and OT services, effective 1/1/2021 (despite receiving more than 10,000 comments against this proposal).
Thirty-six (36) different specialties face cuts in 2021 (including acupuncturists, PT/OT, ophthalmology, chiropractors, audiology, and clinical social workers) with the increase in payment for the physician E/M codes. However, CMS has not determined the actual cuts to each code as of press time.
What's Being Done (and What You Can Do)
All Medicare provider groups have formed a coalition to block these scheduled cuts and there are things that you can do. Several House representatives have introduced the Holding Providers Harmless from Medicare Cuts During COVID-19 Act. This comprehensive bill has wide support in Congress and among Medicare providers. H.R. 8702, through what is known as a "hold harmless" approach, would ensure that payments to Medicare providers, including acupuncture providers, remain at current levels through 2022.
This critical legislation recognizes the importance of allowing significant scheduled pay increases to primary care and others who primarily provide E/M services to take effect; while also avoiding the devastating corresponding cuts for physician and non-physician providers that will occur because of Medicare's budget neutrality requirements. Given the ongoing COVID-19 pandemic, it is more important than ever to halt the implementation of any payment reductions that will further exacerbate the financial instability of health care providers, especially acupuncturists.
Yes, there is something you can do to protect your fees: Take a moment today to send a letter to your local congressperson and urge them to co-sponsor this critical legislation. (To find your congressional representatives in the House and Senate, visit https://www.govtrack.us/congress/members.) This rule is not finalized and with the support of acupuncture providers and others, hopefully, it will be blocked, as it will affect much more than Medicare claims. Let's do our part.
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; it may be the subject of a future column.
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