Coding concerns: Providers decry proposed cuts to infusion services in 2023 fee schedule

Providers are slamming the Biden administration’s proposal to cut reimbursements for procedure codes that cover oncology, hematology and other infusion services. 

Some groups are pressing the Centers for Medicare and Medicaid Services for changes to the proposed Physician Fee Service, which outlines payments to doctors in 2023. Several groups are seeking changes to proposed codes, including psychologists who want reimbursement for caregiver training. Oncology practices say that the formula CMS is using to determine reimbursements doesn’t fully account for their costs and staffing.

“The big issue we are struggling to get around … is the way services are reimbursed for physicians,” said Bo Gamble, director of quality and value for the Community Oncology Alliance, which represents independent oncology practices. 

CMS predicted hematology services will only go down 2% and expects a base reduction of 4.4% across all lines. 

“They use a series of components to determine that price,” Gamble said. “One of the main components is called the practice expense for infusion and hematology. All the numbers for that ratio went down. We don’t understand the why.”

Advocates say that CMS is overlooking that costs have increased for practices, which could deepen the impact of the cuts.

“We don’t understand the logic behind that reduction given what the practice has to put in to run an infusion center as far as the nursing and staffing support,” said Sheila Plasencia, director of practice support for COA, in an interview with Fierce Healthcare. 

Oncology practices, like most of the healthcare industry, have been hit hard by staffing shortages and higher expenses due to inflation. COA officials say this has raised costs overall for practices. 

“We are struggling to get nurses,” Gamble said. “We’ve got to make sure they are going to be paid for if they are going to provide services next year.”

Codes for caregiver training

Psychologists are hoping to convince CMS to make changes to behavioral health caregiver training, which advocates say is vital to helping patients. 

"The focus of those codes is to train caregivers in how to manage individual patient behaviors," said Stephen Gillaspy, senior director for health and healthcare financing for the American Psychological Association (APA) in an interview. "The gold standard for treatment in kids with disruptive behavior disorders ... is to get the caregivers together in a group format and train the caregivers on how to manage those."

CMS, however, is concerned that the patient is not in these caregiver meetings and thus won't benefit, he added. 

"We are going to be providing all kinds of evidence that training those caregivers is for the direct benefit of the patient," Gillaspy said, referring to comments the APA will be submitting on the rule.

Overall, CMS is proposing a conversion factor of $33.08 for each relative unit, which determines how much Medicare will pay for a particular service. The $33.08 is slightly below the 2022 factor of $34.61.

The fee schedule is required to be budget neutral under federal law. However, several physician groups said after the proposed rule was released last month that the cuts will hit practices hard. Congress included a 3% boost to the fee schedule payments to help provide relief due to the COVID-19 pandemic, but that sweetener went away in 2022.

Comments on the proposed fee schedule rule are due on Sept. 6.