Letter to CMS on the 2003 Physician Fee Schedule proposed rule

August 27, 2002

VIA HAND DELIVERY

Mr. Thomas A. Scully
Administrator
Center for Medicare and Medicaid Services
U.S. Department of Health and Human Services
Hubert H. Humphrey Building., Room 445-G
200 Independence Avenue, S.W.
Washington, D.C. 20201

RE: CMS-1204-P

Dear Administrator Scully:

On behalf of the Society of Vascular Technology ("SVT")(1) and the Society of Diagnostic Medical Sonography ("SDMS") we thank you for the opportunity to comment on the June 28, 2002, Notice of Proposed Rulemaking ("NPRM") released by the Centers for Medicare and Medicaid Services ("CMS") regarding the Medicare Physician Fee Schedule for 2003. These remarks relate solely to the treatment of technical component ultrasound services under the fee schedule.

SDMS represents general and cardiac sonographers and vascular technologists and has 13,500 members. SDMS members are involved in the delivery of echocardiography, obstetrical, urological, abdominal, vascular, and ophthalmic ultrasound services. SVT, in turn, is a professional society comprising over 3,500 members who consist of registered vascular technologists, nurses as well as 1,000 physicians. SVT members provide vascular ultrasound services.

Ultrasound is a critical diagnostic imaging modality that uses sound waves to obtain images of the interior of the body. Because ultrasound offers a highly sensitive, non-invasive, low-cost means of looking into the body of a patient to examine structures, such as organs, vessels or a fetus, physicians from numerous specialties and primary care rely on ultrasound as their primary, and often definitive, diagnostic tool in many instances.

We recognize what a daunting task it has been for CMS to design and implement the resource-based practice expense relative value unit system (PERVU), and we commend and appreciate the continued commitment of the fee schedule staff to this process. Both SDMS and SVT have been involved with this transition since it was first mandated by Congress. Together our societies have dedicated enormous time and resources to understanding the dramatic negative impact the original top-down PERVU methodology had on technical component ("TC") services and helping to find options to deal with the zero work pool ("ZWP").

Both providers and end-users of ultrasound services joined together in meetings with CMS (then HCFA) almost immediately after the rule proposing the top-down PERVU methodology was issued to consider ways to mitigate the devastating cuts to the PERVUs assigned TC services. The ZWP was the result of these discussions. Since then, our organizations have remained intricately involved in the process of refining, and, ultimately, trying to replace the ZWP with a sound alternative. We are among the handful of societies that met with the Lewin Group to provide both historical and substantive information regarding payment of TC services under the fee schedule. Further, we were responsible for organizing a conference call with CMS (to which we invited as many interested organizations as possible to join) following the publication of the 2002 Final Fee Schedule Rule to discuss the cause of the unexpected four (4) percent cut in the PERVUs for the ZWP services.

It is with this background in mind, we urge CMS to give heed to the comments that follow and to work together with us to ensure that Medicare beneficiaries have continued and necessary access to high-quality ultrasound services.

I. Blended Utilization Data

In light of the devastating four (4) percent cut in PERVUs suffered by the services in the ZWP (and the corresponding global service) last year due to the update in utilization data inputs to determine the PERVUs for these procedures, we support without hesitation the proposal to use a blend of multiple years of utilization data for determining PERVUs. Like CMS, we believe this proposal will help to minimize the year-to-year changes in PERVUs and improve the overall stability of the system. Any changes to this mechanism in the future, however, must be subject to notice and comment.

II. Removal of the Non-Invasive Vascular Diagnostic Study Codes and Codes 76857, 76872, and 76942 from the ZWP

SVT and SDMS support fully the requests by the Society for Vascular Surgery and the American Association for Vascular Society to remove the non-invasive vascular diagnostic study codes from the ZWP as well as the request submitted by the American Urological Association to remove from the ZWP the services represented by CPT codes 76857, 76872, and 76942. Our support for removing these codes from the ZWP is premised, however, on CMS implementing its proposal to determine TC PERVUs under the top-down methodology as equal to the difference between the global PERVUs minus the professional component (PC) RVUs. If, for some reason, CMS decides against implementing its proposal to calculate the TC in this manner, we cannot be sure we would continue to support the removal of the non-invasive vascular ultrasound or urology codes from the ZWP, and would expect the Agency to provide affected stakeholders the option to remain in the ZWP.

III. Removal of General Ultrasound Codes from the ZWP

For the same reasons, we support the removal of the non-invasive vascular and the three urology codes from the ZWP, we urge CMS to remove the general ultrasound services listed below from the ZWP.(2) As the two largest societies representing the actual providers of these services, and the most familiar with the resources required to furnish ultrasound, SDMS and SVT believe we are as qualified, if not more so, to judge whether these codes should be removed from the ZWP. Like the codes that have been removed from the ZWP in previous years, we believe that the families of codes listed below would be more stable out of the ZWP. The families of codes we advocate be removed from the ZWP are:

Our rationale for requesting the removal of these twenty-six (26) codes from the ZWP is not unlike other requests CMS has received and acted upon since the creation of the ZWP. It is our understanding that codes typically have been removed from the ZWP because they would be reimbursed more accurately under the basic methodology than in the ZWP. This is most apparent in those situations where codes were requested to be removed from the ZWP because the practice expense per hour associated with the specialty area responsible for providing a high percentage of the services is greater than the "all-physician" practice expense per hour used for purposes of the ZWP. Similarly, we are requesting the codes listed above be removed from the ZWP because it appears that the PERVUs assigned these TC services under the revised methodology will capture more completely the true practice expenses associated with the delivery of these ultrasound services. Given CMS' favorable treatment of other requests to remove codes from the ZWP to date, we feel our request should be granted, particularly in the interest of consistency. Otherwise, these services will continue to be underpaid and be at risk for further uncertainties in the ZWP without reason.

* * *

As always, we thank the CMS staff for its consideration of our comments, and look forward to our continued cooperative efforts to ensure that Medicare beneficiaries have access to high-quality diagnostic imaging services such as ultrasound. We are committed to continuing to work with CMS to find an alternative to the ZWP that is fair to TC services. Please feel free to contact us if you have any questions.

Sincerely yours,

Bonnie L. Johnson, RVT, RDMS
President
SVT

Kevin Evans, MS, RT, RDMS
President
SDMS

_________________________

(1) As of September 2, 2002, the Society of Vascular Technology will be known as the Society for Vascular Ultrasound (SVU).

(2) This request assumes the technical component service will be the difference between the global minus the professional component.

(3) The CPT codes noted in the parentheticals represent the range of codes from which the requested codes are found. We are not advocating that all services found within these ranges be removed from the ZWP.