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  • Washington Committee Report

    Author: Katie O. Orrico, Esq.

    Legislative Affairs

    Congress Urges CMS to Increase Global Surgery Payments

    As previously reported, the Centers for Medicare & Medicaid Services (CMS) plans to adopt a new American Medical Association (AMA) CPT coding structure for office visit codes as well as the AMA/Specialty Society RVS Update Committee-recommended values for these evaluation and management (E/M) codes. However, unlike it has done the past, CMS has said it will not adjust the E/M portion of the global surgery codes to reflect the increased values, citing the agency’s continued work to evaluate the current global surgery code values.

    Working with the American College of Surgeons (ACS) and other surgical organizations, the Congress of Neurological Surgeons (CNS) and the American Association of Neurological Surgeons (AANS) collaborated with members of Congress in calling on CMS to adjust the global surgery codes to reflect the increased E/M values. Spearheaded by Reps. Ami Bera, MD, (D-Calif.) and Larry Bucshon, MD, (R-Ind.) — who have served as our champions on this issue since the global surgery codes first came under threat in 2014 — on Sept. 27, 25 members of Congress sent a letter to CMS Administrator, Seema Verma, urging the agency to increase the global surgery codes. Sens. Rand Paul, MD, (R-Ky.), John Barrasso, MD, (R-Wyo.) and John Boozman, OD (R-Ark.) sent a similar letter.

    Unfortunately, despite these efforts, on Nov. 1, CMS announced in Medicare Physician Fee Schedule (MPFS) Final Rule that the agency will not adjust the E/M portion of the global surgery codes to reflect the increased values, citing its continued work to evaluate the current global surgery code values.


    CNS and AANS Ask Congress for Positive Medicare Payment Updates

    On Oct. 15, the CNS and the AANS joined the Alliance of Specialty Medicine in asking Congress to adopt positive Medicare payment updates as well as increases in the Merit-based Incentive Payment System (MIPS) exceptional performance bonus pool and Advanced Alternative Payment Models (A-APM) incentive payments. Currently, these positive payments are scheduled to expire at the end of 2019, and the MIPS exceptional performance bonus and A-APM incentive payments expire at the end of 2022.


    Neurosurgery Calls for a Balanced Solution to Surprise Medical Bills

    Joining more than 100 state and national medical associations, on Oct. 16, the CNS and the AANS sent letters to House and Senate leaders calling on Congress to adopt “a balanced legislative solution to protect patients from unanticipated (‘surprise’) medical bills.” This balanced approach should:

    • Provide a timely upfront, commercially reasonable payment for out-of-network services;
    • Include an efficient independent dispute resolution (IDR) process designed to incentivize health insurers to make fair payments for out-of-network care, while also preventing bills from physicians or other providers that are outside generally acceptable ranges; and
    • Encourage, rather than discourage, health insurance companies and providers to contract for in-network care to avoid adverse market distortions or patient access problems.

    The letter concludes by requesting that “any final bill represents a fair, market-based approach that treats all stakeholders equally while protecting patient access to care.”


    CNS and AANS Endorse National Spinal Cord Injury Awareness Month

    The CNS and the AANS endorsed S.Res. 329, a resolution designating September 2019 as "National Spinal Cord Injury Awareness Month." The resolution supports research to find better treatments, therapies and a cure for spinal cord injuries, including clinical trials for new therapies that offer promise and hope to individuals living with paralysis. In the letter, the groups highlighted the work of the ThinkFirst Foundation. Click here to read the letter.


    Neurosurgery Calls on Congress to Repeal the Medical Device Tax

    Joining more than 600 innovators, patient groups, physicians, hospitals, venture capitalists and other stakeholders, on Sept. 24, the CNS and the AANS urged Congress to repeal the medical device excise tax. Repealing this tax has been one of organized neurosurgery’s longstanding advocacy priorities since it was adopted as part of the Affordable Care Act. The Senate and House have both previously passed repeal legislation with strong bipartisan majorities, and the letter asks Congress to act now before the current suspension of the tax expires on Dec. 31, 2019.


    CNS and AANS Urge Congress to Increase Funding for Stroke Research

    On Oct. 15, the CNS and the AANS joined the National Coalition for Heart and Stroke Research in urging House and Senate appropriators to support funding for stroke research. Specifically, the neurosurgical societies recommended, among other things, $2.49 billion for the National Institute of Neurological Disorders and Stroke (NINDS) and $160 million for the Centers for Disease Control and Prevention’s (CDC) Division for Heart Disease and Stroke Prevention. The letter points out how previous funding for cardiovascular disease research and prevention has led to significant declines in heart disease and stroke mortality rates.


    Regulatory Affairs


    CNS and AANS Call on CMS to Reduce the Prior Authorization Burdens

    The CNS and the AANS joined the AMA, ACS and other physician organizations in sending a letter to CMS calling on the agency to broaden its efforts to reduce the burdens associated with prior authorization. The letter notes medicine’s concerns that CMS is placing too much emphasis on automation as a means for streamlining prior authorization (PA). While an essential component, automation is but one element of reforms necessary to reduce the PA burdens. The letter also urges CMS to facilitate payer adoption of the following principles: 

    • Selective application of PA to only “outliers”;
    • Review/adjustment of PA lists to remove services/drugs that represent low-value PA;
    • Transparency of PA requirements and their clinical basis to patients and physicians;
    • Protections of patient continuity of care; and
    • Automation to improve PA and process efficiency.


    White House Issues Executive Order on Protecting and Improving Medicare 

    On Oct. 3, President Donald J. Trump issued an Executive Order (EO) on Protecting and Improving Medicare for Our Nation’s Seniors. The EO notes that “America’s seniors are overwhelmingly satisfied with their Medicare coverage” and “believe that the program delivers high-quality health outcomes.” Through this action, the Trump Administration aims “to protect and improve the Medicare program by enhancing its fiscal sustainability through alternative payment methodologies that link payment to value, increase choice and lower regulatory burdens imposed upon providers.”

    The EO includes the following provisions: 

    • Providing More Plan Choices to Seniors. The Department of Health and Human Services (HHS) shall take actions to provide beneficiaries with more diverse and affordable plan choices and to modify Medicare fee-for-service (FFS) payments to more closely reflect the prices paid for services in the commercial insurance market.
    • Improving Access through Network Adequacy. HHS shall propose a regulation to provide beneficiaries with improved access to providers and plans by adjusting network adequacy requirements for Medicare Advantage (MA) plans.
    • Enabling Providers to Spend More Time with Patients. HHS shall eliminate burdensome regulatory billing requirements.
    • Encouraging Innovation for Patients. HHS will take steps to streamline the approval, coverage and coding process so that innovative products are brought to market faster.
    • Reducing Obstacles to Improved Patient Care. HHS shall propose regulatory changes to reduce the burden on providers and eliminate regulations that create inefficiencies or otherwise undermine patient outcomes.
    • Maximizing Freedom for Medicare Patients and Providers. HHS shall identify and remove unnecessary barriers to private contracts that allow Medicare beneficiaries to obtain the care of their choice.

    CNS/AANS Washington Office staff will continue to monitor the execution of this EO as reports, recommendations and regulations are issued by the Trump Administration.


    Coding and Reimbursement

    Neurosurgery Comments on Medicare Hospital Outpatient/Ambulatory Surgery Center Proposed Payment Rule

    On Sept. 27, the CNS and the AANS submitted a letter to CMS expressing concerns about several reimbursement-related provisions of interest to neurosurgeons included in the 2020 Medicare Hospital Outpatient Prospective Payment System/Ambulatory Surgery Center proposed rule. In the letter, the AANS and the CNS: 

    • Provided feedback to CMS regarding the proposed removal of six spine codes from the Medicare Inpatient Only list. Neurosurgery supported the removal of the codes, but provided strong caveats emphasizing that the inpatient setting should be available for patients who need that level of care;
    • Supported “pass-through” device status for Vagus Nerve Stimulation for Treatment-Resistant Depression; and
    • Urged CMS to assign Magnetic Resonance-guided Focused Ultrasound for Essential Tremor to an Ambulatory Payment Classifications that more appropriately reflect the resources required.


    CNS and AANS Comment on CMS Action Plan on Pain Management

    On Oct. 11, the CNS and the AANS submitted comments to CMS responding to the agency’s request for information on the development of a CMS action plan to prevent opioid addiction and enhance access to medication-assisted treatment. The letter noted that while physicians are under significant pressure to reduce opioid prescribing, patients continue to suffer from undertreated chronic pain. The letter pointed out that evidence-based and effective therapies — such as spinal cord stimulation, peripheral nerve stimulation, deep brain stimulation, peripheral neurectomy and cordotomy — reduce the dependence of chronic pain patients on opioid medications, but unfortunately, Medicare, Medicaid and many private insurers often deny the use of these treatments, despite high-quality peer-reviewed evidence supporting their efficacy in reducing chronic pain and patients’ dependence on opioid medications.


    CMS Publishes Medicare Physician Fee Schedule for 2020

    On Nov. 1, 2019, released the CY 2020 Medicare Physician Fee Schedule Final Rule. According to CMS, next year, overall payments to neurosurgery would not change. CMS also finalized its intention to adopt the new AMA CPT coding structure for office visit codes as well as the AMA/Specialty Society RUC-recommended values for these evaluation and management (E/M) office/outpatient visit codes. In addition, CMS has said the agency will not adjust the E/M portion of the global surgery codes to reflect the increased values, citing the agency’s continued work to evaluate the current global surgery code values.  The CNS, the AANS, the AMA and the majority of specialty societies participating in the RUC had supporting including the values in the global surgical codes.  More details are provided in a CMS factsheet and press release.


    Biomedical Research


    Organized Neurosurgery Comments on NINDS Strategic Plan 

    On Sept. 29, the American Academy of Neurological Surgeons (AAcNS), the AANS, American Board of Neurological Surgery (ABNS), CNS and Society of Neurological Surgeons (SNS), submitted comments to the National Institutes of Neurological Disorders and Stroke (NINDS) responding to its request for information about its strategic planning process. The letter points out that neurosurgeon “researchers provide a unique opportunity to advance biomedical understanding and the development of new therapies for nervous system disorders.” It further notes that there are mechanisms that would have an immediate and transformative impact in lessening the burden of neurologic disease, including: 

    • Expanding the support of successful in-training and early career support, including the R25, K12, K08 and K23;
    • Targeting grants at surgical technologies;
    • Growing support for observational natural history and treatment studies;
    • Supporting neurosurgeons who can more effectively translate nervous system therapies/technologies; and
    • Creating a pool of expert clinical trialists who use randomized trials and prospective observational database methodologies to turn basic and translational discoveries into effective clinical therapies.


    Of Note


    Washington Committee-AMA Fellow Selected 

    Congratulations to Jay K. Nathan, MD, for his selection as the 2020 CNS/AANS Washington Committee-AMA Fellow. Dr. Nathan is a PGY-7 resident at the University of Michigan. The Washington Committee/AMA Fellowship offers a current or recent former Council of State Neurosurgical Societies (CSNS) socioeconomic fellow an opportunity to participate in the Washington Committee, its five subcommittees and to serve as the CNS/AANS delegate to the AMA Resident and Fellow Section (RFS). This two-year fellowship provides a full immersion experience into the socioeconomics of neurosurgery.


    For more information on these or other health policy issues, please contact Katie O. Orrico, director of the CNS/ AANS Washington Office at


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