Hello and welcome to Episode 5 of The Beat, brought to you by the Digital Education Committee of the Heart Rhythm Society. I'm Michael Lloyd of Emory University, Vice Chair of the Digital Education Committee. Today's episode is A Seat at the Table, Understanding CPT and RUC. This is the first webinar in a series presented by the Heart Rhythm Society's Health Policy and Regulatory Affairs Committee, chaired by Dr. Christopher Liu. Today's webinar is presented on demand and free of charge for Heart Rhythm Society members, so please enjoy this informative hour brought to you by Drs. Fred Kusumoto, Christopher Liu, Mark Schonfeld, and Amit Shankar. The statement of intent for the Heart Rhythm Society Health Policy and Regulatory Affairs Committee and this session's title is that all statements contained in this webinar are intended for informational purposes only. These are our disclosures. Hi, my name is Amy Klinans and I get the honor today to introduce our panelists. I'm going to start by introducing one of our moderators, Dr. Fred Kusumoto. He is the Director of the Heart Rhythm Services at Mayo Clinic in Florida. He is the Associate Dean of Faculty Affairs at Mayo Clinic Alex School of Medicine. He is the author of five books on cardiac pathophysiology and devices. He is our immediate past president of the Heart Rhythm Society and past member of the HRS's Health Policy and Regulatory Affairs Committee. Dr. Kusumoto has also served as chair of the 2018 ACC AHA HRS Bradycardia and Conduction Disorder Guidelines, the 2017 ACC AHA HRS Sudden Cardiac Death and Ventricular Arrhythmia Guidelines Evidence-Based Review Committee, and the 2017 HRS Expert Consensus Statement on Lead Management and Extraction. The first of our panelists I'd like to introduce tonight is Dr. Christopher Liu. Dr. Liu is a clinical cardiac electrophysiologist. He is full-time faculty at Weill Cornell Medical College and Newark Presbyterian Hospital. There he serves as the Director of Complex Arrhythmia Ablation and Structural Heart Electrophysiology. He has been in practice since 2008. He also currently serves as the primary advisor on the American Medical Association CPT Advisory Committee. He is the chair of the Health Policy and Regulatory Affairs Committee here at HRS, and he advocates on behalf of HRS and its members to the Center of Medicare and Medicaid Services, the Food and Drug Administration, and many other federal agencies. Welcome, Dr. Liu. Our second panelist tonight is Dr. Amit Shankar. Dr. Shankar is also a clinical cardiac electrophysiologist. He's the chair of cardiovascular medicine at St. Lawrence Health Systems. Dr. Shankar completed both the academic investigator track and the electrophysiology track at the National Institute of Health and Washington University School of Medicine. He has served both in academic medicine and multinational med tech firms. He has also served as the American Medical Association CPT advisor for HRS from 2010 to 2013, and is the alternate RUC representative for the American College of Cardiology in 2011 to 2013. Currently, he is the vice chair of Heart Rhythm Society's Health Policy and Regulatory Affairs Committee. Welcome, Dr. Shankar. Our final panelist tonight is Dr. Mark Schoenfeld. Dr. Schoenfeld is a past president of HRS and also serves as a committee member on several ACC committees. He is the professor of clinical medicine at Yale University's School of Medicine and has had a longstanding interest in health policy. He works with multiple federal agencies on behalf of both the HRS and ACC on reimbursement and coverage policies, and with the FDA on drug and device approvals and research protocols. Currently, Dr. Schoenfeld is HRS's primary representative for the Relative Value Scale Update Committee, advising both AMA and CMS on valuations and reimbursement for EP services. I'd like to welcome all three panelists. Welcome everybody, and I'd like to hand it over to Dr. Kusumoto to get us started. Great. Thank you very much, Michael. Thank you. I really appreciate it. Just for all of you who are out there sort of watching, such a critical sort of piece to our field. Really important in terms of thinking about access to the important things that we do in medicine. And so really, this is going to be the introduction to several webinars, as was mentioned earlier. And so we're going to first talk about the history of CPT. What does that mean? And what are all these different codes? And then how are these sort of codes generated? And then what is this editorial panel? And finally, relevant to this discussion is, how is HRS involved in CPT? And how then is a CPT code for arrhythmia care therapies developed? We'll then talk about the history of the ablation CPT code family. And then ultimately, so the CPT helps us define in a procedure, but in terms of payment, that then is then thought of and determined by what's called the RUC. And what we'll then talk about is the RUC process and how that in fact works. Sort of the components of what the RUC then decides on these relative value units or RVUs, the definitions and how these rates are set. And then finally, the challenges that are associated with the current RUC process. There are a couple of learning objectives that we have through this. So at the conclusion of this, you'll number one, know how these CPT codes are developed. You'll understand why there are different CPT code categories and why changes were needed in the ablation CPT code family. I mean, that's obviously something that's been impactful to our world in the United States for the last several years. We'll then talk beyond the CPT code, thinking about the RVU or the relative value unit and how it was developed, what's its history. And then how RVUs are then converted into payment. And then finally, and most critically, what is HRS's involvement in the CPT and RUC process as your advocates? And with that, I'd like to turn it over to Chris Liu to speak to us about an overview of the CPT, this procedural technology and sort of what does that mean? How does that work? Chris, as was mentioned earlier in the introduction, has been our health policy chair at HRS. So Chris, the floor is yours. Thanks very much, Fred. As you have said so importantly, in the past couple of years, we in electrophysiology have really understood and have begun to understand how important it is to be involved in these processes that determine procedure coding and relative value determination. So this is really an essential process to get our members and all of our colleagues in electrophysiology to understand the process so that we can move together forward as a field. So CPT stands for Current Procedural Terminology. The CPT codes were first developed in 1966. So this was almost 60 years ago now by the American Medical Association. The initial version of CPT primarily contained surgical procedures. This was a method for the American Medical Association and physicians to classify and categorize procedures so that they can be described and communicated and reimbursed. So the second edition that came out in 1970 contained significant expansion of the initial edition where diagnostic and therapeutic procedures, in addition to surgeries, were added. So this was a new version of medical procedures and other specialties like ophthalmology. An initial four-digit system was converted over to the five-digit coding system that we see today. In the 1980s, CPT, after it was developed by the AMA, was adopted initially by the Health Care Financing Administration, the HFAA, which then subsequently became CMS, the Centers for Public Health. You'll see that CPT sometimes is also called the Health Care Common Procedure Coding System, HCPCS, H-P-C-P-C-S. So again, we're going through some of these acronyms that you may run into, and we want to clarify and educate our members on what these acronyms mean. These CPT codes, or HCPCS codes, then became mandated to report services for Part B of the Medicare program, and subsequently the Medicaid program, and for reporting other outpatient hospital surgical procedures. Next. CPT codes have several categories, and for most intents and purposes, we will focus on two categories. The Category 1 codes are the most relevant codes to physicians in practice. So Category 1 codes are the most commonly used codes. These codes refer to devices and drugs necessary for the procedure of service that have received FDA approval, if required. These codes are performed by many physicians or other qualified health care professionals across the United States. So essentially, these codes are used to describe procedures that are standard of care. They are performed with frequency that is consistent with the intended clinical use. So, for example, a service for a common condition should have high volume. These codes are used for procedures that are consistent with current medical practice, and that the efficacy is documented in an appropriate level of clinical literature. So what you see here are the criteria used to determine whether a code is appropriately described as a Category 1 CPT code. The other category of CPT codes that we electrophysiologists will sometimes see are Category 3 codes, or these T codes. Category 3 codes are meant for new technology that is in an experimental phase. And so these codes are not considered standard medical procedures or surgical procedures. The procedure of service, however, needs to have been and currently performed in humans, and there needs to be at least one of the following criteria. The application for the CPT 3 code is supported by at least one specialty medical society. So the CPT and HCPAC advisors that we'll talk about in a little bit that represent practitioners who would use this procedure or service. So this, of course, includes the Heart Rhythm Society and our representatives to the CPT panel. Another criterion is the clinical efficacy of the specific procedure or service is supported by peer-reviewed literature, which is available. So this, of course, is expected to be preliminary evidence, and there should be at least one Institutional Review Board-approved protocol of a study or the description of a current and ongoing United States trial outlining the efficacy of the procedure or service, or there's some other evidence of evolving clinical utilization. So these are the criteria used to determine when a code would be appropriate to be considered for Category 3. So the CPT codes are managed by the CPT editorial panel. This is a panel that is created by the AMA Board of Trustees, and the CPT editorial panel was created to revise, update, or modify the CPT codes, the descriptors, their rules, and the associated guidelines. This CPT editorial panel consists of 17 members. The 17 members include members that can be nominated by any AMA-recognized medical society. And so these are medical societies that are in the AMA House of Delegates. This is, by the way, why it is critical for the Heart Rhythm Society to maintain our presence in the AMA House of Delegates. So these medical societies can nominate someone to the panel, and the AMA Board makes final approvals of who sits on the editorial panel. Currently, there are two cardiologists on the CPT editorial panel, including one who is an electrophysiologist. Blue Cross Blue Shield Association America's Health Insurance Plans, the American Hospital Association, and CMS also nominate physicians to the panel. And then there are two seats on the panel that are reserved for members of the Health Care Professionals Advisory Committee, which is a non-physician panel. So how does HRS work at the CPT meetings? All of the activities of the CPT editorial panel are supported by a large body of CPT advisors, and this is called the CPT Advisory Committee. These advisors are primarily physicians nominated by the National Medical Societies that are, again, represented in the AMA House of Delegates. And so ACC has representation in the House of Delegates, so the ACC is able to send two advisors to the CPT Advisory Committee. Currently, these people are Mandy Thompson and Barbara Pisani. HRS, because we have representation in the AMA House of Delegates, we are also allowed to send two advisors to the CPT Advisory Committee. Currently, it is myself and Sumit Manigy. So we, the CPT advisors, are a significant resource to the editorial panel because we provide advice on procedure coding and appropriate nomenclature as relevant to our specialty. We provide advice regarding the medical appropriateness of various medical and surgical procedures under consideration for inclusion in the CPT code set. We would routinely review code proposals and provide opinions and expertise before and during panel meetings through the advisor review process. We review relevant coding issues and help to prepare technical education material and articles pertaining to the CPT code set that are published by the AMA. And, of course, one of our jobs is to promote and educate the specialties membership, our specialties membership, on the use and benefits of the CPT code set. So how does a procedure get a new CPT code or how does a procedure get revised in the CPT coding? So general criteria for all CPT codes include the fact that the descriptor needs to be unique, well-defined, and describes a procedure or service which is clearly identified and distinguished from existing procedures and services. Structure, guidelines, and instructions are consistent with CPT standards and maintenance of the code set. A procedure or service is neither a fragmentation of an existing procedure or service nor currently reportable as a complete service by one or more existing codes. I know that this is very technical information. We hopefully will have a chance to discuss some of the issues. For example, one of the common questions that has recently been raised is whether we should have a separate CPT code for conduction system pacing. This is one of the dilemmas that we have to look at in relation to whether it would satisfy criteria for a distinct and separate CPT code. Do we have enough clinical evidence and distinction to be able to define conduction system pacing as a clearly identified and distinguishable service from existing pacemaker implantation codes? This is a question that would need to be addressed before we can proceed to apply for a new code, for example, for conduction system pacing. Next. If a decision is made to request a new or revised CPT code, the proposed code description must accurately reflect the service as typically performed. If a procedure is always or frequently performed with one or more other procedures or services, the descriptor, structure, and content must reflect the typical combination or complete procedure or service. So this is a phenomenon also known as bundling. So this is, of course, relevant because ablation services recently were modified to include such add-on procedures that were previously separately billable, including 3D mapping, intracardiac echocardiogram. The procedure or service also is not proposed as a means to report extraordinary circumstances related to the performance of a procedure or service already described in the CPT code set. If there are procedures that may be more difficult, you cannot just create a separate CPT code simply because the procedure is more difficult or extraordinary. The procedure or service being requested for a code must satisfy the category-specific criteria as well. Next. So when a decision is made to proceed with a code change application or CCA, it goes through this rigorous process. The applications must meet the specific procedures and criteria for requests to the CPT. There are certain deadlines for meetings at every step of the process. And it's very important to indicate that anyone, anyone may submit applications to the editorial panel. So this includes medical specialty societies, such as HRS and ACC, can be individual physicians, can be hospitals, third party payers, or even other interested parties. For example, industry can apply for code change applications when they develop new technologies. Just so our members know, HRS and ACC have set a longstanding precedent to submit applications for new EP procedures and technologies so that we work very closely with industry partners so that we have very important input with regard to timing and specific wording and terminology for CPT code applications. All applications with new and revised codes must first undergo internal review to ensure that the issue has not already been addressed. And of course, all new issues or significant new information refer to the advisory committee for evaluation and commentary. Next. Applications that do not gain advisor support. So for example, if someone, including industry, went to CPT with an application that HRS or ACC does not agree with, then the application goes in as unsupported. Usually, applications that are not supported by medical specialty societies that are relevant would usually not be approved, with some exceptions. Applicants will be notified if their applications have received no advisor support. And this usually occurs by 14 days prior to each meeting. And the applicants have the ability to withdraw applications until the actual meeting itself. Next. So these applications, code change applications, are discussed at the CPT panel meetings that are held three times a year. The prep time for each of the three meetings is about three months. So pretty much after each meeting is very closely follows the deadline for the next meeting to be prepared. The initial staff and advisor review is completed when all the relevant responded and all information requested of an applicant has been provided to AMA staff. So this is a fairly rigorous process. And following review and compilation of the comments, the AMA staff will ready the application and prepare a ballot for decision by the editorial panel. Once the panel has taken an action and preliminarily approved the minutes of the meeting, the AMA staff will inform the applicant of the outcome. Next. So the final outcome could be that the application is approved. And so then there would be addition of a new or revised code, in which case the change would appear in the next volume of CPT, which would typically be the next time they meet. It's also possible that the co-change application, if it's not approved, would be referred to a work group for further study. Or the application could be postponed to a future meeting to allow submittal of additional information. Or the application could be rejected. Next. So then what happens after the CPT? Well, this is indeed the subject of further discussion of the RUC by Dr. Schoenfeld. So in short, the CPT code changes are sent to CMS and the RUC. The RUC, which is also a process that is constructed at the AMA, consists of physicians and determines a recommended RVU value for each of the procedures. CMS then takes the RUC recommendations into consideration when creating a National Coverage Decision, or NCD, and eventually finalizes the RVU value in the Annual Medicare Physician Fee Schedule, which is the NPFS. Commercial payers then will base usually their reimbursement rates on the NPFS. So Chris, sorry. Great. So Chris, thank you very much for a super overview of sort of the whole CPT process and the history. I mean, it really is remarkable. And when one thinks about it, there's so many procedures that are developed throughout the entire House of Medicine. Of course, we're electrophysiologists, often doing ablations. And so really, let's take this general information and really then apply it to something that we do constantly, and that's ablation. And it's really my honor to introduce Amit Shankar, who has been in this health policy field for a decade and change and really understands sort of the history of the ablation family code set. So Amit, the floor is yours. Thank you, Fred. And Chris, thank you for providing that comprehensive background. I think we'll provide the framework that'll be necessary for many of you who are participating in this webinar to really get an understanding of the journey that we took to get these new ablation codes. Well, not new, but the most recent iteration of family of ablation codes basically accepted. And actually, much of the recent structure of these ablation family of codes was developed, as Fred alluded to, about 11, 12 years ago. And they were actually developed in response to, paradoxically, CMS's request to bundle the existing SVT and VT ablation codes. They actually want to make things less granular. And basically, in a nutshell, with the physician fee schedule for 2010, CMS asked the joint CPT and RUC panel to combine the comprehensive EP study, which at the time was 93620, with the ablation codes 93651, which is a standalone SVT ablation code, and with the standalone VT ablation code 93652, due to the frequency of performance on the same day. So in other words, the EP study's standalone code was being built more than 50% of the time with the SVT ablation code, and also being built more than 50% of the time with the VT ablation code, which is why they requested that we bundle those codes. We did agree, of course, with that request. However, we pushed back, as I alluded to before, and felt that these codes needed to be updated to more accurately reflect, at the time, current clinical practice, because now we were ablating much more complicated arrhythmias, atrial tachycardias, VTs, and really tackling more complex substrates. And also, AF ablation was starting to become more of the workhorse ablation procedure for EPs around the country. So this promulgated a letter that was sent to both the CPT and RUC to their panel in November 2010. And Lisa, can you just quickly toggle over to that next slide? Yeah, thanks. And basically, this letter that was sent in November, we argued that the services that were submitted with code 93651, which was the SVT ablation code, didn't really capture all that was really being done now in clinical practice. We were treating far more complex arrhythmias, whether atrial or ventricular in origin. And now we were also ablating AF. And our feeling was that 93651 really didn't capture the complexity of the work, the practice expense, and the intensity that was required with these procedures. Moreover, having 93651 as a bundled code to really capture all, at least with SVT and AF ablations, we felt that would probably provide some issues at the RUC. And Mark will get into that a little bit later, in terms of sampling times and really evaluations. And it's for that reason we propose revitalizing, developing, basically, a whole new code set that kind of better captured evolving advancements in cardiac ablation procedures. So Lisa, could you go back to the previous slide, please? Thanks. So in November, so we sent that letter in November 2010. They agreed with us. And that pretty much set the basis for the establishment of a joint HRS-ACC work group, which was solely focused on developing this new ablation code set. It consisted of HRS and ACC staff in the health policy committees, respectively, in both the organizations. It included physician representatives, such as Dr. Robert Piana, who at the time was the ACC delegate for the CPT, Dr. Rob Cowell, myself. I was the HRS CPT delegate and RA chair, Dr. Rich Fogle, who was a president at the time of HRS, and immediate past president, Bruce Wilcoff. So Lisa, can you go ahead two slides, please? The next slide. Yes, so over the course of the next year, we had very close engagement with a whole variety of stakeholders, namely those on the CPT panel, including Dr. Holman, who at the time was a CPT panel chair, Dr. Brin, who was also a cardiologist and vice chair of the CPT panel and previous ACC CPT delegate, and also Dr. Heather Hambrick, who was the CMS delegate at the CPT panel. So in June 2011, we brought a new code change proposal, kind of capturing this new code set, which now detailed a new SVT ablation code that was bundled with the EP study, a new VT ablation code that was bundled with the EP study, a new AF ablation code that was now bundled with the EP study. And we also proposed a formation of three add-on codes that had not existed before to capture more of the complexity of what we were dealing with, a code for additional arrhythmia mechanisms, a code for additional linear lesion sets in the context of AF ablation. And we actually also proposed an epicardial access code for VT. When we went to the June meeting, it was brought to our attention after some discussions with the panelists that they were concerned preliminary discussion of pre-facilitation discussions, that they didn't think that an epicardial VT access ablation code would hit the benchmark for widespread utilization. And for that reason, we did omit that code with the code change proposal. But more importantly, we used an abbreviated application form. There's kind of a more of administrative logistical issue, which is actually advised by them. And they advise that we use an abbreviated application code for the new bundled codes and a new application code for a new change application for the new codes. So we asked for an extension, and they granted the extension for us to present the new codes in the October meeting. Next slide. Over the course of the summer, we had very intense engagement with our CPT panel colleagues. And this letter kind of memorializes some of those communications that we had. In May, as I alluded to, we made the switch to a long-form application. In August, they requested that we bundle intracardiac echo with all of the SVTAF and VT ablation codes, which we pushed back on. They requested that we bundle 3D mapping with SVT, VT, and AF ablation, which we, of course, backed on as well. They also asked for service usage, and they wanted to determine whether these codes met the bar for Category 1 codes. And I think their focus was on AF ablation. They wanted us to bundle left atrial pacing with the SVT, VT, and AF ablation codes, which we pushed back on. And then most alarmingly, about a week before the panel meeting on October 8, they proposed that perhaps the AF ablation code should be a Category 3 code and not a Category 1 code. And we pushed back and said this was a code, this is a procedure that had been performed since, well, since we all know, since 1996, since it was first done in Bordeaux. But there was widespread utilization, and that it would actually affect claim submissions for physicians and would have possibly represent a significant access issue for patients if these procedures could not be billed. And it's for that reason we sent this letter that you see here, because we sought to have closed-door meetings a few days or a day before the meeting to really have some discussions for pre-facilitation to ensure that we could get this code change proposal through in October. And through a lot of deliberation in that meeting and hand-wringing, next slide, we were able to get the code change proposal through in October. A CPT assistant article was then published in February 2013, reflecting the codes that had now become operative in January 2013. And at the end of the day, we were able to establish five new codes, a new SVT ablation code, a new VT ablation code, a new AF ablation code, and also new add-on codes, a code for additional lesion sets for AF, and then add-on code for additional arrhythmia mechanisms for SVT ablation or VT ablations that are sitting if there were other foci. We were able to push back on the request to have LA recording for all the base codes. And they agreed that it would only need to be bundled with the AF base code. They also agreed that 3D mapping should only be bundled with the VT code because it wasn't necessary for all SVTs and AFs at the time. And they agreed with allowing ICE to remain as a standalone code. So after that process, and I think Chris alluded to that, it was sent over to our RUC colleagues who helped devise a RUC strategy. And in retrospect, I think these codes really should have been reviewed by the RUC in 2018. It's called it the five-year review that was mandated by Medicare in 1997, where they look at high utilization codes and they examine practice expense and work our views. But we kind of flew under the radar for a few years even thereafter, which I think we were fortunate. But at some point, the review was going to happen. But in any case, I think this is a great segue for Mark to start his discussion on the RUC. So thank you. Great. Amit, thank you very much for that really wonderful presentation, really putting this whole CPT process into context. It also illustrates how important it really is for professional societies really to work as proponents for clinicians, particularly for these new and developing procedures, and the fact that professional societies can work together hand-in-hand to really provide best care delivery. Because that's really what it gets down to, right, is this was care that was necessary, important, and really improved people's lives. And by having this sort of work, which everyone's eyes glaze over when they think about health policy, it really is something that goes to patient access. So thank you very much. I would now like to turn it over to my really good friend, Mark Schoenfeldt, who I've known for years through health policy and other roles that we have shared together in different committees. He's really going to talk to us now that we've talked about procedures, right, and technologies. How does that then go on to payment? So Mark, please tell us a little bit about how payment then gets developed. All right, then. Well, thanks, Fred, and both Chris and Amit. Fantastic reviews thus far. Perhaps a little bit of a dry topic on the one hand, but it's quintessential for all of you to know what the basics are here so that you can better understand where we've gotten to with regard to CPT and the RUC process. But again, just to consider this pathway to reimbursement, again, if you will, going over the ABCs or the acronyms or the alphabet soup, the FDA, the Food and Drug Administration, identifies that a device is safe and efficacious. This is to be differed from other terminologies and acronyms. Clinical practice guidelines essentially define what we should be doing, and for that matter, not doing with our devices. And it should be noted that Fred, myself, other people on this and related seminars and webinars have worked for years developing medical guidelines. But unfortunately, things do not always fit succinctly into the practice guidelines. Nonetheless, it has become the practice, not just in our society, but other societies, to develop guidelines to serve as essentially a guide by which we should be undertaking various procedures and following through thereafter. But again, to the point, Fred, for example, chaired a document some years back to address certain situations where guidelines don't necessarily reflect the clinical situation. So they do have their limits. There is the CPT, which has been discussed by both Chris and Amit, the current procedural terminology codes, which essentially were initially developed to define what we do. But clearly, though it was useful for saying what we do, and perhaps serving as well for research entities, has clearly gotten its major strength for serving as a basis for reimbursement and whether or not we should be reimbursed. The RUC is the Relative Value Scale Update Committee. That's why we call it the RUC, otherwise people will be out of the room before we announce what we are. It defines what the CPT codes are worth, what are the resources required to provide physician services, and then it makes recommendations to the Centers for Medicare and Medicaid Services, previously HCFA or the Healthcare Finance Administration. CMS and the commercial entities, the third-party payers, have guidelines in and of themselves. This is very often based on CMS and medical guidelines, but not often enough. CMS develops guidelines in terms of what insurers are willing to pay, but as indicated and as I already alluded to, they are often but not always based on the clinical practice guidelines and the clinical practice guidelines don't always necessarily meet the reality. Next. This is an article from years ago and it also demonstrated in the New England Journal of Medicine, when the transition to the RBRVS system was made. It may be hard to see in this slide, but I introduce it just because way back when, under surgery, insertion of a pacemaker took the biggest hit once the relative value scale platform was designed. In part, when things were being valued relative to one another, which is the whole game plan for the relative value scale strategy, some of the people that were being surveyed, which in those days were largely surgeons said, well, I can just slap that sucker in and no time flat. Whether there was any basis to this, it was unclear, but certainly, it didn't reveal the complexity, the time, the intensity of the service being rendered by many individuals. But whether it be through machismo, bravado, some element of truth, I think you can see from this slide that pacemakers really took the biggest hit, going down by close to 50 percent drop in terms of valuation. What about the RUC process? Again, this is an algorithm and the way this process has already been alluded to start is that the CMS will request a review for existing codes, that is one pathway. Separately, the CPT editorial panel will adopt coding changes. This fields and feeds into the specialty society advisors, which review new and revised or existing CPT codes. There will be codes that don't require new values. There will be some that have no comment, comment on other society's proposals, and there will be a survey of physicians where recommended values are requested. There is an RVS update committee, as I already indicated, termed the RUC. Their recommendations go on to the Centers for Medicare and Medicaid Services. Historically, CMS has listened quite intently and closely to the recommendations of the RUC, and for years, closely adhered to the recommendations. But unfortunately, in recent years, we've seen a drift away from that. So that if we say that 75% to 80% perhaps of the recommendations are scrupulously adhered to, that may be closer to the truth than the 90%, 95% that we used to see. CMS does not legally or through any regulatory standpoint have to follow the recommendations of the RUC. And this has become quite apparent in some of the most recent discussions along the lines of the ablation coding challenges that we most recently faced. Ultimately, the Medicare payment schedule has arrived at. Next. So what triggers a RUC valuation or, for that matter, a revaluation? New technology is a very good example, and this has already been discussed by Chris and Amit. And in particular, where there is a new type of technology, which is being evaluated and has been elevated to a CPT Category 3, has already been mentioned, which is still more in the investigational line of work, and there's enough data to transition it to a CPT 1 category. Then the CPT Category 1 is open for assessment as a new technology. It is also triggered by reassessment of evaluation of a new technology. By definition, when a new technology appears, three years later, the RUC is asked to re-evaluate and re-value whether or not the original technology is still worth the assessment that was originally made. And it in part depends on what the original projected volumes may have been. And that can sometimes be a challenge, because if we do not carefully project what the volumes may be based on the existing number of cases that are being undertaken and procedures, then it may trigger a tremendous concern on the part of especially CMS. Procedures that are simultaneously submitted more than 75% of the time is another trigger that may come up to require a RUC valuation. And in particular, what these types of scenarios engender are bundling. So that was one of the issues that we also faced as far as ablation is concerned, because it was clear that early on when the ablation codes were given, many of these were independent. And the original crafters of the CPT codes for ablation at that time, and you've got one of them here, Ahmed, in particular for SVT, it was the case that not all the cases were using three-dimensional mapping. And therefore, very importantly, the 3D mapping code was left as a separate entity. It became clear more recently than more than 75% of the time with enhancements of three-dimensional mapping, and the importance recognized associated with that, particularly at getting at more complex SVTs, that these were being done more than 75% of the time. And this is one of the reasons that the ablation codes were asked to be revalued and re-bundled in particular. And as already indicated, if a procedure is used with significant value, more than projected unequivocally, that will trigger another valuation. Next, please. So here's an example of a RUC survey invitation. And this, you see, is dear Dr. Schoenfeld, and you have been selected to participate in an AMA Specialty Society RUC survey. And all of you will invariably be requested to respond to this. It has already been alluded to that in order to have a presence in the CPT and RUC process, and in particular through the AMA vehicle, that you have to have a certain percentage of membership in the society that will allow for that representation. This is why it is important to emphasize that everybody in HRS should be a member of the American Medical Association, because without that, if we don't have a certain percentage of our members being associated with the AMA, then we will not have a seat at the table. And as is often said, if you are not at the table, then you may well be the meal. And I guess that was the reason behind this clever title of this seminar and webinar. So when you get these surveys, it is important that you respond to it. Yes, there is some tedium associated with it, but it actually is actually somewhat interesting in that it makes you reassess what it is that we do. And it is important as well because there are a certain number of responses that are required in order to make this a robust survey that is subject for discussion at the RUC. Next. The survey asks you in particular to compare the time, the complexity, and the work to perform the survey procedures to an existing procedure. And you are provided with a possible set of references for comparison purposes, hence relative value. Next. And the RUC oversees the survey process of COAS and then recommends its physician work and practice expense values to CMS. There are three meetings a year to parallel those of the CPT. And the society's responsibilities are to coordinate the process for their respective professions and to distribute the work surveys so as to obtain work and practice expense data and then submit the survey results to the AMA RUC organization. Next. So going into the three components that are evaluated is the physician work component, and that accounts for more than half of the total relative value for each service. And the things that it takes into consideration are the time it takes to perform the service, both intra-service as well as pre-service as well as post-service, as well as the technical skill and physical effort, the required mental effort, and the judgment and stress due to the potential risk to the patient. And invariably, and I need not convince you of that, our patients are not healthy. I remember an anesthesiologist years ago when I was putting in one of the first defibrillators, and he said to me, Mark, these guys are sick. So I said to him, we don't put these devices into healthy people. So that goes into the evaluation as well. The physician work relative values are updated each year to account for changes in medical practice. And CMS, as already mentioned, must review the whole scale at least every five years. But fortuitously and fortunately, we did slip under the radar as far as the ablation goes. Very importantly, there's the practice expense component. And this accounts for under 50%, but is extremely important. And there is a whole day at the RUC spent on looking at the individual components, line-by-line items that are meticulously, tediously, and laboriously evaluated in terms of what it costs from the practice standpoint. And there are formulas that go into this. There is a specific subcommittee of the RUC that looks at the practice expenses, and that goes into the equation. And then finally, a very small proportion goes into the professional liability insurance component based on an estimate of the relative risk associated with each CPT code. Next. So the physician work, in particular, the most important thing that you're familiar with, is the time it takes you to perform the service. And again, that's both pre, intra, and post. The mental effort and judgment, as already mentioned, but again, by point of emphasis, the range of possible decisions, the number of factors considered in making a decision, and the degree of complexity of the interaction of these factors. And in particular, the technical skill with respect to knowledge, training, and actual experience necessary to perform the service. Next. Again, psychological stress. I'm having psychological stress just thinking about this whole process. But every time we go into the room and into the lab, there's unequivocally psychological stress. These are not healthy people. And there are two kinds of psychological stress. Firstly, is the pressure involved when the outcome is heavily dependent upon skill and judgment, and an adverse outcome has serious consequences. Over the years, HRS, in conjunction with ACC, has impressed upon the RUC the kind of stress that we are under. And I should mention in passing that we are very fortunate in having developed over the years a good deal of credibility at the RUC because we say it as it is. And when we say this requires a lot of stress, we've gotten the message home. The second is related to unpleasant conditions conducted with the work that are not affected by skill or judgment. And this is with high rates of mortality that are potential or morbidity that are independent of the physician's skill or judgment, dealing with difficult patients or families, physician physical discomfort, such as the lengthy nature of our procedures when we're upright all the time, and we can't take breaks the way the anesthesiologists often do, with all due respect. And the first type of work, however, is the only form of stress accepted, however, as an aspect of work, I should mention, despite the second's presence. Next. So as mentioned, there's the pre-service component and that relates to review of records, discussion with other physicians or the clinical staff, the intra-service period, which begins at the onset of examination and after the examination is interpreted, as well as for the procedure itself. These activities can include performing the procedure, communications with the clinical staff, performing the examination or procedure, review of images, and only the time spent during the procedure should be considered, and time spent by other individuals, whether it be technology, clinical staff, is not included. Afterwards, the post-service period is comprised of signing off on the report for the medical record, discussions with the patient, referring physicians as required. Next. So, as I already mentioned, there's a certain number of surveys that are mandated by the RUC in order to be considered robust. There's a high bar for the methodology standards to ensure that it's really reliable. The RUC requires a minimum number, and it really relates to the number of times in the CMS population that the services are provided. For patients who have certain procedures undertaken, if they're more than 1 million times per year, at least 75 physicians must respond to a survey. For services performed between 100,000 and just under a million times, at least 50 physicians must complete the survey. For services performed fewer than 100,000 times annually, at least 30 physicians must complete the survey. To give you some perspective, I think that there must be, at this point, close to about 5,000 or so. Fred, perhaps, can address that precisely, how many people in terms of the EP realm that may be candidates, maybe a little bit less in the United States, to respond to these. But back in 2012, when the RUC was evaluating the ablation codes, we had 79 to 82 respondents for the survey, which at that time was remarkable. So that the surveys that we had for the ablation codes was extremely robust. That also enhanced our credibility. We typically get a good response rate where it is so important. Next. And how are physician fee-for-service payment rates then determined? The CMS determines the physician payment rates for the Medicare Physician Fee Schedule based on total RVUs, a geographic practice cost index, and a conversion factor, and you see that equation on the bottom. Next. And then there is the editorial process, as mentioned, from the CPT and the RUC process, whereas the CMS, whereby the CMS accepts the RUC RVUs, Medicare Physician Fee Schedule is ultimately generated. Next. So there are problems with the current RUC Guided Reimbursement. With new technologies and new codes, revaluation of older codes is inescapable, such as with the subcutaneous defibrillator, and with trends generally going towards devaluation. This is quite a challenge because it impacts upon the decision as to whether or not to introduce new CPT codes. While intellectually it may be something that is thought to be quite useful, if it is in fact quite close to already existing family of codes, unequivocally, that will likely cause the RUC to revalue the entire family of codes. And if in fact previous codes were thought to be acceptable, invariably the RUC's valuation of the previous family of codes tends downward. I cannot think of a recent or for that matter, a remote example where a family of codes was revalued in an upward direction. So every time there was a new CPT code that is well-intended to add to an existing family of codes, there is the risk of having devaluation of the existing codes. RUC in the past has come under attack as a non-transparent self-serving old boys club. And to a certain extent, there may have been a good deal of accuracy on that. There was a lot of discussion in the newspapers about this. I think it has actually been quite transparent of late. Increasingly, as I already indicated, CMS has not been heeding the RUC recommendations as often. That makes our role even more important. And there is a pressure towards increasingly pay for performance. Next. So with those thoughts in mind, it essentially gets us to where we are now, where the patient is saying to the doctor, don't hold anything back, doc. How much will Medicare pay? And I think I'll stop at this point and let you all take a stand. Mark, that was really just an outstanding discussion going from CPT, from procedures and things that we do or deliver to finally then where that goes to payment. A couple of questions that come up that I'd like to ask the panel. So Chris, I'll start with you. You talked about Cat I versus Category III or T codes. What's the pro and the con, for example, of having a Category III code? Why bother? As Mark is suggesting, maybe we have to keep our codes to a minimum. Yeah, Fred, this is such an important question. And the answer lies in the fact that we want medicine to advance. And the entire history of medicine and medical care, and in fact, what electrophysiology has been built on in the last 20 years is the idea of innovation. This is the reason for the existence of CPT codes and what CPT coding allows for is innovation. So just starting from Mark's last point, which is that procedures that are revalued almost always cause the values to go down. And we have to understand this from the perspective of CMS and the other payers. If we are paying the exact same amount for procedures now that we were paying 10 or 20 years ago, then there will never be a mechanism to pay for new technologies and new treatments and new procedures. Because unless the budget for physician payment goes up, and budget neutrality was another hot topic that we are advocating against for physician payment, but because of budget neutrality, unless there is more money in the pot, if we continue to pay the same amount for the procedures that are done and more procedures are being done, then there will never be a mechanism for new technologies to be paid for. And so category three codes allow new experimental procedures to be tracked. So these procedures, again, are procedures that are under IRB investigation, that are being evaluated. And so it's incredibly important to understand how many of these procedures are being done, where they are being done, and so that the performance and the outcomes from these procedures can be tracked and a determination can subsequently be made with regard to whether these procedures should become standard of care procedures that are then classified as category one codes that are then coded and reimbursed in a standard fashion. So for example, one of the current category three codes refers to the YCRT system. This is that innovative ultrasound-based pacing device that is implanted in the left ventricular endocardial cavity that is then synchronized to an ICD device to allow biventricular resynchronization pacing in people who are non-responders to standard CRT. So currently there are category three codes that are tracking this procedure that is currently being evaluated in a clinical trial. If this trial ultimately leads to FDA approval, then this procedure could then become a category one procedure that becomes standard of care procedure. Super. I mean, it really goes to the point that innovative field in electrophysiology, we've been blessed by having new technology, and obviously it's continuing to go forward. Amit, the next question I have is for you. You know, you've really illustrated the importance of professional society involvement in sort of the CPT code sort of development, and obviously you've also had some, you know, work and rock and thinking about our views. Tell me sort of what do you see with regards to the future, right? I mean, you've had this incredible history of how the professional societies have really impacted sort of care and delivery of care and access. What do you foresee for the future? Because, you know, all of us think, oh, my God, it's the government. You know, we can't do anything, et cetera. What is the professional society role sort of going forward in this role, ensuring access in this process of CPT and RUC? And I'm looking forward to your thoughts. You know, Fred, that's a great question. It is becoming increasingly more of a challenge and, you know, looking at it from Medicare's perspective, that, you know, the focus is on budget neutrality, which is fine, but when, you know, there's a lot of specialties that are coming up with new codes, new procedures. And then, of course, with the recent public health emergency, we've seen, you know, the advent of virtual visits with tele-visits and video visits, and, you know, E&M codes are going to also cause the budget to balloon. So Medicare is really in this difficult position of how do you maintain budget neutrality with, you know, skyrocketing utilization for these E&M codes, and then still try to maintain reasonable valuations for the procedural codes that already exist? I don't know where this is going to go, I really don't. I do know that it's very important that we continue, as Mark alluded to, to be at the table, or we're going to be on the menu, and advocate for our specialty, because there is one pot, and at the RUC, you'll see, you know, we're all physicians in the House of Medicine, but we're all fighting for that same pot of money, if that's the term you want to use, for reimbursement. And I think the paradigm that we saw maybe 20, 10, 20, 30 years ago might be changing in terms of how, you know, payments adjudicated, and I think Mark alluded to that with pay for performance, and that might also be part of the reason why we're seeing that Medicare is not always toying the line with RUC recommendations, and we might start seeing increasingly more of that. So I think from HRS's perspective, and we've had discussions about this, in addition to really advocating at the table, at the CPT and the RUC, which is not going away anytime soon, we have to be there, because if we're not, we're gonna lose out. Coming up with additional strategies, as we're all discussing right now in terms of legislative advocacy, advocacy on the level of working with Medicare to ensure that they're aware of the value that we bring to our critically ill patients in the context of expanding indications, particularly with AF ablation. So I think it's gonna have to be a multi-pronged approach that we take, a little bit more of a global approach, because the rules are changing. The rules are changing, and whether it's software as a medical device, AI, I just saw today that the FDA approved 500 AI applications for some radiology diagnostic procedures. Well, that money has to come from somewhere. So, I think having a strong presence in advocacy for our colleagues in electrophysiology and having a multi-pronged approach is gonna be very, very important. Amit, that's a really great, and yours and Chris's comments really dovetail into each other, right? It's how do you sort of spur innovation to have sort of new ways to then help patients, but then also to sort of what's new and just shiny, even what's new and really practical, and then how do you discern between those? And then ultimately, I mean, it really is, how do we provide access to these technologies, to these procedures, things like that, to our patients so that we can provide best care? I'll leave the last question to you, Mark, as you alluded to. You know, we're thinking, and Amit just spoke about it now, you know, we're going away from paying for things. Whether it be a visit or a procedure or whatever the case may be, to thinking about sort of general health of a population or of a group of people. Do you think the CPT and RVU codes, which have been sort of developed within this sort of technologica space, how are they going to be able to account, you know, for this important notion of taking care of a patient holistically? Do you think it's something that is doable or just requires some changes and some minor modifications or really, I'll leave it to you, do we just have to sort of do something that involves a whole paradigm shift? Well, I suspect ultimately to do that, which the payers are requesting along the lines of pay for performance, it would be a major paradigm shift. I don't see that happening, as Amit already indicated, anytime soon. The CPT and RUC process has been around for a long time, as was already indicated, transitioning way back from HICPHA to CMS. So it's been around for decades. And I can still remember when I was on the CPT side of things, when HICPHA in those days was actually much more interested in clearly doing the right thing. And the people on the HICPHA panel said, you know, we hear that there's this new thing coming along called the transvenous defibrillator. Don't you guys think that we should introduce a code for that? And I was blown away because the whole concept of the regulators actually making something of a positive suggestion was remarkable to me. And shortly thereafter, the transvenous defibrillator was introduced as a code. In those days, I think that there was a lot more working together and less of this divisiveness. And the whole concept that's already been alluded to with regard to budget neutrality, the desire to, well, the need to achieve some agreement recognizing there is a limited pot. And that is unfortunately something that we have to contend with, recognizing the economic stat of things, inflationary interests and the like. So paying for performance, recognizing that whole paradigm shift that we required would be a major undertaking. And again, I think that this, I think it would be what Churchill once said about democracy. It's a terrible form of government, but the best we have. Right now, frankly, it's probably the only one we have. I don't see the shift occurring anywhere soon. And while we are stuck in this platform, if you will, of doing things as they are, we just have to recognize the nuances, the need of working together within the society, working with other societies collusively. And again, to their credit, we've worked very closely with ACC, probably the closest within the two organizations compared to any other front. But the membership needs to know that this process has their backs and has had a longstanding support for the membership. There are other ways of getting that type of support that were quite evident during the recent challenges to the ablation codes. And that entailed getting lobbying efforts, going to Congress and the like. And there was some benefit to be had from that. And there were a lot of grassroots efforts. But I think when it all came to the recognition that the RUC process and the CPT process was the only process that was legitimately recognized, that it was not about to change, you still had to go through that if you wanted to have anything undertaken. And again, this paradigm may shift eventually, but for now, it doesn't seem like it is going to. And rest assured, there are other time-honored codes that await to be reevaluated. Most notably, I would say the device codes. Don't tell anybody outside of this webinar unless they get the idea. And so if there is a survey that comes out, I would ask all the members of HRS, if you get this letter, respond and think very carefully of all the time and effort that is undertaken to undertake these various procedures. And there are new technologies on the horizon, but also recognize that the challenges that are posed when new technologies arise are potentially a revaluation of related families opposed, and therein lies the challenge. Thank you, Mark. And as I close, a couple of things I want to comment on that have been emphasized by our speakers and throughout this panel discussion. One is that I think that all within the House of Medicine clearly recognize that each of us has things that we contribute to take care of patients, and that it really is that working together that is vital. And in partnership with industry, thinking about new technology, with our government, even though the government often is looked upon as sort of the big bad wolf and oftentimes has issues, they're nonetheless this close relationship. But the General Accounting Office looked at this process back in 2015 and really emphasized a couple of things that I think that we need to close on. Number one, that the process really needs to be transparent. And that's all processes, whether it be when we think about what the professional society does, what the RUC does, how the CPTs are developed, how CMS then decides or makes decisions based on that so that there is an open process. The second is that the GAO also commented on the fact that in many of these surveys are unanswered. And it is in fact, although this has clearly gotten better over the years, there are a number of technologies and therapies where the number of surveys have been relatively low. And as Mark just emphasized, it is really critical not to overstate sort of what we do and et cetera, but to be really honest with regards to the amount of time that it takes to do a procedure and to pay attention to these surveys. Because we all are in this together really to improve our patient's care. And with that, I want to thank the panelists and the speakers. Boy, this was just a tremendous hour and change. I really appreciate that. And Mike, I'll turn it back to you. Thank you, Fred. That was truly masterful. I can't think of a better qualified panel. You made a difficult, overwhelming topic for neophytes like me, understandable. It sounds like we need to take our surveys and do our part. And I want to remind our members that you can claim credit for this webinar tonight by following these instructions on the slide. Thank you for joining us for the beat number five.

The Beat

CPT codes

Revaluing Under Relative Value Units

medical procedures

reimbursement purposes

CPT editorial panel

physician involvement

RVU system

physician work

practice expense

professional liability insurance