House Votes to Delay SGR Cuts

This afternoon, the House passed a 2-month extension of expiring appropriations for the Department of Defense that included a 2-month extension of the sustainable growth rate (SGR). In other words, the legislation would stop the 21.2% Medicare pay cut scheduled take effect on January 1 for a period that will end March 1, 2010. The legislation does not affect any of the other payment policies included in the final 2010 fee schedule rule; those will take effect on schedule.

A cloture motion on the DoD extension bill was filed in the Senate today. Votes on cloture and passage should be completed this weekend.

AMA Morning Rounds: Early data for ALS drug candidate shows improved muscle function

The AP (12/10) reports, "Sangamo Biosciences Inc. said Wednesday that early data from a clinical trial shows its Lou Gehrig's disease drug candidate," SB-509, "improved patients' muscle function." Patients injected with the drug "were about twice as likely to have improved muscular function," according to Sangamo. Specifically, "32 percent of patients who received SB-509 had improved muscle function, compared to 17 percent of patients who took standard treatments." The company "is also testing SB-509 as a treatment for diabetic neuropathy."

HIPAA 5010 Resources for January 2012

Are you preparing for the compliance deadlines for the Health Insurance Portability and Accountability Act (HIPAA) 5010 standard transactions, the next version of HIPAA? Beginning Jan. 1, 2012, physicians will be required to use only the 5010 standard transactions when conducting them electronically. The AMA has prepared several educational resources to assist physicians with implementing the 5010 standard transactions.

AMA Morning Rounds: Findings shed light on essential tremor

In the New York Times (12/8, D7) Personal Health column, Jane Brody writes, "Recent studies have begun to unravel the mysteries of essential tremor," a condition characterized by "uncontrollable shaking...that is not due to some other condition." According to Dr. Elan D. Louis, of Columbia University, the progress is marked by "discoveries in three areas -- the brain, clinical findings, and genetics and environment." Researchers have "analyzed and compared...the brains of normal individuals" to those of patients with essential tremor, finding that "this is probably a family of diseases." Abnormal findings include "degenerative changes in the cerebellum," and "a messy arrangement of neurofilaments." Meanwhile, "two environmental toxins have been found to be elevated in tremor patients: lead and a dietary chemical called harmane that occurs naturally in plants and animals."

AMA Morning Rounds: FDA lifts clinical hold on CytRx Lou Gehrig's treatment

The AP (12/2) reported that the FDA "lifted a nearly two-year suspension on development of" CytRx Corp.'s "arimoclomol as a treatment for Lou Gehrig's disease." The agency "halted arimoclomol studies" in January 2008, "citing the need for additional analysis from previously completed animal studies with arimoclomol."

Reuters (12/2) reported that the FDA accepted CytRx's revised trial protocol to review the safety and efficacy of the experimental drug at four times the dose previously studied. The FDA has granted the drug a fast-track review and orphan drug status to treat Lou Gehrig's disease.

Texas Judge Rules EMG, MUA are Beyond Scope of Chiropractors

In a November 24th ruling, Austin State District Judge Stephen Yelenosky said state law prevents chiropractors from performing clinical needle electromyography (EMG) or spinal manipulation under anesthesia (MUA). Yelenosky granted a Texas Medical Association and Texas Medical Board request for a partial summary judgment against the Texas Board of Chiropractic Examiners and the Texas Chiropractic Association.

"Judge Yelenosky ruled that chiropractors cannot perform needle EMGs or manipulation under anesthesia because both of those procedures are beyond the chiropractors' lawful scope of practice," said Austin attorney David F. Bragg, one of the lawyers for TMA. The chiropractors are expected to appeal the ruling, he said.

TMA sued in 2006 to block the chiropractic board's rules that would permit chiropractors to perform clinical needle EMG and MUA, because both procedures constitute the clinical and legal practice of medicine. View the full press release at the TMA website.

Chemodenervation Units: 64614

I was contacted last week by a member who was denied payment by Medicare for 2 units of 64614 (Chemodenervation of muscle(s); extremity(s) and/or trunk muscle(s) {eg, for dystonia, cerebral palsy, multiple sclerosis}) of the right arm and right leg on the same visit. He has received payment in the past for billing 2 units of service in this circumstance. The member believed that policy existed supporting side of the body application for this code. 

I have not located any information supporting a hemisphere concept for this code.  In fact, it’s just the opposite.  By defining the code use for “extremity(s) and/or trunk muscle(s),” the code language indicates that everything--whether 1 extremity or multiple extremities--is covered in 1 unit.  Additionally, a CPT Assistant Q&A from February 2005 touched on this topic. 

Q: Would it be appropriate to append modifier 50, Bilateral procedure, to CPT code 64614, Chemodenervation of muscle(s); extremity(s) and/or trunk muscle(s) (eg, for dystonia, cerebral palsy, multiple sclerosis), if both extremities are treated at the same session?

AMA Comment: From a CPT coding perspective, modifier 50 should not be appended to CPT code 64614 because the language of the code descriptor allows for chemodenervation of muscles of single or multiple extremities, as well as muscles of the trunk, if performed. This code should be reported only one time for chemondenervation of any of these areas within a single session.

Some payors may incorrectly pay for bilateral injection reported with modifier 50. Others may incorrectly pay for 2 units of 64614. However, the correct way to bill this service is to report 1 unit of 64614 for any/all extremities and/or muscles of the trunk.

House Repeals SGR

The AMA Bulletin below provides a good summary of the bill and House actions that led to passage.

By a vote of 243-183 today, the U.S. House of Representatives passed H.R. 3961, a bill that repeals the current Medicare physician payment formula, known as the sustainable growth rate (SGR), and replaces it with a new framework. Michael Burgess, MD, (R-Texas), a former AMA alternate delegate was the sole Republican to vote for final passage.

This legislation would replace the SGR with a new formula that creates two updates: GDP +2 for Evaluation and Management services and GDP + 1 for other services. Additional technical changes will avoid the accumulation or compounding of debt that occurred with the SGR formula.

House Speaker Nancy Pelosi (D-Calif.), House Majority Leader Steny Hoyer (D-Md.), House Committee on Ways and Means Chairman Charles Rangel (D-N.Y.), House Ways and Means Health Subcommittee Chairman Pete Stark (D-Calif.), House Committee on Energy and Commerce Chairman Henry Waxman (D-Calif.), Rep. Frank Pallone (D-N.J.), the bill's sponsor Rep. John Dingell (D-Mich.), and the Obama Administration were strong advocates for passage of H.R. 3961.

House Republican leadership offered a last-minute alternative that would have provided for 2 percent updates over the next four years, reverting back to the SGR and steep cuts. Also, it would have offset the cost with medical liability reforms modeled after California and Texas laws. The AMA opposed the motion to recommit because we do not support any temporary "patches" for the SGR. A permanent repeal is long overdue. The motion to recommit with medical liability reform provisions was ruled non-germane. A second GOP alternative providing for a two-year "patch" was defeated by a vote of 177-253.

The battle now shifts back to the Senate. While action to permanently repeal the SGR was blocked in the Senate last month, the Obama Administration and several senators support a permanent replacement of the SGR formula. The health system reform bill released by Senate Majority Leader Harry Reid (D-Nev.) provides for a one-year reprieve with a steeper cut in 2011. The AMA does not support temporary patches that further grow the problem.

No one expects Congress to allow the 21 percent cut scheduled for Jan. 1 to occur. We regret that Congress has deferred action until the "eleventh hour." The AMA will redouble our efforts in the Senate and with the Obama Administration to achieve a permanent solution.