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Callaghan BC, Burke JF, Skolarus LE, Jacobson RD, De Lott LB, Kerber KA. Medicare’s Reimbursement Reduction for Nerve Conduction Studies: Effect on Use and Payments. JAMA Intern Med. 2016;176(5):697–699. doi:10.1001/jamainternmed.2016.0162
To decrease health care costs, Medicare sought to identify overvalued Current Procedural Terminology (CPT) codes, including those with rapid volume growth, those submitted multiple times, or those submitted in conjunction with other codes.1 The codes for nerve conduction studies (NCS) met all 3 criteria.2 Electromyography (EMG) should typically be performed with NCS.3 Furthermore, EMG and NCS are part of the core residency training for neurologists and physiatrists but not for other health care professionals (physicians, podiatrists, physical therapists, nurse practitioners, and physician assistants). Medicare implemented a sharp reduction in reimbursement for NCS on January 1, 2013,4 but reimbursement for EMG was not changed. The effect of this policy on providers’ use of services and reimbursement payments for this is unclear.
A retrospective analysis was done between July and December 2015 of Medicare EMG and NCS use and payments to health care professionals for 2012 and 2013 using the Physician and Other Supplier Public Use File. Individual billable services were identified by CPT codes and G-codes. For neurologists, other commonly performed services were also investigated (Table 1).
To determine the number of visits for NCS in 2012, the highest number of visits for CPT codes 95900, 95903, and 95904 was identified. To determine the number of visits for NCS in 2013, the number of unique services for codes 95907 to 95913 was summed. A complete EMG was identified with codes 95860 to 95864 and 95886, and limited EMG with codes 95870 and 95885. Payments were calculated by multiplying the number of services by the average Medicare payment received. Analyses were limited to providers receiving a Medicare payment for any CPT code or G-code in both 2012 and 2013. Sensitivity analyses done with multilevel linear regression to adjust for average Hierarchical Condition Category score, hospital referral region, and percentage of EMG and/or NCS services performed at facilities did not change the inferences used in the analysis. Because this study involved research using publicly available data, it was not considered to be regulated by the University of Michigan Institutional Review Board.
In 2012, a total of 11 336 health care professionals performed EMG and/or NCS, as compared with 9807 in 2013 (Table 2). Decreases in the numbers of NCS performed by neurologists were 47 068 (10.1%); by physiatrists, 25 366 (13.8%); and by other health care professionals, 46 676 (30.7%). The number of EMGs performed by neurologists and physiatrists changed by less than 3% from 2012 to 2013. In contrast, the number of EMGs performed by other health care professionals decreased by 3849 (7.3%). Of the other health care professionals performing EMG and/or NCS in 2012, a total of 41% stopped performing EMG and/or NCS in 2013. The number of nerves per NCS and limbs per EMG study changed by less than 7% for all health care professionals.
Total NCS payments to all health care professionals decreased by 68% ($219 million), from $319 653 039 to $101 108 830, with 22% ($48 million) attributable to a decrease in use. Health care professionals other than neurologists and physiatrists accounted for 47% of the decrease in payments through reductions in the use of NCS, even though they accounted for only 23% ($73 559 201 of $319 653 039) of the total payments for NCS in 2012. Total EMG payments to all health care professionals increased by $0.7 million (1.2%).
For the 11 800 neurologists included in the analysis, little change in the number of other commonly performed services (Table 1) was observed.
The Medicare NCS reimbursement policy implemented on January 1, 2013, was associated with a 15% decrease in NCS use, from 801 217 to 682 107 studies, and with the $219 million decrease cited above in Medicare payments during the subsequent year. Other health care professionals disproportionately decreased their use of NCS relative to its use by neurologists and physiatrists, accounting for most of the savings from its decreased use. The use of EMG by neurologists and physiatrists changed little, whereas a decrease in its use among other health care providers was observed, attributable to a large proportion of these providers who stopped EMG and NCS altogether. The reduction in use of EMG and NCS by other health care professionals may be a positive outcome of the change in the Medicare reimbursement policy because these providers typically lack certification and residency training for EMG and NCS. Because NCS should usually be performed with EMG,3 the reduction in neurologists’ and physiatrists’ use of NCS without a concomitant decline in the use of EMG may reflect a decrease in unnecessary tests. Health care professionals also did not change the study length of NCS despite changing incentives for the number of nerves studied. Furthermore, neurologists did not increase their use of other services to compensate for the loss in NCS-related revenue. Past studies revealed that decreases in Medicare reimbursement did not reduce appropriate testing and treatment, but curtailed inappropriate treatment.5,6 Although our study did not contain information on study appropriateness, the pattern of change in use of EMG and NCS suggests findings similar to those in past studies of Medicare reimbursement with regard to reducing inappropriate, but not appropriate, testing and treatment. Notably, our data cannot address the fairness of current NCS reimbursement. Other limitations of our study include the absence of technical payment information for EMG and NCS provided in a facility.
Corresponding Author: Brian C. Callaghan, MD, MS, University of Michigan and VA Center for Clinical Management Research, 109 Zina Pitcher Pl, 4021 BSRB, Ann Arbor, MI 48104 (email@example.com).
Published Online: March 28, 2016. doi:10.1001/jamainternmed.2016.0162.
Author Contributions: Dr Kerber had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.
Study concept and design: Callaghan, Burke, Skolarus, Kerber.
Acquisition, analysis, or interpretation of data: Callaghan, Jacobson, De Lott, Kerber.
Drafting of the manuscript: Callaghan, Jacobson.
Critical revision of the manuscript for important intellectual content: Callaghan, Burke, Skolarus, Jacobson, De Lott, Kerber.
Statistical analysis: Kerber.
Administrative, technical, or material support: Burke.
Study supervision: Callaghan, De Lott.
Conflict of Interest Disclosures: Dr Callaghan reported receiving research support from Impeto Medical Inc and performing medical consultations for Advance Medical, consults for a grant from the Patient-Centered Outcomes Research Institute, and EMG and NCS as a practicing neurologist. Dr Burke reported receiving compensation from AstraZeneca for his role on the adjudication committee of the SOCRATES trial and honoraria from the AAN for contributing to the Continuum. No other disclosures were reported.
Funding/Support: Dr Callaghan is supported by the Taubman Medical Institute and K23 grant NS079417 from the National Institutes of Health (NIH). Dr Burke is supported by grants K08 NS082597 from the National Institute of Neurological Disorders and Stroke (NINDS) and R01 MD008879 from the National Institute on Minority Health and Health Disparities (NIMHD). Dr Skolarus is supported by grants K23 NS073685 from the NINDS and R01 MD008879 from the NIMHD. Dr Kerber is supported by grants R01DC012760 from the NIH and National Institute on Deafness and Other Communication Disorders and R18HS022258 from the Agency for Healthcare Research and Quality.
Role of the Funder/Sponsor: The funding sources had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.
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