The Centers for Medicare and Medicaid Services (CMS) is again proposing reduced work relative value units (RVUs) for electrophysiology (EP) ablation services as part of the proposed 2023 Medicare Physician Fee Schedule.

Despite a second physician work survey to address perceived shortcomings in the initial survey that produced notable cuts for 2022, CMS proposes to further reduce the work RVUs below the revised recommendations from the American Medical Association/Specialty Society RVS Update Committee (RUC). On average, CMS reduced the RUC recommendations of this family of codes by 12.9% as shown in the following table.

Ablation Codes RUC RVU Recommendations vs. CMS Proposed Work RVUs

Service	2023 Code(s)	2023 RUC Survey Time	2023 RUC Survey wRVU		2023 Code	2023 CMS Proposed Time	2023 CMS Proposed wRVU
SVT, 3D mapping, LA pacing	93653, 93613, 93621	199	15.00		93563	199	13.80
VT, 3D mapping, LA pacing	93654	291	18.10		93654	291	16.90
Additional SVT/VT	93655	60	7.00		93655	60	5.50
AF, 3D mapping, ICE	93656, 93613, 93662	263	17.00		93656	263	15.80
Additional AF	93657	60	7.00		93657	60	5.50

This proposal represents the continuation of a troubling trend that is compounded by a confluence of conversion factor cuts, statutory cuts on the horizon from sequestration and PAYGO rules, and a 0% payment update that fails to account for significant inflation in practice costs creating long-term financial instability in the Medicare physician payment system. The 2023 PFS makes clear the need to redouble efforts to ensure patient access to Medicare-participating physicians and services is not threatened. ACC will continue working in concert with Heart Rhythm Society (HRS) to reverse reductions to these important services.

History of Coding Changes and Payment Proposals

Prior to the CY 2022 proposed rule, the EP ablation services code descriptors were re-written with several codes being bundled. Due to these changes, the EP Ablation codes were re-surveyed by ACC and the HRS for the RUC in the fall of 2020. Time is a key factor in fee-for-service RVU rate setting. Physician work surveys executed by the ACC and HRS in the fall of 2020 demonstrated notable reductions in procedure times. The reductions in time were significant for the bundled codes. Additional surveys were launched by ACC and HRS in the winter of 2021 to check the accuracy of the first. Those surveys also showed significant reductions in procedure times.

Because additional surveys were underway for the April 2021 RUC meeting to check the accuracy of and resolve any flaws from the initial survey, CMS proposed to maintain the current work RVUs of SVT code 93653 and AF code 93656 for CY 2022. This represented a reduction commensurate with the RVUs for the newly bundled add-on services. The Agency also disagreed with the RUC-recommended values for the two add-on codes, 93655 and 93657, further reducing those.

In the CY 2023 proposed rule, CMS did not accept the RUC recommendations based on the physician surveys presented at the April 2021 RUC meeting. The Agency noted that the reductions in time required for the services found in the surveys were not commensurate with the reductions in RVUs in their view. On average, the survey times for these procedures went down approximately 31%. The recommended RUC RVUs went down by an average of 17.9%. The CMS proposed RVUs are closer to the reduction in time percentage at 29.1%.

While a reduction in time does imply a reduction in work it is not the position of the ACC that this change is a nearly absolute 1 to 1 ratio. As procedure times are reduced the intensity of the work is not necessarily reduced by the same amount and can in fact result in an increase in intensity of the work. This is part of the reason why the RUC-recommended RVUs were not precisely correlated with the reduction in time. The ACC will reiterate this point along with other arguments in our comments and activity opposing these proposed CMS values.

The below table shows the times and RVUs of the ablation codes before the code descriptors were re-written, the times and RVUs currently active in 2022 and the CMS proposed times and RVUs for 2023.

Ablation Coding Format

Service	2021 Code(s)	2021 Time	2021 RVU	2022 Code	2022 Time	2022 RVU	2023 Code*	2023 Time*	2023 RVU*
SVT, 3D mapping, LA pacing	93653, 93613, 93621	359	22.08	93563	239	14.75	93563	199	13.80
VT, 3D mapping, LA pacing	93654	309	19.75	93654	336	19.75	93654	291	16.90
Additional SVT/VT	93655	90	7.50	93655	60	5.50	93655	60	5.50
AF, 3D mapping, ICE	93656, 93613, 93662	424	26.44	93656	306	19.77	93656	263	15.80
Additional AF	93657	90	7.50	93657	60	5.50	93657	60	5.50

The ACC will submit formal comments to CMS on this topic in September and pursue this topic in separate discussions with policy makers. Members can also share their insights or concerns about how reduced work RVUs would impact patients directly to the agency here.

Clinical Topics: Arrhythmias and Clinical EP, Implantable Devices, SCD/Ventricular Arrhythmias, Atrial Fibrillation/Supraventricular Arrhythmias

Keywords: ACC Advocacy, Centers for Medicare and Medicaid Services, U.S., Medicare, American Medical Association, Fee Schedules, Physicians, Electrophysiology, Administrative Personnel

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