The Centers for Medicare and Medicaid Services (CMS) altered its earlier proposed work relative value units (RVUs) for electrophysiology (EP) ablation services as part of the 2023 Medicare Physician Fee Schedule (MPFS) Final Rule. CMS will implement RVUs recommended by the AMA Relative Value Scale Update Committee (RUC) that are higher than the earlier proposal for SVT, VT, and AF ablation. These values are still lower, overall, than the 2022 work RVUs. RVUs for additional ablations services are unchanged from 2022 or the proposed rule.

"While the changes CMS made in response to feedback from the ACC, Heart Rhythm Society (HRS), members of Congress, and other stakeholders are appreciated, ACC and HRS remain disappointed that the agency did not go further in amending the proposed cuts for key EP ablation services to reflect higher values derived within the established RUC survey process, recognizing the high degree of skill and lengthy period of training required to perform these complex services, the enhanced safety despite increasingly sick patients, improved quality outcomes, and greater clinical value," said ACC President Edward T.A. Fry, MD, FACC, and HRS President Andrew Krahn, MD, FHRS, in a joint statement. "These ongoing cuts, as well as structural cuts to all Medicare services, continue to threaten patient access to important, high value cardiovascular services and underscore the need for not just short-term fixes, but long-term overarching reimbursement reform."

By adopting the RUC recommendations for the main ablation services, the RVUs for this family of codes will be 11.2% higher than proposed and 3.7% lower than 2022 as shown in the following table:

Ablation Codes RUC RVU Recommendations vs. CMS Proposed and Final Work RVUs

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

This decision 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 MPFS 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 all medical specialties to address these statutory shortcomings to the Medicare payment system before these broad cuts take effect next year.

History of Coding Changes and Payment Proposals

Prior to the proposed 2022 MPFS 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 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 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 proposed 2023 MPFS 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	15.00
VT, 3D mapping, LA pacing	93654	309	19.75	93654	336	19.75	93654	291	18.10
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	17.00
Additional AF	93657	90	7.50	93657	60	5.50	93657	60	5.50

*= 2023 CMS Final values.

With the 2023 final rule posted, the ACC will work with HRS and others to ensure members and patients understand this decision and the impacts it will have on patient care.

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

Keywords: Relative Value Scales, Centers for Medicare and Medicaid Services, U.S., Feedback, Fee Schedules, Physicians, Medicine, Electrophysiology, Patient Care, Medicare Part B, ACC Advocacy

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