Login to Access Video or Poster Abstract: MP32-01
Sources of Funding: Emory Urology Research Scholars Grant; Winship Cancer Institute Prostate Cancer Pilot Grant

Introduction

Since the United States Preventative Services Task Force recommended against routine prostate-specific antigen screening in 2012, the incidence of prostate biopsies has dropped substantially. In addition, Medicare decreased reimbursement for ultrasound-guidance for biopsies (Common Procedural Terminology (CPT) code 76942) in 2014. In that context, we examined how Medicare reimbursement for ultrasound-guided prostate biopsies allocated to physicians and ambulatory surgery centers (ASC) changed from 2012 through 2014.

Methods

Using publically available Medicare Provider Utilization and Payment Data (2012-2014), we assessed use of and Medicare payments for transrectal ultrasound-guided prostate biopsy (i.e., CPT codes 55700, 76842, 76972) for men with fee-for-service Medicare Part B coverage. We report average and total payments for (a) providers and (b) ASCs and trends from 2012 through 2014.

Results

From 2012-2014, we identified 359,698 biopsies performed for men with Part B fee-for-service Medicare coverage. Medicare expenditures were $134.5 million ($111.4 million to physicians, 82.8%; $23.1 million to ASCs, 17.2%). Between 2012 and 2014, Medicare payments for prostate biopsies declined by $20.3 million for physicians and only $0.4 million for ASCs. The decline in payments to physicians was due to a 20.4% decline in volume combined with a decline in the median reimbursement per procedure ($405 in 2012 to $273 in 2014, p<0.001). The slight decline in payments to ASCs reflected a 7.6% decline in volume that was offset by significant increases in median payments over time ($451 in 2012 to $463 in 2014, p=0.01). Overall, the share of biopsies performed at ASCs increased from 13.5% to 15.3%, and the overall proportion of payments to ASCs increased from 14.6% to 22.4% over that same time span (Figure).

Conclusions

Policy changes related to prostate cancer screening and procedure-based Medicare reimbursement resulted in drastic decreases in reimbursement for prostate biopsies performed by providers, but not ASCs. These policies may have unintended consequences of diverting typically office-based procedures to more-costly ASCs.

Funding

Emory Urology Research Scholars Grant; Winship Cancer Institute Prostate Cancer Pilot Grant