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 Coding Corner January 2012



By Daniel Nagle, MD
 
Dupuytren's Disease Coding and Reimbursement
 
Dupuytren's contracture can be treated several different ways, depending on the extent of the disease, patient preference, and patient co-morbidities. For 2012, there are two new CPT codes (20527 and 26341) to report treatment of Dupuytren's contracture by injection of an enzyme and follow-up manipulation to disrupt the palmar fascial cord.
 
The table below provides a perspective on the Medicare physician payment for treating this disease. Dupuytren's treatment codes are listed in columns A and B and the Medicare fee schedule global period and total RVUs in columns C and D. CMS uses total physician time (column E) as one of the factors to assign total RVUs. Total time includes pre-op time, procedure time, and post-op time, including time for office visits if the code has a 10 or 90-day global period. For some codes, total physician time is still based on the Harvard study conducted in the late 1980's. For other codes, the time is based on RUC surveys. 
 
Using total physician time, Medicare payment, and a physician's practice expense per hour data, you can calculate whether you would make a profit or loss for each service that you perform. Columns H and I show this information for these Dupuytren's treatment codes based on current Medicare payment rates against average practice expense per hour data for either a hand surgeon's practice or a general orthopaedic surgeon's practice. As you can see, unless your total time for patient care for each procedure is less than shown in column E, most of the work you do to treat these Medicare patients is at a loss.
 
A
B
C
D
E
F
G
H
I
CPT
Procedure
Global
Period
Total
RVU
CMS
Total
Time
Medicare
Payment1
Medicare
Payment
Per Hour
Hand
Surgeon
Profit
Loss2
Per Hr
General
Ortho
Profit
Loss3
Per Hr
20550
Injection(s); single tendon sheath, or ligament, aponeurosis
000
1.68
20
$57.18
$171.55
-$21.53
$8.61
20527
Injection, enzyme, palmar fascial cord
000
2.23
18
$75.90
$253.01
$59.93
$90.07
26341
Manipulation, palmar fascial cord, post enzyme injection, single cord
010
2.90
52
$98.71
$113.90
-$79.18
-$49.04
26040
Fasciotomy, palmar; percutaneous
090
9.08
135
$309.06
$137.36
-$55.72
-$25.58
26045
Fasciotomy, palmar; open, partial
090
13.66
207
$464.95
$134.77
-$58.31
-$28.17
26121
Fasciectomy, palm only
090
17.51
200
$596.00
$178.80
-$14.28
$15.86
26123
Fasciectomy, partial palmar with release of single digit including proximal interphalangeal joint
090
24.38
308
$829.84
$161.66
-$31.42
-$1.28
26125
Fasciectomy, partial palmar with release of single digit including proximal IP joint; each add'l digit
ZZZ
8.13
161
$276.73
$103.13
-$89.95
-$59.81
99212
Level 2 Office visit, estab pt
XXX
1.25
16
$42.55
$159.55
-$33.53
-$3.39
99213
Level 3 Office visit, estab pt
XXX
2.07
23
$70.46
$183.80
-$9.28
$20.86
 1 Based on Medicare conversion rate of $34.0376 that has been extended through Feb 29, 2012. 
 2 Average hand surgeon practice expense per hour of $193.08 based on AMA 2007 Physician Practice Information Survey. 
 3 Average orthopaedic surgeon practice expense per hour of $162.94 based on AMA 2007 Physician Practice Information Survey.
 
When reviewing insurance contracts, surgeons should always consider the payment per hour for the procedures that you perform most often and compare that against your own practice per hour data. If you do not perform this calculation and comparison, your bottom line at the end of the year may be negative like the reimbursement for most of the codes in the table above.
 
Dermofasciectomy
 
Dermofasciectomy is an infrequently performed procedure reserved for severe cases of Dupuytren’s disease in younger patients and in patients with severe recurrent disease. This procedure includes excision of the diseased fascia and associated skin (usually including the majority of the surface of the finger extending into the palm) and the harvesting and insetting of a full thickness skin graft taken from the groin. No code currently exists to describe this procedure, so it should be reported with 26989 Unlisted procedure, hand or fingers. CPT code 26123 Fasciectomy, partial palmar with release of single digit including proximal interphalangeal joint has a CMS intra-service time of 120 minutes, includes fasciectomy and skin grafting, and includes the harvesting and insetting of skin grafts. Code 26123 does not include the excision of the digital and palmar skin and does not capture the increased work associated with this significant undertaking (both intra and postoperative work). When reporting 26989, the surgeon can estimate the value of a dermofasciectomy by comparing its intra-service and post-service time, complexity, and intensity to that of a procedure(s) with similar intraoperative and postoperative work.
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