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 Coding Corner April 2006

Daniel Nagle, MD
By Daniel J. Nagle, MD
Chair, ASSH Coding and Physician Reimbursement Committee

Distal Radius Fracture Codes

The ASSH Coding and Reimbursement Committee has been working on the creation of new codes to describe the operative treatment of distal radius fractures since 2004. This process was rolled into the Committee’s preparation for the 2005 Five Year Review1.  The initial steps in this process included a preliminary survey of our members to help define how many codes were needed. This survey included 24 proposed codes describing the use of pins, screws, plates and combinations of these. The number of incisions made, the complexity of the fracture and whether the fracture was intra-articular or extra-articular were considered. The survey data led to the following conclusion:

A. There is a significant difference between fixing a fracture with wires/screws and fixing a fracture with a plate.
B. There is little difference between the intraoperative time needed to fix a fracture with a plate alone or a plate combined with pins/screws.
C. There is more work involved if more than one incision is needed.
D. The more fracture fragments fixed the more work involved.
E. The “typical” case is not the simple case but rather the more complex cases.

Since the creation of new distal radius fracture codes would impact not only hand surgeons but also general orthopaedic and plastic surgeons performing upper extremity surgery, we asked for input from these specialties.  The AAOS Coding, Coverage and Reimbursement Committee (CCRC) was concerned that the ASSH proposal was too “granular” and that it did not follow the coding conventions established for fractures. It was pointed out that the AMA CPT Editorial Panel has frowned on the addition of new codes simply based on the number of incisions needed (even though we demonstrated that more incisions imply more physician work) or on the number of fracture fragments (even though we also demonstrated that the more complex fractures require more physician work). The recommendations of the AAOS CCRC were taken to heart and with the input of that committee the original 24 codes were pared down to three.

1. ORIF of an extra-articular distal radial fracture
2. ORIF of a simple (two fragments) intra-articular distal radial fracture.
3. ORIF of a complex (three or more fragments) intra-articular distal radial fracture.

While the Five Year Review process is one that deals with RVUs and thus falls within the purview of the AMA RUC (Relative Value Update Committee), because we wished to create new codes to replace 25620, we were obliged to first present our new code proposal to the AMA CPT Editorial Panel. This was done during the AMA CPT Editorial Panel Meeting in Seattle, Washington in November 2005. The AMA CPT Editorial Panel accepted our proposal though it weighed in and “refined” the final nomenclature and made adjustments to the fracture family nomenclature to insure consistency within that family of codes.

Next, the three new codes were subjected to the AMA RUC process.  Almost 200 of our members completed the AMA RUC survey tool - thank you! Our proposed relative values were defended in what could only be termed a hostile environment before the AMA RUC during its February Miami, Florida meeting.  The non-surgical (“cognitive”) specialties and surgical (“non-cognitive”) specialties were still battling the Evaluation & Management (E&M) revaluation war.  (The non-surgical specialties requested significant increases in the E&M RVUs during the Five Year Review.) Needless to say, the non-surgeons were not feeling particularly generous toward their “non-cognitive” colleagues. In spite of this, we were able to pry relatively reasonable relative values out of the RUC for the new codes.  The final relative values will not be known until CMS (Centers for Medicare and Medicaid Services) reviews the AMA RUC values.  The definitive relative values will appear in the 2007 Medicare Fee Schedule which will be published in the Federal Register in November 2006.

The definitive nomenclature (this cannot be released until this fall) and relative values will be published in a Coding Corner this fall. I appreciate the input from the members regarding these codes and particularly your support during the survey process.

More New Codes

The ASSH Coding and Reimbursement Committee, in an effort to keep the CPT nomenclature up to date, has systematically reviewed the CPT nomenclature looking for outdated codes and inconsistencies. In addition it has reviewed ASSH member requests for new codes.   This process led to several recent CPT code change proposals. These changes include adjustment to the nomenclature as it relates to the excision of tendons in the forearm, reconstruction of flexor tendon pulleys, and the relatively new technique of using conduits for nerve repair including vein grafts, allografts, and synthetic conduits. These proposed changes were presented to the AMA CPT Editorial Panel during its February, Puerto Rico meeting. The AMA CPT Editorial Panel accepted our proposed changes.  We immediately started working on our relative value surveys for these new codes.  Many of you have already completed surveys  - thank you - and we are analyzing the data.  We will defend our recommended RVUs during the April AMA RUC Meeting. The code changes will become effective in 2007.

Nerve Wrapping

The ASSH proposal for a creation of new codes describing the work associated with nerve wrapping using vein graft, allograft, or synthetic material was discussed with the CPT Editorial Panel, but due to a lack of what the CPT Editorial Panel considered adequate peer review literature support, this issue was tabled until more scientific data are available to support the creation of such a code.

From a practical point of view, this means that in a case in which vein wrapping is performed, the unlisted procedure code 64999 should be used and an operative report and explanation of the procedure should be included when requesting payment from third party payers. It is helpful when submitting support for an unlisted procedure that similar procedures and their fees be quoted so as to help guide the insurer in their decision regarding reimbursement. For example, to report the vein wrapping of a median nerve at the wrist one could explain that the work is similar to the combined work of the following procedures:

64721 Neuroplasty and/or transposition; median nerve at carpal tunnel

64727 Internal neurolysis, requiring use of operating microscope (List separately in addition to code for neuroplasty) (Neuroplasty includes external neurolysis)

35500 Harvest of upper extremity vein, one segment, for lower extremity or coronary artery bypass procedure (List separately in addition to code for primary procedure.) At least this would capture the work of harvesting the graft but not of the actual wrapping.

These codes and their fees would give the third party payer a good approximation of what work goes into a vein wrapping. (Please note that 64727 and 35500 are add on codes and therefore the multiple procedure rule does not apply.) This methodology is only a suggestion and is an approximation.  Clearly, the work associated with vein wrapping would be best estimated by a survey.

It should be noted that during the CPT Editorial Panel presentation, the Editorial Panel initially considered creating a Category III code for these procedures. A Category III code permits tracking of the code, but does not allow the movement of the code through the RUC process and therefore no relative value would be assigned. While that might have seemed to be a reasonable approach, we were informed that many third party payers consider all Category III codes as being “experimental” and do not reimburse the physician or the facility for the work associated with such procedures. In view of this, we felt it wiser to not pursue this at this time and to withdraw our request so that physicians could still be reimbursed for nerve wrapping using the unlisted procedure code 64999.

Other Coding and Reimbursement Issues

Congress has canceled the proposed 4.4% decrease in the Medicare Fee Schedule that was calculated using the infamous SGR equation.  Senator Johnson of the Ways and Means Committee has suggested that in exchange for this, Pay-For-Performance should become the law of the land before the end of this decade. The issues of Pay-For-Performance and practice guidelines are being carefully looked at by the ASSH Evidence-Based Practice Committee headed by Drs. Michael Keith and Victoria Masear. This is an extremely important issue for all physicians and for medicine in general. Over one hundred insurance companies and other entities are already developing practice guidelines that are essential for the implementation of a Pay-For-Performance program. The Centers for Medicare and Medicaid Services has demanded that specialty societies develop and deliver (at their own expense; sort of like paying for the bullets that will be used for your own execution) practice and performance guidelines. There is no doubt that this effort will have as big an effect on physician and facility reimbursement as did the RBRVS system. Pay-For-Performance is one more effort on the part of insurers and the government to pay less for healthcare, while promoting the perception that by paying less, patient care will improve. That sounds like Orwellian “Newspeak” to me… “War is Peace,” “Freedom is Slavery,” and “Ignorance is Strength.”

Code well.

Dan Nagle

1The Five-Year Review process is a process mandated by Congress during which the relative values of all procedures are reviewed and mis-valued codes’ RVUs adjusted as needed. The Five-Year Review process theoretically, allows the introduction of new codes without having to consider family budget neutrality. That is, new codes created within the context of the Five Year Review do not dilute the Medicare funds available for that family of codes.

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