From Daniel J. Nagle, MD
Practice Division Director
High Frequency Code Reviews
The year 2008 was spent defending the relative values of our codes against attempts on the part of the federal government to squeeze more revenue from physicians through “adjustments” of RVUs. The Center for Medicare and Medicaid Services (CMS) has requested that the American Medical Association Relative Value Update Committee (AMA RUC) review those codes that have been identified as having a “significant increase” in frequency during the past year. One such code is 25447, first CMC arthroplasty. Currently we are not certain this code will need to be revalued. I will keep you up-to-date on this issue.
Tumor Codes
The American Society for Surgery of the Hand Coding and Physician Reimbursement Committee (CPRC) has been very active in the creation and valuation of the new soft tissue and bone tumor codes. This has proven to be a very contentious issue within the CPT Editorial Panel as well as in the AMA RUC. The update of these codes has been going on for nearly 15 years. Approximately 92 tumor codes must be valued at the upcoming February 2009 RUC meeting. This process has required input from multiple surgical specialty societies. The American Academy of Orthopedic Surgeons and the American College of Surgeons have spearheaded this process. Through the collaborative efforts of the various surgical specialty society RUC advisors and consultants, relative value recommendations have been crafted that are appropriate across several anatomic regions. Many of the codes that are being reviewed merit an increase in their relative value. Unfortunately, this 15-year odyssey is nearing its end at a time when the federal government is in no mood to increase surgical reimbursement. The Medicare Payment Advisory Commission (MedPAC, an independent Congressional agency established by the Balanced Budget Act of 1997) is of the opinion the RUC has not controlled the increase in Medicare expenditures as well as it should have. The RUC is making it very difficult to increase any relative values as it endeavors to prove to MedPAC it can control costs. I should be able to report back to you by the end of 2009 regarding the relative values of these tumor codes.
ASSH & AAOS Global Services Guidelines
The ASSH CPRC Global Services Subcommittee (John Bednar MD Chair) has been actively working with the American Academy of Orthopedic Surgeons to update and refine the Global Services Guidelines. Each and every hand surgery code has been meticulously reviewed by the members of the ASSH CPRC and edited to render the Global Service Guidelines as accurate as possible. The fruits of the committee’s labor have been shared with the AAOS, and together the ASSH and AAOS will update the AAOS Global Services Guidelines books such that the ASSH and AAOS global services data will be identical. In the past, the discrepancies that existed between these books have caused confusion and payment denials. The changes that have been made will appear in the 2010 ASSH Global Services Guidelines, which should be available at the ASSH annual meeting in September.
ICD-9 & 10
Another coding related publication is the ICD -9 guide maintained by Dr. Marwan Wehbe. Dr. Wehbe has indicated a 2010 edition the Hand Surgery ICD-9 Guide will available for the September 2009 annual meeting.
ICD-10 is scheduled to become the de facto standard for diagnostic coding by 2011. We continue to watch this very closely and will keep you informed as to whether or not that deadline will be met. There is significant pushback regarding the 2011 implementation date by many specialty societies including the AMA, as it is felt the 2011 deadline is unrealistic.
National Correct Coding Initiative (NCCI) & Medically Unlikely Edits (MUEs)
Dr. Mitch Nahra continues to monitor the National Correct Coding Initiative (NCCI) edits as well as the Medically Unlikely Edits (MUEs). The MUEs were created to help CMS screen for inappropriate billing of multiple procedures performed on the same patient on the same day. For example, it would be very unlikely to have three carpal tunnel releases on one patient in one day. Monitoring these edits is a very tedious undertaking that Dr. Nahra has done with great skill and dedication. We owe him much for his vigilance.
CMS has recently created MUEs that are inconsistent with upper extremity anatomy. The current MUEs have been updated and modified and are based on the frequency with which procedures are reported per patient / per day in a Medicare database, rather than on the patient’s anatomy. For example, the number of times one can report an ORIF of a metacarpal is 4 in spite of the fact there are 10 metacarpals! The good news is that with appropriate modifiers (-59) and perhaps an appeal or two, one should be able to report and get paid for procedures even if they exceed the MUE limits.
Current NCCI edits can be found at:
http://www.cms.hhs.gov/NationalCorrectCodInitEd/NCCIEP/list.asp#TopOfPage.
The MUE edits are published on the CMS Web site at:
http://www.cms.hhs.gov/NationalCorrectCodInitEd/08_MUE.asp#TopOfPage.
Medicare Fee Schedule
The 2009 Medicare Physician Fee Schedule was published in the Federal Register on October 30, 2008. I thought it would be of interest to our members to compare the current Medicare reimbursement per hour with their hourly overhead cost. Your office manager can calculate how much revenue you must generate per hour just to cover your overhead. By using this Excel file, you should be able to assess the economic viability of providing care to Medicare patients. Simply compare the per hour reimbursement listed in the database to your per hour overhead cost. I would suggest you calculate your overhead costs per hour excluding physician compensation. This will give you a better understanding of your breakeven point.
Contracts based on Medicare Physician Fee Schedule
Many insurance companies base their physician reimbursement on the Medicare physician fee schedule (PFS). If your insurance company contracts are based on the PFS, you need to consider whether to negotiate using the relative value units (RVUs) of the fee schedule or the Medicare payment amount. Beginning in 2009, the work adjuster that was applied to the physician work RVUs has been eliminated and shifted into the conversion factor. This is one of the reasons the conversion factor decreased for 2009. However, the geographic practice cost indices (GPCIs) still exist, and these can impact the payment amount. Each component of the fee schedule has a different set of GPCIs. The physician work GPCI can be greater than 1, while the practice expense and malpractice insurance GPCIs can be less than 1. If you live in Chicago, where all three GPCIs are greater than 1, you would want to consider using a multiple of the Medicare payment amount for negotiating contracts. If you live in Arizona or Alabama, where the three GPCIs are less than or equal to 1, you would want to consider using a multiple of the RVUs for negotiating contracts.
The two formulas listed below should help you understand this concept. I have also provided the 2009 GPCI table, so you can look up the GPCIs for your area.
Medicare payment formula:
Total RVU =
physician work RVU +
practice expense (PE) RVU +
malpractice insurance (PLI) RVU
Medicare payment ($) =
[(physician work RVU * Work GPCI) + (practice expense RVU * PE GPCI) +
(malpractice insurance RVU * PLI GPCI)] x Conversion Factor ($36.06)
25609
I would like to remind our members that when performing an open reduction and internal fixation of a three-part or greater distal radius fracture (25609), the release of the brachioradialis is considered an integral part of the procedure and is NOT separately billable.
Please let us know via email addressed to Ms. Dawn Briskey (dbriskey@assh.org) of any problems you have noted with the current CPT nomenclature. We value your comments as we strive to improve the nomenclature.
I wish you all a happy and healthy new year.
Dan
2009 Medicare Reimbursement Rates:
CPT_M_Reimbursement_Rates.xls
2009 Geographic Practice Cost Indices (GPCIs) by State and Medicare Locality:CPT_AddendumE_GPCI09.xls