By Daniel J. Nagle, MD
Chair, ASSH CPT/RUC Committee
Background
CPT 64718 (Neuroplasty and/or transposition; ulnar nerve at elbow) was selected for review by AAOS during the first 5 year review process. The AAOS felt that 64718 was undervalued. The RVU for 64718 prior to 1995 (the year of the first five year review[1]) was assigned using magnitude estimation during Phase Three of the Harvard, Hsaio study. For their presentation during the five year review the AAOS selected submuscular transposition as the typical anterior ulnar nerve transposition technique even though subcutaneous transposition is by the far the most frequently used technique. The service descriptor provided by the AAOS included the Z-lengthening of the flexor pronator tendon. The RUC rejected the AAOS request for a higher RVU but through a clerical error, kept the AAOS survey data in the RUC database. As the edits of the correct coding initiative (CCI), as well as many third party payer payment policies are based on the RUC database, this error lead to an incorrect CCI edit and inappropriate bundling of 24305 and 64718 by Medicare, the AAOS Global Services Guidelines and third party payers. This inappropriate bundling of 24305 and 64718 has lead to denials for the Z-lengthening of the flexor pronator tendon (24305) when performed during a submuscular anterior transposition of the ulnar nerve.
The first step on the journey to correcting this error was to figure out why it existed. Initially it was thought that the AMA CPT department had indicated to those who asked that the two procedures were to be bundled. Investigation revealed that was not the case. That revelation directed us to the AMA RUC database. The database indicated that the new values proposed in 1995 by the AAOS had been rejected. That meant that the RVU for 64718 was based on Harvard data. But what was the procedure considered by Harvard when they assigned a value to 64718? Did they value a simple anterior transposition or did they look at a submuscular technique? For that information we had to go back to the Phase Three Harvard data of the late 80’s which is not readily available. Some digging was done and as it turns out the description of the 64718 used by Harvard was its CPT descriptor; Neuroplasty and/or transposition; ulnar nerve at elbow. There is no mention of a submuscular transposition. Furthermore the Hsaio Harvard data indicates that the RVU for 64718 was developed using magnitude estimation. This means that the value for 64718 was determined via a mathematical model without ever going through a survey process.
At this point in our walk through the “Garden of RUC” the source of the problem had been identified; the source was not a bad apple but something even more insidious, bad data! AH! But what to do to correct this evil data! We had to go to the Source; to the RUC. But not just to the RUC but to the RUC Practice Expense Subcommittee as it was that committee that requested that the rejected AAOS data, including the descriptor of a submuscular transposition as the typical case, be left in the database to help assign practice expense RVUs to 64718. This request to keep rejected data in the database is against the rules of the RUC. This contravention had to be gently brought to the attention of the new chairman of the AMA RUC Practice Expense Subcommittee. The chairman was good enough to put this item on the January 2004 agenda for consideration. He and his committee saw the error of their predecessors and recommended to the full RUC that the AAOS data should be purged from the RUC database.
Are we there yet?
No! What about all that misinformation that was influencing Medicare, third party payers and the AAOS CPT Committee and its Global Services Subcommittee? We could not begin our work to set the record straight until we had something in writing from the AMA RUC supporting our holy quest. That written support would come in the form of the minutes of the January 2004 RUC meeting published in April 2004.
We must be there now! Well almost. We contacted the AAOS and they have seen the light and have updated their Global Services Guide to reflect “the truth” about 64718 and its illicit relation with 24305. (The second edition of the ASSH Global Services Guide does not bundle 64718 with 24305.)
So what’s left?
Medicare and its agent, AdminiStar, must now be brought into the fold. That is the last leg of our quest. I will let you know if we make it. Until you hear from me you should not code for both 64718 and 24305 for Medicare patients but for all other payers you should be able to bill for both. I will let you know when the CCI edit is corrected.
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[1] The five year review process is mandated by the federal government. During this process the relative values of all CPT codes are analyzed for RVU errors.