By Daniel J. Nagle, MD
Chair, ASSH CPT/RUC Committee
Global Service Guide for Hand Surgery; Genesis and Evolution.
The now defunct Physician Payment Review Commission (PPRC) recognized in 1988 that a national payment system would require a standardization of what should be included in each procedure listed in the CPT nomenclature. The PPRC convened consensus panels of Medicare insurance carriers and surgical specialists to create a list of “global services” for each CPT code. The American Academy of Orthopaedic Surgeons, along with representatives of the ASSH (Drs. Gary Frykman, Blair Filler and Dennis Phelps) participated in the process. The 300 most highly reimbursed orthopaedic procedures were carefully reviewed and global service guidelines created. The global services were extrapolated from this core of 300 codes to the remaining 1,300 orthopaedic procedures. Of all the surgical specialties, only orthopaedics and hand surgery went on to publish global service guidelines. The AAOS and ASSH believed that if they did not participate in the global service project, the federal government would be less than accurate in assigning global services to procedures.
While the PPRC was promoting global services, the Health Care Financing Administration (currently know as the Centers for Medicare and Medicaid Services) had engaged Dr. Hsaio of the Harvard School of Public Health to engineer a resource based relative value system (RBRVS) to serve as the basis for Medicare physician reimbursement. These two processes (global services development and RBRVS development) occurred independently and no exchange of data between them ever occurred. The creators of the global services descriptors never took into consideration what physician work was being considered as “global” by the creators of the RBRVS. They could not do this as the RBRVS was not implemented at the time of the definition of the global services. This lack of coordination between the RBRVS and the delineation of global services may have led to the bundling of some procedures into individual codes that would not have been considered a part of the physician work in the development of the RBRVS. As a result, for some procedures, the “bundled” physician work requires more physician time than the primary procedure described by the code.
Unfortunately, to this very day, because of the methodology used by Harvard (magnitude estimation without precise work descriptions), we have no way of knowing exactly what work was actually considered during the development of the original RBRVS system. However, since 1992 the American Medical Association Relative Value Update Committee (RUC) has required that all new codes have precise and detailed pre-, intra-, and post-service descriptors.1 Thanks to the RUC database, we now can create service descriptions for new codes that accurately reflect the physician work included in the calculation of the RVU.
Dr. John Bednar and the Global Services Subcommittee2 have created a second edition of the Global Service Guide for Hand Surgery, which contains accurate lists of the components of hand surgery procedures. This second edition presents global service guidelines that reflect current hand surgery practice, taking into consideration the current information contained in the RUC database. Such an accurate listing should help lessen the frequency of inappropriate bundling, while preserving the notion of a global service. We owe Dr. John Bednar and his Global Services Subcommittee a great debt of gratitude for the Herculean effort they put forth to create the Second Edition of the ASSH Global Services Guide for Hand Surgery.
Coding Vascularized Bone Grafts for Scaphoid Non-Unions
This procedure continues to be a coding challenge. Here is one technique:
25440 Repair of nonunion, scaphoid carpal (navicular) bone, with or without radial styloidectomy (includes obtaining graft and necessary fixation) RVU 23.1
25430-51 Insertion of vascular pedicle into carpal bone (eg, Hori procedure) RVU 17.94
Rationale: Clearly 25440 describes the preparation of the nonunion for bone grafting, harvest and insertion of a bone graft, internal fixation and radial styloidectomy. The only thing missing is the vascular pedicle. 25430 describes the placement of a vascular pedicle into a carpal bone. This is in fact what is being done though the pedicle is attached to a piece of radius. The argument can be made that the work associated with the harvesting of the bone is already included in 25440, and that 25430 describes the work associated with harvesting the vascular pedicle.
Please feel free to let me know of any changes to the CPT nomenclature you feel are needed. Also, we are anxious to hear from you if you note any errors or omissions in the Global Services book.
Good coding to you all.
1 Pre-service = physician work completed before the skin incision; Intra-service = physician work completed during procedure (“skin to skin”); Post-service = physician work completed from the time the skin is closed until the end of the global period.
2 The ASSH Global Services Committee consists of John Bednar,MD, Elliot Ames, MD, David Hildreth, MD, Kendrick Lee,MD and Daniel Nagle, MD.