By Daniel J. Nagle, MD
Chair, ASSH Coding and Physician Reimbursement Committee
Fifteen Year Review Results 2005 - Hand Surgery Codes
Seven codes were reviewed by the ASSH CPT/RUC Committee within the Five Year Review (5YR) process. Six of these codes were proposed by CMS (Center for Medicare and Medicaid Services) and one code (64702) was proposed by the ASSH. These codes were surveyed according to the standard AMA Relative Value Update Committee (RUC) methodology. The data was analyzed and presented by Dan Nagle before the AMA RUC Orthopaedic Workgroup in late August, 2005. Three codes saw their work relative value units (RVU) increase including the code brought forth by the ASSH (64702). The RVUs of the remaining four high volume codes retained their 2005 values.
The results of the AMA RUC Orthopaedic Workgroup were presented to the full RUC on September 29, 2005. Dan Nagle attended that meeting prepared to defend the ASSH recommendations. Luckily the values accepted by the Workgroup were accepted by the full RUC and were sent to CMS for review and eventual inclusion (hopefully without change) in the Spring 2006 Proposed Rule and Fall 2006 Final Rule, to be made into law on January 1, 2007.
E&M
This fall, AMA RUC (Relative Value Update Committee) was nearly brought to its knees by the contentious debate that accompanied the request by the non-surgeons to increase the RVUs (Relative Value Units) for all E&M codes. This maneuver has the potential of shifting up to 10 billion dollars away from surgery to medicine. Dan Nagle participated in the debate as a member of the AMA RUC Surgical Executive Committee. When all was said and done no agreement was reached. Negotiations continue…
Casting Material Coding
The Notice of Proposal for Rule Making (“Proposed Rule”) published in the August 1, 2005 Federal Register, contains a proposal by CMS to eliminate the casting material Healthcare Common Procedure Coding System (HCPCS) Q codes and roll the materials contained in those codes into the practice expense of the casting, splinting and fracture care codes. Third party payers have not been paying for the Q codes and this bundling of the casting materials into the casting, splinting and fracture care codes should be beneficial to our members.
The following text is extracted from the proposed rule:
Payment for Splint and Cast Supplies
In the Physician Fee Schedule (CY 2000); Payment Policies and Relative Value Unit Adjustment final rule, published November 2, 1999 (64 FR 59379) and the Physician Fee Schedule (CY 2002); Payment Policies and Relative Value Units Five-Year Review and Adjustments final rule, published November 1, 2000 (66 FR 55245), we removed cast and splint supplies from the PE database for the CPT codes for fracture management and cast/strapping application procedures. Because casting supplies could be separately billed using Healthcare Common Procedure Coding System (HCPCS) codes that were established for payment of these supplies under section 1861(s)(5) of the Act, we did not want to make duplicate payment under the PFS for these items. However, in limiting payment of these supplies to the HCPCS codes Q4001 through Q4051, we unintentionally prohibited remuneration for these supplies when they are not used for reduction of a fracture or dislocation, but rather, are provided (and covered) as incident to a physician’s service under section 1861 (s)(2)(A) of the Act. Because these casting supplies are covered either through sections 1861(s)(5) of the Act or 1861(s)(2)(A) of 66 the Act, we are proposing to eliminate the separate HCPCS codes for these casting supplies and to again include these supplies in the PE database. This will allow for payment for these supplies whether based on section 1861(s)(5) of the Act or section 1861(s)(2)(A) of the Act, while ensuring that no duplicate payments are made. In addition, by bundling the cost of the cast and splint supplies into the PE component of the applicable procedure codes under the PFS, physicians will no longer need to bill Q-codes in addition to the procedure codes to be paid for these materials. Because these supplies were removed from the PE database prior to the refinement of these services by the PEAC, we are proposing to add back the original CPEP supply data for casts and splints to each applicable CPT code….. The following cast and splint supplies have been reincorporated as direct inputs: fiberglass roll, 3 inch and 4 inch; cast padding, 4 inch; webril (now designated as cast padding, 3 inch); cast shoe; stockinette /stockinette, 4 inch and 6 inch; dome paste bandage; cast sole; Elastoplast roll; fiberglass splint; ace wrap, 6 inch; and Kerlix (now designated as bandage, Kerlix, sterile, 4.5 inch) and malleable arch bars. The cast and splint supplies have been added to the following CPT codes: 23500 through 23680, 24500 through 24685, 25500 through 25695, 26600 through 26785, 27500 through 27566, 27750 through 27848, 28400 through 28675, and 29000 through 29750. Because we are proposing to pay for splint and cast through the PE component of the PFS, we would no longer make separate payment for these items using the HCPCS Q-codes.
It is the understanding of the ASSH Coding and Physician Reimbursement Committee that subsequent casts applied within the 90-day global period will continue to be coded separately using the 29000 series codes without Q codes, the casting material for which will be that listed in the CPEP database.
The committee is proactively collecting casting material data in the event CMS decides to limit the amount of casting material used per fracture code. <Addendum 11/21/2005: This process has been put on hold until at least 2007.>
Practice Liability Insurance (PLI)
The ASSH Coding and Physician Reimbursement Committee noted in reviewing the 2004 PLI Risk Factor summary table included in the November 15, 2004 Final Rule, that hand surgery risk factors are incorrect relative to other specialties. This fact was brought to the attention of the AMA RUC and CMS during the spring 2005 AMA RUC meeting. We indicated to CMS and the AMA RUC that the risk factors shown for hand surgery (4.71) are significantly lower than orthopaedics (non-spine) (4.71 vs 8.06), vascular surgery (6.85), and plastic surgery (6.92). The AMA RUC agreed with the ASSH that a crosswalk to the orthopaedic PLI risk factor would be more appropriate for hand surgery. This recommendation was sent to CMS in time for consideration for inclusion in the NPRM (Proposed Rule) of August 1, 2005. CMS did not comment on the hand surgery PLI risk factor recommendation in the August 1, 2005 NPRM. The AMA makes note of this in its response to the NPRM. The extracted text from the AMA response follows:
The RUC also recommended the following crosswalks be considered:
* Hand surgery (currently 4.71) should be crosswalked to orthopaedic surgery (without spine) (currently 8.06).
CMS rejected the new crosswalk for gynecology oncology and colorectal surgery and did not mention hand surgery in the NPRM. We request that CMS reconsider this action and adopt the RUC recommendations in the Final Rule.
New Codes
The ASSH Coding and Physician Reimbursement Committee successfully presented a proposal during the October AMA CPT meeting in Seattle to create more precise codes for the reporting the care of distal radius fractures. Relative values for the new codes will be developed and presented to the AMA RUC during its February meeting. This will require the ASSH to collect survey data on which to base RVU recommendations.
During the same Seattle CPT meeting, the AAOS, through Brad Henley, MD presented a proposal to remove “external fixation” from all codes which read “with or without internal OR external fixation”. While Brad presented a compelling rationale for this change, it was referred to a work group for refinement.
The deadline for the last CPT meeting for the 2007 code cycle is November 7, 2005. Leon Benson, MD his New Code Subcommittee and Dan Nagle, MD have put together a proposal for several code changes. These changes deal with tendon excision, nerve wrapping and pulley reconstruction. The codes will be defended at the February CPT meeting and if all goes well will have their relative values assigned at the April 2006 AMA RUC meeting. The proposed codes describe infrequently preformed procedures and should have a minimal budgetary effect on the rest of the hand surgery codes.
64718
We are getting close to getting the revised AAOS Global Services Guide information from the AAOS needed to correct the inappropriate bundling of 64718 Neuroplasty and/or transposition; ulnar nerve at elbow with 24305 Tendon lengthening, upper arm or elbow, each tendon. The AAOS staff has forward the needed data and a letter has been sent to AdminaStar Federal to once again plead our case. (A new wrinkle in this process is that AdminaStar Federal has lost its contract to administer the CCI edit process. They will stop working with CMS as of November 30, 2005.)
Medicare Fee Schedule 2005
The Centers for Medicare & Medicaid Services (CMS) has published its final rule containing its 2006 fee schedule. If no action is taken in Washington, Medicare reimbursement will decrease by 4.4%. The ASSH Coding and Physician Reimbursement Committee is waiting for its consultant’s analysis of the rule. (The rule is over 1200 pages long.)
I wish you a happy holiday season!
Dan Nagle