Health Policy Update

One of the more frustrating aspects of coding and reimbursement is the denial of payment for legitimate services performed by surgeons for the benefit of their patients. We all have experienced this from both Medicare and private insurers as we scrutinize EOB’s to find out why our income is dropping despite seeing more patients, doing more surgery and becoming more adept at both E and M and surgical coding. It has become a fight, an expensive and time consuming fight, to merely get paid for work already performed. Navigating the NCCI (National Correct Coding Initiative) of Medicare and the various "bundling packages" used by insurance companies is useless as it seems that many denials are based on the arbitrary or ill-informed opinion of insurance bureaucrats or even worse, underemployed orthopaedic surgeons working for "disease management companies".

With this issue in mind, the Committee on Health Policy and Practice set about the task of recognizing and reconciling the various global billing packages in an effort to come up with a universally accepted reference that could be used to both justify coding practices and appealing denial of payment. William R. Beach, MD started this effort three years ago by proposing a policy statement for the AAOS that recognized the current Global Service Data Book (GSD) as the "gold standard" for musculoskeletal coding. In our effort to push this statement forward we found that there were issues with the book that we would have to change to make it accurately reflect that policy statement. We started by reconciling the GSD with the Hand Society’s global book in March of 2008. Then, over the summer, we completed revising all the arthroscopic codes to make sure that each one had the appropriate bundling package. We took this work to the Coding, Coverage and Reimbursement (CCR) Committee meeting last fall with the hope that we could get a consensus on our work but ran into several issues, mostly related to the semantics and organization of how the packages are presented in the GSD and Codex (the electronic GSD format). As a result, the Committee charged several subcommittees with the task of reviewing the entire GSD with the purpose of coming up with a reference that we could then bring to CCI to come up with our envisioned universal coding guide.

The CCR had Niles Rosen, MD the head of the National Correct Coding Initiative, attend the fall meeting and conducted a question and answer session with him. After this session, it was agreed that the best way for us to influence CCI and come up with a universal reference would be to revise the GSD and then petition CCI to consider the GSD bundling packages.

This is proving to be a bigger and lengthier project than initially considered but it could prove quite valuable to all of us if successful. Imagine the time, effort and capital that could be saved if there was one accepted and transparent coding reference? Not to mention the fact that I would not have to wind up screaming at some person on the other end of the phone who doesn’t know the difference between a SLAP and Bankart repair!

The RBRVS Update Committee (RUC) of the AMA will meet in February and the only issue before it relevant to arthroscopy is the application of Michael Kolczon, MD of the Cleveland Clinic for several office arthroscopy codes. This application, if successful, would give value to diagnostic arthroscopic procedures done in the office setting. The Health Policy and Practice Committee was asked to comment on this application in 2006 and declined to support it for reasons related to patient safety, physician certification ( any doc could do them) and the realization that the value for these codes would most likely come from our existing arthroscopy codes. In other words, current codes would lose the value associated with the overall cost of the new codes. The CCR Committee reviewed the application and recommendation of our HPP in addition to inviting Dr. Kolczon to present his case for valuation to the overall committee. The committee declined to support the effort of the applicant to obtain valuation before the RUC for the same reasons our HPP committee had previously sited. Dr. Kolczon will be presenting his case to the RUC in a few weeks and I will report on the outcome in the next newsletter.

Coding Center

We have worked to align the National Correct Coding Initiative (NCCI) and the American Academy of Orthopaedic Surgeons (AAOS) Global Services Data Book (GSD). As Louis F. McIntyre, MD has noted there are codes that continue to be bundled together under the Medicare payment guidelines. Two examples of NCCI illogical bundling are:

1. 29873 (Arthroscopy, knee, surgical; with lateral release) and 29877(Arthroscopy, knee, surgical; debridement/shaving of articular cartilage (chondroplasty)). NCCI denies 29877 and 29874 (Arthroscopy, knee, surgical; for removal of loose body or foreign body (eg, osteochondritis dissecans fragmentation, chondral fragmentation)) with any/all other knee arthroscopy codes. The Center for Medicare and Medicaid Services (CMS) created a code, G0289, to use anytime 29874 or 29877 would have been listed as long as it is performed outside the compartment of the index code. The problem is the format of the NCCI listing does not allow for any parentheticals or explanation of when G0289 should be used. Private insurers add insult to the situation by denying the code entirely noting that NCCI denies the code, not realizing that NCCI allows the "surrogate code – G0289". The final straw being, CMS granted themselves at significant discount on the add-on code G0289.

2. 29806 (Arthroscopy, shoulder, surgical; capsulorrhaphy) and 29807 (Arthroscopy, shoulder, surgical; repair of SLAP lesion) are incorrectly bundled under NCCI. When these codes were created and granted we made clear designations and differentiates between repair of a SLAP lesion and a capsulorrhaphy. Unfortunately, CMS and NCCI have not heeded our continued reminders of the anatomic reasons not to bundle these as well as the original intent for these codes.

Remember, these are not bundled and are correctly separated under the AAOS GSD Book and publications. As a final note, surgeons should watch closely for details of the AMA vs. Ingenix class action law suit. The basis of the suit and ruling are as follows: UnitedHealth, the owner of Ingenix, has agreed to pay $350 million to settle the AMA’s class-action suit. The suite argued that UnitedHealth’s and Ingenix rate-setting practices violated federal statutes. Mark one up for and thanks to the AMA.