Health Policy Update
At the AANA Board meeting in Palm Desert an AANA Health Policy Fellowship was approved and funded. The fellowship is meant to nurture interest among young AANA members in the healthcare policy arena to ensure that AANA has members that can advocate on behalf of our patients to promote access to high quality arthroscopic care. The description of the Fellowship and the application process are outlined in the “call for applications” in this issue of the Newsletter. Please consider the Fellowship if you have an interest in this dynamic and important aspect of healthcare.
I outlined changes in CPT concerning 29826, Arthroscopic Acromioplasty, in the last Newsletter and there still may be some confusion as how to report this code as of January 1, 2011. As of that date, 29826 became an “add-on” code which means it cannot be reported alone and now has a 0 day global, meaning there is no pre or post work associated with the code. There is reimbursement value to the add-on code so it is not the case that we are no longer compensated for it; there are 3.0 RVU’s associated with the code. According to Medicare data, 29826 is reported greater than 95% with the codes 29827 (cuff repair), 29828 (biceps tenodesis) or 29824 (AC joint resection). For those few patients in the Medicare population that have an acromioplasty alone, it will have to be reported with an additional index code. There has been discussions among the members of the Coding, Coverage and Reimbursement Committee of the AAOS that the most appropriate codes to use are 29822 (limited debridement) or 29823 (extensive debridement) depending on the extent of the work involved. I had previously written that 29805 (diagnostic arthroscopy) was an appropriate code to use with 29826 but this may not completely comply with CPT rules.
The above discussion applies to primarily to Medicare patients. Private insurers may not adhere to some CPT rules and may not adopt 29826 as an add-on code. They may reimburse based on the old convention that 29826 is a stand-alone code. It is best to consult the individual carriers to ascertain their rules concerning 29826.
Remember also that as of January 1,2012 chondroplasty (29877 and G0289) will be bundled in with 29881 (medial or lateral menisectomy )and 29880 (medial and lateral menisectomy) in any compartment. Loose body removal (29874) and abrasion chondroplasty (microfracture 29879) can still be reported with both 29881 and 29880. As with 29826, private insurers may or may not adopt this rule so consulting with the carriers on this coding change is also recommended.
We have completed the surveys for 29828, Arthroscopic Biceps Tenodesis, which will be re-valued by the RUC at the end of January, 2012. I will report on the outcome of the review in a future newsletter.
Coding Corner
Embrace Appropriate Use Criterion
Healthcare stake holders; the Center for Medicare and Medicaid Services (CMS), insurers, payors and providers, want to better define what is the most appropriate and cost effective treatment for our patients. To answer that question we must determine what tools we could/should use to help make treatment decisions. The Department of Health and Human Services and the Agency for Healthcare Research and Quality (AHRQ) have created the National Guideline Clearinghouse (NGC). On the NGC website ((www.guideline.gov/index.aspx), a part of the www.hhs.gov and the www.ahrq.gov/) there are 200 orthopedic items listed on the site. These guidelines, by definition, are based on evidenced based medicine (EBM), which relies on randomized clinical trials (RCT) as its highest level of evidence and trumps all other studies when creating clinical treatment guidelines (CTG’s). However, as Robert A. Pedowitz, MD has identified in JBJS there are significant moral and ethical issues involved in the creation of such CTG’s for many surgical procedures. Pedowitz states, “The question stimulates examination of the concept of clinical equipoise. For a surgeon-researcher to enroll patients in a RCT, it is widely accepted that a state of ‘‘clinical equipoise’’ must exist. Clinical equipoise describes a state where ‘‘there is no consensus within the expert clinical community about the comparative merits of the alternatives to be tested’’ with ‘‘honest professional disagreement among...clinicians.’’ Pedowitz continues specifically discussing recently released rotator cuff CTG: “For an RCT to be ethical, each treatment arm should minimize the likelihood of a reversal of the risk-benefit ratio, in other words: primum non nocere. This principle evokes concerns about the design and implementation of an RCT of chronic, symptomatic rotator cuff tears, which was the topic of Guideline 2 (again, weak evidence). There are two ethical considerations. First, there is a large body of published information and broad clinical experience that demonstrates strong likelihood of decreased pain and improved function following surgery for symptomatic rotator cuff tears for which nonsurgical treatment has failed. Is it ethical to randomize patients to prolonged periods of persistent suffering in order to compare outcomes with a surgically treated group? Second, basic science and clinical literature demonstrate that prolonged nonsurgical treatment is associated with progressive tendon retraction and adverse changes in muscle architecture, which can lead to an irreparable rotator cuff tear. Is it ethical to randomize patients to known and potentially permanent morbidity?” The response is obvious - NO and no institutional review board could/should allow such a study. So what is the solution – Appropriate Use Criterion! The following is excerpt from the American Academy of Orthopaedic Surgeons (AAOS) website.
What are Appropriate Use Criteria?
Appropriate Use Criteria (AUC) specifies when it is appropriate to use a procedure. An “appropriate” procedure is one for which the expected health benefits exceed the expected health risks by a wide margin. Often sound data are not available, or they do not provide evidence that is detailed enough to apply to the full range of patients seen in everyday clinical practice. Nevertheless, physicians must make daily decisions about when to use or not use a particular procedure. AUC’s facilitate these decisions by combining the best available scientific evidence with the collective judgment of physicians from in order to determine the appropriateness of performing a procedure.
What procedures are addressed by Appropriate Use Criteria?
AUC topics focus on widely and frequently used procedures whose effectiveness is supported by evidence-based information. Additionally, AUC topics could be procedures that consume significant resources, have wide variations in their use (e.g. geographic), or are associated with substantial morbidity and mortality. AUC topics are derived from AAOS Clinical Practice Guidelines that establish the effectiveness of various procedures for a given disease, disorder or condition. AUC’s then address the patients in which these procedures are appropriate given the nuances of everyday clinical practice.
Why develop Appropriate Use Criteria?
AUC’s are developed to ensure the highest QUALITY of care for patients undergoing musculoskeletal procedures.
How are Appropriate Use Criteria developed “for Orthopaedics”?
The AAOS uses the RAND/UCLA Appropriateness Method to develop AUC’s. AAOS AUC’s are developed using evidence-based information in conjunction with the clinical expertise of physicians from multiple medical specialties in order to improve patient care and obtain the best outcomes while considering the subtleties and distinctions necessary in making clinical decisions.”
Another factor that must be considered in the creation of CTG is their relationship to the “standard of care (SOC).” The AHRQ notes: As Evidence of Customary Practice - A core principle in medical malpractice litigation followed in most, but not all, cases is that the legal standard of care is set to customary practice in the relevant medical community, the so-called professional community standard. Thus, in most jurisdictions, under most circumstances, adherence to prevalent professional standards is an adequate defense to a claim of medical negligence. The most obvious possibility for the use of CPGs, then, is that a court could look to them as evidence of what is customary practice in the medical profession. A physician who practiced in conformity with a CPG would be shielded from liability to the same extent as one who could establish that she or he followed professional custom. Conversely, a physician’s failure to conform to a recognized guideline could raise an inference that she or he did not perform up to the required standard; at the least, it would obligate the physician to explain why the CPG was not followed.
With that information what is our logical course?
1. Realize that RCT’s are not morally or ethically possible for many/most surgical procedures.
2. The creation of CTG’s should be halted because of our inability to create RCT’s/high levels of research. The energy and resources previously directed at CTG’s should be re-channeled into the creation of research studies that preserve our moral and ethical patient responsibility but collect meaningful data.
3. Because of the complex relationship of CTG and the SOC and the issues surrounding RCT’s, we should immediately endorse and create Appropriate Use Criterion. AUC panels should be convened for any/all procedures for which stakeholders question their appropriateness or cost effectiveness.