Coding Corner
Dr. McIntyre has eloquently explained the coding changes for 2012. Operative times are critical in the value of new and established codes. The Center for Medicare and Medicaid Services (CMS) has created an environment of concern for all physicians but especially surgeons. CMS via the Relative Value Update Committee (RUC) and the Congressionally mandated Five Year Review process is requiring the "re-surveying" of many CPT codes. The maneuver is targeting common and/or increasing frequent procedures. The American Medical Association (AMA) and its Common Procedural Terminology (CPT) administration, have strict rules regarding "coaching" of survey participants. With that background, what needs to be done?
1. AANA needs volunteer surgeons to become educated and to complete AMA/RUC surveys. These surveys are paramount in the valuation of new and existing CPT codes. An example of the survey requirements/process is the recently completed survey for 29880/29881, which resulted in a significant reduction in both RVU values.
2. AANA members must become engaged in the advocacy "battles". Not for selfish motives but to "battle" for the appropriate care of our patients. Two examples of the current battle: The Washington State Health Care Authority (WSHCA) has issued a negative coverage determination for the operative treatment of femoroacetabular impingement (FAI) and autograft osteochondral transplantation (OATS). Patients who are unfortunate enough to be under the control/decision making of the WSHCA will be denied, what we physicians and surgeons are convinced is appropriate care and treatment.
3. These "battles" will continue to occur and we will continue to struggle with negative coverage decisions until we organize and commit to data collection. The American Academy of Orthopedic Surgeons has rendered guideline after guideline that illustrates the lack of meaningful, validated data for surgical procedures. These are procedural guidelines on conditions that we know are beneficial for our patients, such as rotator cuff repair. So would it not be logical to commit to data collection before we repeatedly indict ourselves on poor or limited data via unsupported treatment guidelines?
In conclusion, there are many issues that are growing battles and potential "snow balling" problems. We firmly believe that the greatest threat to your practice is government and regulatory control. It is absolutely imperative that we focus an appropriate amount of resources to this area. A concerted effort by providers, patients and the entire health care industry is required to regain control of healthcare.
Health Policy Update
The challenges confronting us in the health policy arena are picking up speed and breadth of scope as 2011 comes to a close. On the RUC (RBRVS Update Committee) front, we have completed the survey and valuation process for the arthroscopic codes 29881 (arthroscopic menisectomy medial OR lateral), 29880 (arthroscopic menisectomy medial AND lateral) and 29826 (arthroscopic acromioplasty). All three of these code values were reviewed as part of the government-mandated 5 year review process because they are reported to Medicare with a frequency of >30,000 cases per year and had previously been valued under the older Harvard algorithm methodology. In addition, 29826 is reported in conjunction with other codes (namely 29827, 29828 and 29824) > 90% of the time. CMS considers this type of reporting to be potentially "redundant work" and therefore subject to payment decrease by bundling the affected codes together.
We believe our survey and valuation processes were valid and were consistent with national databases for service times for these procedures. Unfortunately, the times were significantly less than the times that existed under the old Harvard database. For example, 29881 had an intra-service time (the time estimated by the algorithm to perform a menisectomy) at 66 minutes. Our survey data of currently practicing orthopedic surgeons of varied skill level and practice setting produced an intra-service time of 40 minutes; a 40% decrease. The same occurred with 29880 where intra times went from 80 minutes to 45; a 44% decrease. Since the valuation of any given procedure is greatly determined by the amount of time it takes to do, any loss of time means loss of value. We were well aware of the potential loss of value that these codes could undergo and tried to defend their current value at the RUC. This proved an impossible task and as a result both codes will lose about 20% of their current value for 2012. There are also new reporting rules for the menisectomy codes. As of January 1, 2012, 29881 and 29880 will not be reportable with the chondroplasty codes 29877 and G0289. This will hopefully eliminate the confusion amongst payers with these codes and the rules of their reporting. The abrasion/microfracture code (29879) will still be reportable with both codes in any compartment as well as the loose body code (29874).
As of January 1, 2012, 29826 will become an add-on code which means it will only be reportable with another index code and cannot be reported alone. If an acriomioplasty is the only procedure performed, then it needs to be reported with 29805 (diagnostic shoulder arthroscopy) or a debridement code (29822 or 23). This change in code status was done to accommodate CMS’s contention that 29826 represents redundant work and therefore should be bundled in with other codes, namely 29827, 29828 and 29824.
The RUC has also asked us to resurvey the 29828 Biceps Tenodesis code. The code is only four years old but CMS is concerned with the frequency of reporting and wants its’ value reassessed as a result. We have begun the process to resurvey and value the code.
A new challenge comes from various Evidence Based Medicine (EBM) treatment guidelines promulgated by organizations and government. Allegedly produced to promote better, more appropriate patient care, these guidelines are being used by some to limit patient access to surgical procedures with coverage denials based on the guidelines. The EBM mantra is "level of evidence" (LoE) and the level they seek is the highest quality randomized clinical trial (RCT), or Level 1. This presents orthopaedic surgeons with a real dilemma as there is little Level 1 evidence for anything we do. In addition, acquiring such evidence presents real economic, ethical and informed consent limitations that make designing these types of studies expensive and difficult to approve through the IRB process. When EBM guidelines, with an exhaustive and thorough review of the orthopaedic literature come out and conclude that there is no evidence that a given procedure holds any clinical value does that mean the procedure doesn’t work? Of course not because we do have a wealth of level 3 and 4 evidence that confirms the value of orthopaedic procedures. EBM guidelines, however, consider these lower levels of evidence to be of "poor quality" and insufficient to prove efficacy. What happens when these guidelines are used to limit access to care? We are currently dealing with this very occurrence in Washington State where the Washington State Healthcare Authority (WSHA) and its Health Technology Assessment are about to decide that FAI and mosaicplasty surgery will not be covered by the WSHA because of lack of evidence to support their value to patients. In California, the California Technology Assessment Forum has made a finding that there is insufficient evidence to prove the efficacy and safety of hip resurfacing. These types of reviews are gaining popularity, especially with government agencies and insurance companies charged with paying for healthcare and we are likely to see an explosion of EBM guidelines in the next few years. AANA has committed to reviewing these guidelines from a patient-centered point of view to insure access to necessary care. If anyone becomes aware of treatment guidelines in your area, please let me know at lfm@woapc.com so that AANA can review and comment appropriately.
The Congress has created a "super committee" that is tasked with cutting over a trillion dollars from the federal budget as a result of the agreement raising the debt ceiling last summer. Many believe the committee will not accomplish any meaningful savings and will just be a venue for political posturing by both parties. If nothing is accomplished, however, the defense department is slated to take a huge cut in funding. This has resulted in Pentagon officials lobbying Congress to avoid these cuts contending that they would lead to deterioration in the nation’s defenses that would make the United States unsafe. The Commission may therefore be forced to come up with results and healthcare spending is a huge target. With the SGR slated to decrease physician reimbursement by almost 30% in January and MedPac recommending specialty fees being reduces by 5.6% per year for the next three years, we may be in for some significant cuts in Medicare fees in the near future. Please contact your Representatives and Senators to let them know what draconian Medicare cuts will do to patient access to orthopaedic care.
Finally, the 800 pound gorilla in the room is the Affordable Care Act (ACA or ObamaCare). Will the Supreme Court uphold the constitutionality of the law? Will a new Congress and/or President try to repeal all or some of the law’s provisions? Will some of the law collapse under the weight of economic viability such as the long-term care or CLASS ACT portion which was recently closed by HHS Secretary Sebelius? Will there really be ACO’s? There are lots of questions and uncertainty as we head toward the holiday season and 2012. All the best to you and your families for a happy and healthy 2012.