The American Academy of Orthopaedic Surgeons; Coding, Coverage and Reimbursement Committee is tasked with determining the correct coding of many scenarios that face orthopaedic surgeons. One coding question is the appropriate coding of an initial patient visit for a patient with a fracture that does not require a manipulation. The correct treatment is to evaluate the patient and then to provide non-manipulative care for the fracture. Evaluation and management is required for the initial care of all patients. The specific treatment is the non-manipulative treatment of the fracture. The correct coding is to list the appropriate E&M code (determined by the level of service and the service setting) and the correct non-manipulative fracture code. This is similar in rationale to the decision for surgery. If a patient is seen in the ER and a decision is made for surgery the same thought process and medical decision making is required for the decision for non-manipulative treatment. Therefore, the correct coding is both the E&M and procedural code.

On a more somber note, in my twelve years as a member or chairman of the Committee on Health Policies and Practice of AANA, I have never been so concerned about the attitude and direction of regulators regarding physicians. Louis McIntyre, MD in his health policies report will update you on the RUC but there are so many other actions underway that undermine and "vilify" our efforts as businessmen and physicians. The "anti-markup" provision of the recent Final Rule for Medicare is a perfect example. A very brief review of this provision would have made it illegal for a physician to charge more than the technician time and minimal costs for performing an MRI for Medicare. It would have been cost prohibitive to provide MRI’s for Medicare patients. Thankfully, but only after a "ground swell" of objection and criticism for the decision, its implementation has been delayed for a year. There are other moves afoot such as Stark law changes, differential payment scales for radiologic tests, etc. which illustrate the contempt our government has for physicians. The question is what will we do? Will we wait until we have no options? I trust the leadership of AANA and the AAOS for a timely discussion and action on these and many more questions. Support for the legislative agenda of our parent organization, the AAOS, is critical in these difficult times.

Most of the work of the Committee on Health Policy and Practice has centered on work at the RBRVS Update Committee (RUC) of the AMA this winter. The committee has worked closely with the AAOS on coding issues that affect orthopaedists and arthroscopists at that committee. The current issue before the RUC in February was "site of service anomalies" identified in the Medicare database. The CMS identified 25 orthopaedic procedures that have inpatient value associated with them and are currently done mostly or exclusively in the outpatient setting. The RUC requested that the AAOS survey its’ members concerning physician work on those codes. AANA was specifically tasked with six codes to present to the RUC; the open shoulder codes 23120, 23410, 23412, 23420, 23415 and ACL reconstruction, 29888. Surveys were sent out in late 2007 and our response was good. Thanks to all who completed surveys. We were especially concerned about 29888, believing that it is currently undervalued and at severe risk of being further devalued by the RUC process.

The RUC meeting was especially adversarial. Two of our presenters, myself included, were dismissed before the entire committee and not allowed to present because of alleged conflicts of interest despite the fact that these interests had been reported prior to the meeting. The RUC agenda became very clear early on in the meeting: any code brought before the meeting for site of service anomaly was going to lose the value associated with inpatient work regardless of what the surveys indicated. In addition, the RUC tried to push through various pre-procedure time "packages" that severely cut into the time reported by surgeons for preparing patients for surgery. It also changed its’ rules regarding the level of proof necessary to affect code value. In the past, RUC "compelling evidence" standards were necessary to increase code value. In regards to site of service issues, "compelling evidence" was necessary merely for a code to retain its’ current value. This was despite the fact that most of the codes had never been surveyed and were valued under the old "Harvard" method. The RUC in the past has put more credence in survey data over the older method. With site of service issues, it was acceptable to site the Harvard value over the survey data. It seems the goalposts keep moving.

Dr. Bill Creevy of the OTA did a great job filling in for me and got the best possible outcomes on these codes. Four of the open shoulder codes were devalued by the amount of RVWs associated with inpatient work. One code, 23120, was deferred until the April RUC. The good news is that ACL reconstruction, 29888, was also deferred and did not lose value. The bad news is that it is in significant danger of doing so at the next RUC. This is obviously unacceptable to us and we will be working very hard to make sure this does not happen.