The American Medical Association’s (AMA) Relative Value Scale (RVS) Update Committee (RUC) is currently much involved in reviewing the procedures in the Medicare Fee Schedule (MFS) considered to be misvalued. Health Care Finance Administration (HCFA) has agreed to use the RUC to examine and propose changes in the existing relative value units (RVUs) for physician work that will stand the test of “compelling evidence” of misvalued codes.
Many of you have suffered one or more survey instruments designed to retrieve the data necessary to support the”compelling evidence” standard set by the RUC. For all of you that have spent much time and effort at completion of such surveys, I thank you. The results from the survey of Key Reference Procedures last Fall has been particularly valuable due to the validation of key periods of time identified in the survey.
One specific fact that emerged was evidence of a serious underestimation of time, and hence, work in the pre- and especially the post-operative parts of the service in the Harvard / Hsiao and then the HCFA database. The data from the survey showed clearly that the amount of time and work in the post-operative period was on average 39% undervalued by HCFA for the more complex procedures such as 61700 (carotid aneurysm) or 61510 (cerebral neoplasm).
When the additional physician work that was omitted from the data HCFA used to generate the Medicare Fee Schedule was added back, the total RVUs for the high valued procedures increased to values that reflect more appropriate relativity to other simpler services in the schedule. This also explains a substantial portion of the compression of high valued procedures that has been the basis for a running series of complaints to HCFA these past three plus years.
Another group of neurosurgical procedures in the MFS that were identified as misvalued are being prepared for review at the next RUC meeting, as part of the Five Year Review process. This has required still another survey of a select number of procedures in each of the families of codes under review, and some of you were asked once again to help by providing data on time and estimates of intensity/complexity along with a judgment about an appropriate total work RVU. These efforts are necessary in order to influence HCFA to accept recommendations that will help to restore relativity to the procedures in the neurosurgical section of the CPT- 4 codes.
The good news is that at the most recent RUC meeting in July, at which our misvalued codes were reviewed by a workgroup of RUC members, our recommendations for corrections to physician work values were accepted as presented. This means that the RUC will review these tentatively approved values before the whole committee in August and then forward their final recommendations to HCFA for their review. HCFA’s actions should appear in the December issue of Federal Register. If the currently approved corrections survive these subsequent reviews, the spectrum of values for neurosurgical services should be restored to a more reasonable degree of relativity that will match the phrase in the title of the RBRVS that says “Relative Value Scale”.
Spinal Implant Codes
A group of CPT code revisions that deal with implantation of spinal catheters and infusion pumps for management of pain or spasticity were submitted to the RUC at the April meeting and the proposed work values for the new codes were accepted. They will be forwarded to HCFA, and if approved will then appear in the 1996 Medicare Fee Schedule.
Spinal Fusion and Instrumentation Codes
A joint effort between the AANS and the American Academy of Orthopaedic Surgeons (AAOS) during the past year has resulted in significant revisions in the set of orthopedic spinal surgery codes (22100 to 22899). The codes have been revised to better define the actual services delivered, and include the spectrum of associated services that may be done on the same date as separate procedures. This represents deliberate unbundling with the attendant revaluation of the RVUs for these services.
The survey of these codes was completed in March and the results presented during the April meeting of the RUC. They were accepted by the RUC, with compliments to the team presenting the material that included Richard Roski, MD, representing the AANS, and Richard Haynes, MD, from AAOS. The survey and data analysis was done by Janet Martin who is providing valuable staff support for these projects. These new values assigned to these codes will also be submitted to HCFA for incorporation into the 1996 Medicare Fee Schedule.