The AANS/CNS Coding and Reimbursement Committee identifies and responds to coding and reimbursement issues of concern to neurosurgeons. To this end, committee membership includes a liaison from each of the AANS and CNS sections. The committee membership also includes AANS and CNS representatives and advisers to the American Medical Association Current Procedural Terminology (CPT) Editorial Panel, AMA Relative Value Update Committee (RUC), and the AMA Practice Expense Advisory Committee, which is a subcommittee of the RUC.
Through regular meetings during the AANS and CNS annual meetings, and “as needed” communications in conjunction with meetings of the CPT, RUC, and the Neurosurgical Leadership Development Conference, committee members stay abreast of current issues and developments that impact coding and reimbursement for neurosurgeons.
Cracking CPT Codes
The committee has been very active in reviewing and introducing new and revised neurosurgical codes for CPT. Suggestions for new codes typically come from AANS/CNS sections and individual AANS and CNS members Regardless of the source of the initial request, the committee consults the appropriate section to determine if a new code is deemed necessary and of interest to the section’s neurosurgeons. If the issue proves to be of concern, the committee works with the section to propose a new code. In some cases, committee members and the Washington Office staff work with physicians and staff from other specialty societies who also perform the procedure. For example, the AANS and CNS have worked with radiology groups on the creation of several new codes. A proposal for an intraoperative magnetic resonance imaging code will be presented at the November meeting of the CPT Editorial Panel. The code was developed in conjunction with the American College of Radiology and the American Society of Neuroradiology.
Some CPT proposals are intended simply to make the wording of the code easier to understand and more consistent with the format of the CPT book. These “editorial” changes are brought to the attention of the CPT panel by the advisers and often are passed with little discussion. For example, at the August meeting of the CPT Editorial Panel, the AANS and CNS suggested that the wording of CPT Code 63173 Laminectomy with drainage of intramedullary cyst/syrinx; to peritoneal space, should be changed to add the words “or pleural space” to make the code consistent with other cerebral spinal fluid shunt codes currently listed in CPT. The CPT Editorial Panel considered this an editorial change and does not expect the code to require revaluing by the AMA’s RUC panel.
Other proposed codes submitted to CPT for consideration at the November 2002 CPT Editorial Panel meeting include new codes for epilepsy and for vertebral corpectomy with a lateral extracavitary approach. For consideration at the February 2003 CPT Editorial Panel meeting, the committee is working with radiology specialties to submit a proposal for new codes for endovascular procedures.
Workgroup Evaluates E&M
At the November 2001 CPT Editorial Panel meeting, the panel appointed a workgroup to develop new codes for evaluation and management (E&M) services. Neurosurgery was fortunate to have Troy Tippett, MD, on this blue-ribbon panel to reorganize E&M guidelines. (The Coding Corner column in this issue discusses E&M codes in detail.)
RUC Recommends Work Values
The RUC is the body that makes recommendations to the Centers for Medicare and Medicaid Services (CMS) for relative work values for new CPT codes. Following a CPT Editorial Panel meeting, the RUC reviews the changes and sends out a memo to specialty societies asking their interest in surveying the physician work involved in the new code. In the case of revised codes, the RUC would require that the code be resurveyed if the level of physician work was significantly changed.
When a new code is to be considereed by the RUC, surveys are sent to a random sample of the appropriate AANS/CNS section. RUC surveys are very important and a good response rate helps ensure that neurosurgical codes are appropriately valued. Neurosurgeons who receive an RUC survey should fill it out or pass it on to a colleague who performs the procedure in question. The survey packages always contain e-mail contact information for committee members and Washington Office staff who can answer questions about the survey. New codes valued at the RUC during 2002 include codes for neuroendoscopy, which were approved at the February 2002 RUC meeting and codes for implantation of brain intracavitary chemotherapy agent, endovascular extracranial balloon occlusion, and four new codes for craniotomy/craniectomy for trauma, approved at the April RUC.
The RUC recommendations are important not only for Medicare payment but also for private payers who increasingly are basing their payment on the Medicare Fee Schedule. It is estimated that more than 90 percent of all medically insured people in the United States are affected by the system of relative value units (RVUs).
CCI and Medicare “Edits”
Another function of the committee is to review and respond to proposed “edits” implemented by the Medicare National Correct Coding Initiative (CCI). In May 2002, the AANS and CNS received a letter from Niles Rosen, MD, CCI director, regarding possible edits for the use of CPT 61795, stereotactic computer-assisted volumetric (navigational) procedures, intracranial, extracranial, or spinal. Specifically, Dr. Rosen requested a list of spinal procedures for which it would be appropriate to use CPT 61795. The Coding and Reimbursement Committee does not believe that such a list is advisable, due to the rapidly developing use of the technology. The committee sent a letter to Dr. Rosen stating that a list of codes was not appropriate and stating that with multiple codes used in spinal procedures and evolving technology, many combinations of codes might occur in which CPT Code 61795 is used.
On May 1, 2002, CMS issued a Program Memorandum to its Medicare Carriers requiring them to correct an error in the payment for bilateral billing of CPT 63030. AANS and CNS had brought to the attention of CMS the fact that the Medicare Fee Schedule file on the CMS Web site indicated that billing of CPT 63030 with the 50 when the procedure was performed bilaterally would be denied. Believing the item to be an error, AANS/CNS Washington office staff contacted CMS in mid-January. CMS subsequently resolved the issue and, after July 1, 2002, Medicare carriers will be required to cover CPT 63030-50. In addition, physicians may resubmit claims for CPT 63030-50 denied by Medicare between Jan. 1, 2002, and July 1, 2002.
PEAC Accepts Cranial and Spinal Values
AANS and CNS presented proposed practice expense values for 33 cranial codes to the AMA Practice Expense Advisory Committee at its meeting in Chicago March 21 through March 23, 2002. In addition AANS and CNS joined the North American Spine Society in presenting proposed practice expense values for 23 spine codes. The practice expense values for all the codes were accepted as presented.
Medicare Coverage Decisions
The committee tracks Medicare Coverage Decisions and assists in responding to proposals when appropriate. Two methods exist by which Medicare coverage decisions are made. Local Medicare contractors may develop local coverage policies (90 percent of Medicare’s coverage policies are determined by local carriers) or CMS may develop national coverage policies.
Recently the committee has been involved in both levels with regard to Medicare coverage decisions for Deep Brain Stimulation (DBS). At the local level, the committee worked with other societies to the effect that the California Medicare carrier (NHIC) agreed not to implement proposed bundling payment recommendations for DBS.
At the national level, comments annd testimony through the committee regarding scientific evidence of DBS for several new indications influenced the Medicare Coverage Advisory Committee Medical and Surgical Procedures Panel to consider a national coverage policy for DBS in treatment of Parkinson’s disease.
Proposed 2003 Medicare Fee Schedule
On June 28, 2002, the CMS published its proposed rule for the 2003 Medicare Physician Fee Schedule. The proposal contains several changes that impact the income of neurosurgeons. First, CMS made changes in its formula for calculating the Medicare economic index, which is one of the key factors used to determine the annual fee schedule payment update. These changes would result in a cut in the payment update by four and four-tenths percent. In addition, CMS made some global changes in its calculation of practice expense RVUs, fees that result in an addition reduction of slightly less than one percent. Thus, neurosurgery’s total reduction is estimated at about five percent. Absent from the proposal were any adjustments to the malpractice RVUs to reflect skyrocking professional liability insurance premiums.
At press time, the AANS/CNS Coding and Reimbursement Committee is working with the AANS/CNS Washington Committee to finalize formal comments for submission by Aug. 27, 2002. The comments address concerns about the Medicare economic index and sustainable growth rate and strongly emphasize the need to use more current professional liability cost data in figuring the malpractice portion of the fee schedule.
Samuel Hassenbusch, MD, is chair of the AANS/CNS Coding and Reimbursement Committee.