Significant increases in the value of evaluation and management codes are a welcome result of the recent Medicare physician fee schedule five-year review. In particular, the higher levels of service in the most commonly used E&M codes received the highest increase in work values. Because E&M services can represent more than one quarter of a neurosurgeon’s clinical revenue, reimbursement and documentation changes for E&M codes merit a closer look.
E&M for Outpatient Services
Consultation codes 99241–99245 for office visits are among the most common codes used in practice. Although there was a negligible increase in value for codes 99241–99243, there was a 10 percent increase in value for code 99244 (5.04 total relative value units) and a 6 percent increase in value for code 99245 (6.26 total RVUs).
The documentation requirements developed in 1997 for codes 99241–99245 are unchanged although they recently were examined by a work group assigned by the American Medical Association. Documentation for code 99244 is requested by several insurers in prepayment audits. Considering the relatively high volume of consultation codes, it is not surprising that these codes frequently are audited.
In addition, clarification on coding for outpatient consultation versus transfer of care was recently provided by the Centers for Medicare and Medicaid Services in response to a medical group that questioned whether a consulted physician who manages a specific problem for a patient can bill for a consultation; the CMS responded in the affirmative. For example, if a primary care physician asks a neurosurgeon to evaluate a patient for lumbar stenosis and the neurosurgeon alone manages this problem for the patient, the neurosurgeon can bill for a consultation provided that he or she communicates back to the requesting physician.
E&M for Inpatient Services
There was a significant increase in valuation of consultation codes for inpatient hospital services. For example, the value of code 99254 increased 19 percent (4.46 total RVUs), an increase that is reflective of sicker inpatients as greater numbers of healthier patients are being managed as outpatients. Inpatient consultations require documentation that differs somewhat from documentation requirements for outpatient consultations. While for an outpatient the consultant can document the request for consultation, for an inpatient the requesting physician must document the request for consultation in the chart. The higher values for outpatient services reflect the practice expense component rather than the work value component, which is higher for the inpatient consultation.
Some of the greatest increases in values were for hospital admission E&M codes, and these increases also can be attributed to greater numbers of sicker inpatients. For example, code 99221 increased in value by 35 percent (2.43 RVUs total) and code 99223 increased in value by 20 percent (4.96 total RVUs). Hospital admissions require documentation that includes a more detailed history and examination for a level one service in comparison to services or consultations for new patients.
Even the work values for established patient codes 99211–99215 increased significantly. For example, code 99213 increased by 20 percent (1.66 total RVUs), and code 99214 increased by 16 percent (2.52 total RVUs). These increases can be attributed to the greater number of comorbid conditions that require management. Note that the documentation requirements for established patients are less stringent than those for other patients: For established patients, only two of three key components (history, examination, and medical decision-making) are used to determine the level of service.
The valuation for critical care services, time-based services that require management of an organ or organ system that is at significant and imminent risk of injury, increased by smaller margins. For example, the first hour of critical care services increased in value by 9 percent (5.96 total RVUs), making this service equivalent in intensity to some neurosurgical intraoperative services.
The value of postoperative E&M services in the hospital and during the global period in the office was increased in the calculation for values of procedures, mitigating the decrease in values of procedural services. Moreover, the “discounted” hospital E&M values that were previously attributed to procedures were removed, further increasing the work values of these codes.
Overall Reimbursement Increase
Although a significant increase in work values for E&M services resulted in a reduced work value for all services in the Medicare fee schedule, neurosurgeons should see an increase in reimbursement for the office and inpatient E&M services they provide. It remains important for neurosurgeons to periodically review the documentation requirements for E&M services and to perform periodic audits of their records. It would not be surprising if insurers soon followed the increase in E&M code valuation with a close inspection of E&M code documentation.
Gregory J. Przybylski, MD, is chair of the AANS/CNS Coding and Reimbursement Committee and a member of the CMS Practicing Physicians Advisory Council. He also plans and instructs coding courses for the AANS and the North American Spine Society.
For More Information
Przybylski GJ: Five-year review results: neurosurgery sees significant successes. AANS Bulletin 16(1):26, 2007. Article ID 44446