The Coding and Reimbursement Committee (CRC), the newest iteration of joint action by the AANS and CNS, was created in January 2000. The CRC is neurosurgery’s oversight body for the AMA CPT Editorial Panel and the AMA Relative Value Update Committee (RUC), both of which influence the medical payment policies of the Department of Health and Human Services’ (DHHS) Health Care Finance Administration.
CRC was created within a cauldron of high emotion and acrimonious debate. It would be hard to imagine a more conflicted and contradictory topic than coding and reimbursement in neurosurgery in the 21st century. In a tug-of-war using CPT rules and fee schedule manipulation, Medicare and private managed care payers seek to reduce payments, while physicians seek to hold or raise them. Reimbursement for surgery, declining steadily for the past decade, remains in a tailspin that has yet to reach bottom.
For the past four years the Washington Committee has reported to the leaders and members of the AANS and CNS at their annual meetings about the fall in Medicare fees under resource-based practice expenses rules and conversion factor adjustments under the Balanced Budget Act of 1997. Major cuts in payment for the practice expense component of the Medicare Fee Schedule, which will not be completed until 2002, have driven this recent decline. All efforts taken by organized neurosurgery to stop the hemorrhage have slowed the decline in reimbursement but have not been able to reverse the trend.
Medicare is not the only source of payment problems. Commercial health insurance payments have fallen similarly, although for different reasons and by different mechanisms. However, they are linked by Medicare’s Resource-Based Relative Value System (RBRVS). Because the RBRVS is used by a majority of payers, the cuts imposed by HCFA on surgical reimbursement reduce commercial health insurance payments. The phased reduction in all payment sources has resulted in financial strain, frustration and anger in neurosurgery practices, both academic and private, across the country.
Beyond public and private fee discounting, federal payment policy is enforced by fraud investigations of medical practices. Investigators from the Justice Department and the Office of Inspector General of the DHHS have pried into large academic institutions and small private practices, discovering errors or excesses in coding and billing, prosecuting simple misunderstanding or disagreement as felonious fraud. The profession has been transformed from an object of public respect and authority to a target for public accusation and distrust.
Determining Reimbursement
The significance of the CPT Editorial Panel and the RUC should not be underestimated, just as the threat of further loss in Medicare payment can hardly be overestimated. The CPT Panel considers and recommends any changes sought by individual physicians, medical organizations, device manufacturers or others in the 7000 CPT codes, whether by addition, deletion, or modification. Those codes are the building blocks of payment, determining by precise description what services are rendered and how many allowable separate parts compose the reimbursable service. They translate the language of medical care into the jargon of accounting and payment. They are the tools of control or manipulation of payment policy and payment amount and thus are the source of struggle between physician organizations and HCFA for control of policy and flow of funds.
The AMA RUC is the counterpart, or other end of the seesaw, of federal payment policy for physician services. While CPT codes itemize the services eligible for payment, the RUC assigns relative values to new or revised CPT codes that represent the consensus of organized medicine as the best estimate of the relative value of each service considered. HCFA receives these recommendations from the RUC and most of the time accepts the relative values offered. Assigning a dollar amount requires applying the current Medicaree conversion factor to the relative value units for the procedure, which yields a service price for each CPT code.
The CPT Editorial Panel meets quarterly to act on all requests to alter the CPT code and code modifier list. Those specialty societies recognized within the AMA Federation may designate an adviser to submit comments and give testimony supporting or opposing requests for coding changes that affect the specialty. The influence of the specialty over CPT code revisions or additions flows through its specialty adviser. Coding changes can have powerful effects on payment, either positive or negative, and the effect is not always intuitive or immediately apparent. Many code submissions require negotiation and coordination among several specialties, since gain for one may mean loss for another. In overlapping specialties, competing strategies may threaten one another’s gain.
The RUC meets three times annually to recommend relative values based on the RBRVS for new or revised codes received from the CPT Editorial Panel. The RUC serves as an interface between medical specialties and HCFA to assign values to codes. Twenty-two specialties, the AMA, the CPT Editorial Panel and the American Osteopathic Association have a voting member at the RUC, and each specialty society within the AMA has a specialty adviser at the RUC. Advisers and the committee member determine if the specialty has interest in a submitted code and may submit codes themselves for valuation. The advisers initiate and defend the valuation process based on the best available data. This includes a survey of members of the specialty society to determine work time and intensity, which are ultimately translated into a numerical value.
Coding Committee Formed
The RUC and CPT processes were handled by a small core group within neurosurgery for years. Byron C. Pevehouse, MD, responded to CPT requests for years. He parlayed vast personal knowledge and experience in CPT coding into a persuasive influence over its evolution. A decade ago, those responsibilities went to Richard Roski, MD, for the CPT Editorial Panel and to Robert Florin, MD, for the newly created RUC. Those tenures have come to an end. The opportunity existed to coordinate, expand, and support the combined CPT and RUC activities, which have such a profound influence on all neurosurgery payment for service.
Acting on the recommendation of the Washington Committee, the AANS and CNS in January 2000 approved the creation of a joint Coding and Reimbursement Committee, composed of CPT and RUC subcommittees. The goals of the committee are:
- expand the number of neurosurgeons involved in the RUC and CPT process, adding expertise, ensuring succession and reducing the individual time burden.
- coordinate information, decisions and action between and among CPT and RUC advisers, recognizing that each cannot think or act independently of the other without creating confusion or unexpected problems.
- enlist the assistance of neurosurgical subspecialties in considering CPT changes or code valuations.
- expand the oversight and support of the combined CPT activities to include both the AANS and CNS (formerly the AANS supported RUC activities alone).
Reporting Structures
The CRC is independent of the Washington Committee but acts closely with it. The CRC reports at Washington Committee meetings and joins the Washington report to the parent governing bodies. Creation of a Regulatory Affairs staff position within the Washington office, now ably filled by Cherie McNett, represented permanent staffing for the CRC. The CRC has a separate budget, including expenses for RUC and CPT meeting attendance and internal operations. But budgetary approval is gained from the parent bodies only after discussion and recommendation at the Washington Committee. This coordination with the Washington Committee has improved communication among all involved in political and regulatory affairs and broadened oversight of committeee activities.
Robert Florin, MD, is the current RUC Subcommittee chair for the CRC and neurosurgery’s RUC committee member. Upon completion of Dr. Florin’s term in 2001, Gregory Przybylski, MD, will assume those positions, backed by John Wilson, MD, as AANS RUC adviser and Frederic Boop, MD, as CNS RUC adviser. The CPT Subcommittee is chaired by Samuel Hassenbusch, MD, formerly a neurosurgery CPT adviser. Dr. Hassenbusch is one of only 10 elected CPT Editorial Panel members (four additional seats are reserved for payer and hospital representatives). CPT advisers and alternate advisers are John Piper, MD, Jeffrey Cozzens, MD, Michael Nosko, MD, and Patrick Jacob, MD.
Other committee members are: CRC chair: Jim Bean, MD; CRC Vice-chair: Lyal Leibrock, MD; CPT Subcommittee: Richard Fessler, MD; William Mitchell, MD; James Metcalf, MD; Isabelle Germano, MD; RUC Subcommittee: Monica Wehby, MD, and Gary Bloomgarden, MD
Section liaisons have been appointed to include the expertise and interest of subspecialties in coding and reimbursement recommendations. The liaisons are expected to provide advice on CPT and RUC issues that pertain to their subspecialty, gather feedback from leaders in the Sections, help ensure response to RUC time surveys and serve as a two-way communication link between the Section Executive Committee and the CPT and RUC advisers. The Section liaisons are: Cerebrovascular: Robert Harbaugh, MD; Spine: John Piper, MD; Pain: Samuel Hassenbusch, MD; Stereotactic: Kim Burchiel, MD; Pediatric: Paul Grabb, MD; Trauma: Donald Marion, MD; Tumor: Lawrence Chin, MD.
The CRC expects to be an important mechanism for building neurosurgery’s future ability to interact with federal rule-making agencies. Along with federal legislative advocacy through the Washington office and interaction with federal administrative agencies such as the FDA, the CRC completes the organizational structure needed to at least try to bring sense to federal policy, fairness to payment and rationality to regulation.
James R. Bean, MD, a private practice neurosurgeon in Kentucky, chairs the Coding and Reimbursement Committee.