The five-year review, mandated by Congress, compels the Centers for Medicare and Medicaid Services to examine the physician fee schedule for misvalued procedures in terms of relative value units. This Coding Corner reviews some of the codes that the CMS recommended for analysis as well as those brought forth by the AANS and CNS and reports the outcome of the process.
The CMS brought forward a group of cranial and spinal codes for revaluation. Codes for burr hole drainage of a subdural hematoma, code 61154, and craniotomy for evacuation of a subdural hematoma, code 61312, were resurveyed. While the surveys of 61154 supported the current value, the surveys completed by neurosurgeons for 61312 identified the procedure as undervalued, predominantly as a result of increased postoperative work. As a result, in 2007 there was a modest increase for 61154 to 30.96 RVUs from 28.68 RVUs, and a substantial increase in the value of 61312 to 51.60 RVUs from 45.95 RVUs.
The AANS and CNS brought forward four craniotomy-for-aneurysm codes and two epilepsy codes.
Aneurysm Codes Several years ago when complex aneurysm codes were developed, the codes were valued identically to the simple aneurysm codes. This allowed for a period of volume tracking in order to make accurate assumptions in the budget neutrality adjustment required when one code is split into two codes. The 2005 survey process identified all of the codes as undervalued; consequently, the AANS/CNS Coding and Reimbursement Committee made the strategic decision to bring the codes to the five-year review.
The neurosurgeons completing surveys identified substantive increases in postoperative work for patients with complex aneurysms. Despite the Relative-Value Update Committee’s reticence to assign some intensive care services to the initial postoperative care, the volume and level of postoperative visits increased significantly, supporting higher values. While the value of craniotomy for simple anterior circulation aneurysm, code 61700, decreased modestly to 90.41 RVUs from 91.30 RVUs, the craniotomy for simple posterior circulation aneurysm, code 61702, increased to 97.28 RVUs from 85.21 RVUs. More significant increases were seen in the craniotomy for complex anterior circulation aneurysm, code 61698, to 104.40 RVUs from 91.34 RVUs, and for craniotomy for complex posterior circulation aneurysm, code 61697, to 109.87 RVUs from 87.61 RVUs.
Epilepsy Codes Two codes for craniotomy for temporal lobe epilepsy also were identified as misvalued. Code 61537 for temporal lobectomy without electrocorticography increased to 58.80 RVUs from 46.66 RVUs, while the code for temporal lobectomy with electrocorticography, 61538, increased to 62.55 RVUs from 49.04 RVUs.
Spine Codes The CMS also requested examination of seven spine codes. After mini-surveys were presented in cooperation with the North American Spine Society, thoracic vertebroplasty and posterior nonsegmental instrumentation were recommended and accepted for no change. As a consequence of reduced hospital length of stay, anterior cervical discectomy, code 63075, and anterior cervical arthrodesis, code 22554, were recommended for reduced values. With the budget neutral adjustments, 63075 was revalued at 33.97 RVUs from 36.12 RVUs, while 22554 was revalued at 35.97 RVUs from 35.42 RVUs. As these procedures often are performed together, the net reduction is less than 1 RVU after the –51 multiple procedure modifier is applied to 63075. It is important to note that the value of 22554 is now higher than that of 63075 and should be coded as the primary service. Lastly, modest increases occurred in posterior lumbar laminectomy, code 63047, to 28.25 RVUs from 27.74 RVUs, and adjacent level laminectomy, code 63048, to 5.77 RVUs from 5.64 RVUs.
E&M Codes Neurosurgeons also may benefit from the nearly complete examination of evaluation and management services, which the primary care coalition identified as undervalued. These E&M codes, comprising office and hospital visits, were last examined 10 years ago. There were some substantial increases in the values of E&M codes for performing office visits and hospital consultations, and some of the budget neutrality adjustment to procedure codes was mitigated by increases in the calculated E&M component of the postoperative global period.
In summary, there were significant successes in this five-year review process. Despite CMS concerns regarding overvalued cranial and spinal codes, only a small reduction was seen in anterior cervical decompression. The values of several codes were reaffirmed, whereas craniotomy codes for subdural evacuation, temporal lobectomy for epilepsy, and aneurysm clipping saw substantial improvements in total value.
On behalf of the Coding and Reimbursement Committee, I personally would like to thank all of the neurosurgeons who participated in the survey process that led to a successful result for all neurosurgeons. We are all greatly indebted in this endeavor to the tireless efforts of RUC advisers John Wilson, MD, and Rick Boop, MD, as well as Cathy Hill in the AANS/CNS Washington office.
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 for Medicare fee schedule. AANS Bulletin. 14(1):
22–23, 2005. Article ID 27702