July 1999
Volume 63 |
Number 7
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WHAT'S NEW IN ...
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| ...Coding and
Billing |
L. Charles Novak, M.D., Chair
Committee on Economics
As surgical and anesthesia practices and procedures change over
time, so must the coding and billing systems that provide the
support structure needed to accomplish efficient reimbursement
for anesthesia services. The Committee on Economics is charged
with tracking changes in anesthesia practice and recommending
appropriate alterations to the coding system for consideration
by the House of Delegates. Final acceptance by the medical and
insurance communities of new codes is dependent upon the approval
of those codes by the Current Procedural Terminology (CPT) Editorial
Panel and publication in the CPT book by the American Medical
Association (AMA). This update will touch on five subjects related
to coding and billing that have recently undergone, or are about
to undergo, significant change.
Obstetrical Anesthesia
Recognizing that there is no single, widely accepted method
of accounting for time during neuraxial labor analgesia, ASA has
developed guidelines for development of charge systems for this
service. Underlying the guidelines is the principle that "professional
charges and reimbursement policies should reasonably reflect the
intensity and time involved in performing and monitoring any neuraxial
labor analgesic."1 The ASA Relative
Value Guide (RVG) for 1999 lists four methods (as guidelines)
for determining charges that are consistent with the underlying
principle:
- Basic units plus patient contact time (insertion, management
of adverse events, delivery, removal) plus one unit hourly.
- Basic units plus time units (insertion through delivery),
subject to a reasonable cap.
- Single fee.
- Incremental fees (e.g., 0<2 hrs, 2-6 hrs, >6 hrs).
The recommended methodology is most significantly applicable
to codes 00955 and 00857, which are for neuraxial analgesia/anesthesia
ending in vaginal delivery or cesarean section, respectively.
Skin Codes
The 1999 RVG contains significant changes related to coding
anesthesia for procedures on the integumentary system. Coding
for procedures involving the skin has been collapsed into two
codes. Code 00300 is for procedures on the head, neck and posterior
trunk and carries a basic unit value of 5. Code 00400 is for procedures
on the extremities, anterior trunk and perineum and carries a
basic unit value of 3. A number of codes have been deleted from
various anatomic sections of the RVG since those services are
now incorporated into codes 00300 and 00400. These changes related
to anesthesia for skin procedures do not appear in CPT for 1999,
but will be incorporated in CPT 2000.
CROSSWALK®
CROSSWALK® is an ASA publication designed to assist members
and third-party payers in matching anesthesia codes with procedure
or service codes for which an anesthesia service was provided.
CROSSWALK® had its beginning as an informal work product of
the Committee on Economics. It is now an annual ASA publication,
still under the purview of the Committee on Economics, but under
the formal editorship of Stanley W. Stead, M.D. Although updates
had occurred each year, the committee had not comprehensively
reviewed the CROSSWALK® for several years. In the fall of
1998, a group of five experienced individuals accomplished a review
of the full document. As a result of the review, more than 1,000
changes have been made for the 1999 edition!
There is a tendency for anesthesia practices to use the electronic
version of CROSSWALK® in an automated fashion to convert CPT
procedure codes into CPT anesthesia codes for billing purposes.
This practice is fraught with danger. Due to differences in the
underlying principles of the anesthesia coding system and the
remainder of the CPT coding system, one procedure may cross to
more than one anesthesia code. The CROSSWALK® does provide
alternate crosses for these situations. The pitfall is that many
computer systems only load a single anesthesia code and not the
alternate(s). The committee and Dr. Stead welcome comments and
questions about CROSSWALK® as part of our efforts to continually
improve its quality and usefulness to members.
Cardiac Anesthesia
Coronary artery bypass graft (CABG) procedures without the use
of cardiopulmonary bypass (CPB) are rapidly gaining popularity.
The current anesthesia coding system does not adequately support
this change in practice. Presently, most heart surgery falls under
one of two anesthesia codes. Code 00560 (basic unit value 15)
is for procedures without CPB, and code 00562 (basic unit value
20) is for procedures with CPB. Most anesthesiologists feel that
the work involved in providing anesthesia for non-pump CABG is
at least equal to, if not more than, the work if CPB is used.
The Committee on Economics is finalizing a proposal to address
this issue and will have a recommendation for the House of Delegates
this October.
Transesophageal echocardiography (TEE), as commonly performed
by anesthesiologists during cardiac surgical procedures, does
not fit well with current CPT codes for the service. The Committee
on Economics is studying the feasibility of introducing a new
code for TEE that would "fill the bill" for anesthesiologists.
Block Codes - Sweeping Changes
The CPT Editorial Panel has approved significant changes to
procedure codes commonly referred to as "block codes" or "pain
management codes." Gone are the familiar codes for single-shot
and continuous spinal and epidural procedures. They are replaced
by new codes. In addition, there are new series of codes for facet
joint injections, transforminal approaches to the epidural space
and epidurolysis. Code numbering and physician work values under
the Resource-Based Relative Value Scale (RBRVS) await finalization,
but in 2000, the new codes will be in and the old ones will be
out.
The panel handled changes in three groups. The first group involves
spinal and epidural injections, not involving neurolytic substances,
for both single-shot and continuous techniques. The generic descriptor
includes needle (and catheter) placement, use of fluoroscopy (with
or without contrast material) and injection of any agent that
is not neurolytic. Various codes within the family break down
services between single-shot and continuous and distinguish between
various levels of approach.
The second group involves facet injections and transformational
approaches to the epidural space. This represents a vast expansion
of the previous codes for facet injection. The codes are unilateral
and distinguish between single and additional levels of injection
as well as varying levels of approach.
Finally, there will be a code for percutaneous lysis of epidural
adhesions, with or without endoscopic guidance. It will cover
the use of hypertonic saline, enzyme or mechanical techniques
for lysis.
The AMA/Specialty Society Relative Value Update Committee (RUC)
has reviewed the new codes and formulated a list of recommended
physician work relative value units for submission to the Health
Care Financing Administration (HCFA). HCFA will make the final
decision on the values and incorporate them into the RBRVS. Medicare
and many private third-party payers use the RBRVS as a guide to
physician reimbursement.
As this issue matures and publication nears, more detailed information
will become available. Significant efforts will be put forth to
inform the membership of these important changes coming for Y2K.
Reference:
1Relative Value Guide, American Society
of Anesthesiologists. 1999:14-15.
L. Charles Novak, M.D., is a practicing
anesthesiologist, Wenatchee Anesthesia Associates, Wenatchee,
Washington.
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