Continuous Infusion Coding Change 2009 - American Society of Anesthesiologists (ASA)
The Medicare program has received substantial criticism from organizations such as MedPAC, from members of Congress, and from some medical specialty groups that the agency has not adequately addressed overvalued services in the physician fee schedule. In response, the AMA Relative Value Scale Update Committee (RUC), created a standing workgroup to identify potentially incorrectly valued services through a number of statistical screens. To date, hundreds of codes have been reviewed and many have had their values adjusted. These adjustments have predominantly been reductions.

Changes in the Continuous Infusion Pain Codes:
In the fall of 2007, the RUC Five-Year Review Identification workgroup identified several services as having site of service anomalies. Codes with a site of service anomaly are services that have hospital days included in the global period but according to the Medicare claims files are services performed as outpatient procedures more than 50 percent of the time. Global period procedures bundle all work associated with the procedure, including follow-up visits, into a single payment. These documented follow-up visits were included in the valuation for the continuous catheter codes from the time these codes were created earlier this decade. In fact, if the follow-up work is not performed, some payers require that the fee be diminished. All specialty societies with codes falling into site of service anomalies were asked to submit an action plan to the workgroup and RUC to explain this site of service discrepancy

Two of the codes that describe the placement and daily management of a continuous peripheral nerve catheter were identified as having a site of service anomaly. These codes had a 10-day global period. The RUC requested that the codes be re-surveyed with a zero day global. The codes were first presented to the CPT Editorial Panel so that their descriptors could be revised to facilitate this change. (Reference to daily management had to be deleted). In order to maintain consistency within the code set, the same process was applied to the two other continuous PNB codes.

CPT revised the descriptors for the following pain codes. The codes were then surveyed with a new global period of 000:

64416 Injection, anesthetic agent; brachial plexus, continuous infusion by catheter (including catheter placement), including daily management for anesthetic agent administration

64446 Injection, anesthetic agent; sciatic nerve plexus, continuous infusion by catheter (including catheter placement) including daily management for anesthetic agent administration

64448 Injection, anesthetic agent; femoral nerve plexus, continuous infusion by (including catheter placement) including daily management for anesthetic agent administration

64449 Injection, anesthetic agent; lumbar plexus, posterior approach, continuous infusion by catheter (including catheter placement) including daily management for anesthetic agent administration

These revised descriptors no longer include daily management. Postoperative daily visits will be eligible for separate reporting with an appropriate E&M (evaluation and management) code.

The table below lists the current value for these codes with a 10-day global; the current value minus the hospital visits built into the 2008 010 global designation, the current 2009 recommended value with the new 000 day global assignment.

CPT code 2008 Global Period (days) 2008 Work RVU Number of Postoperative Visits in 10-day global
64416 010 3.85 3 - 99231
64446 010 3.61 3 - 99231
64448 010 3.36 3 - 99231
64449 010 3.24 2 - 99231

2008 Work RVU Minus Hospital Visits 2009 Work RVU 2009 Change in Procedure Work Value 2009 Global (days)
1.57 1.81 +0.24 000
1.33 1.81 +0.48 000
1.08 1.63 +0.55 000
1.72 1.81 +0.09 000

Subsequent hospital care, per day, for the evaluation and management of a patient, which requires at least 2 of these 3 key components: A problem focused interval history; A problem focused examination; Medical decision making that is straightforward or of low complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the patient is stable, recovering or improving. Physicians typically spend 15 minutes at the bedside and on the patient's hospital floor or unit. (0.76 RVUs)

If the patient is an inpatient, and the same number of hospitals visits are performed and documented with 99231, then value of the procedures plus postoperative visits would be higher in 2009 than in 2008. If the patient is discharged with a catheter and the physician conducts post-operative face-to-face follow-up visits, these visits may be reported using subsequent care office visit codes (99211-99215).

Practices that were not performing and documenting the included global services may regard this a devaluation and burden. As mentioned, some payers would have required the physician to report a reduced service in these circumstances, with probably an associated reduction in payment. However, practices that were and are performing and documenting the follow-up described in the codes prior to 2009 will enjoy a small increase in valuation. This also allows physicians who work on an acute pain service to separately report and receive payment for visits that had not been payable previously due to bundling in the global fee.

Conversion factor
One other factor has contributed to the reduction in payment in 2009 for almost all Medicare physician services. The Medicare conversion factor for most services saw a 5.3 percent decrease from 2008 levels.

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