April 1997 Bulletin

Why accurate CPT codes are important

How Academy developed 3 new codes, RVUs

By Alan H. Morris, MD

Alan H. Morris, MD, is chairman, Council on Health Policy and Practice

One of the Academy's most important activities, as stated in the Academy's Strategic Plan, is to seek "fair reimbursement" for our services. We cannot hope to achieve fair reimbursement, however, unless the Current Procedural Terminology (CPT) codes that we and our office staff use accurately reflect the services that we provide. Coding and payment are like two sides of the same coin. The link between them became even stronger when Medicare started using the resource-based relative value scale (RBRVS).

This article was written for two reasons. First, to describe the relationship between coding and payment, especially as it affects your reimbursement from payers who use the RBRVS, most notably Medicare. Second, to describe how the Academy deals with this important issue, and how you can personally help make the Academy's work more effective. To illustrate coding and payment issues in real-life terms, here is the following case example:

Patient X was struck by a car and sustained an open tibia and fibula fracture. Dr. Y was called to the hospital emergency room at 1 a.m. He quickly assessed the injury and saw exposed bone and obvious skin and muscle damage with street dirt and gravel contaminating the wound. Luckily for Patient X, Dr. Y noted that the peripheral circulation and sensation to the leg was intact.

While the operating room team was being called in, Dr. Y thoroughly examined Patient X for other injuries, and reviewed his past history. Dr. Y had a frank discussion with Patient X and his family about the severity of this injury, including the problems that occur with soft tissue and/or bone healing, plus the possibilities of infection which might lead to the loss of the limb.

Dr. Y knew he would have to do an extensive and meticulous debridement of the wound and he would have to provide some means of stabilization for the fracture. The appropriate operative permit was discussed and signed. The nursing staff was already at work administering tetanus prophylaxis and antibiotics while following Dr. Y's other orders.

Dr. Y worked approximately 90 minutes meticulously debriding the open contaminated wound both with lavage and sharp dissection to remove all devitalized tissue. After this portion of the procedure, Dr. Y decided to insert a non-reamed locked intramedullary tibial nail and leave the wound open. Within the next 48 hours, he planned to inspect the wound, do further debridement as necessary and make decisions about wound closure.

Dr. Y spent about an hour talking to Patient X's family, writing postoperative orders and spending time at the bedside to ensure that Patient X's condition was stable before leaving the hospital.

The next day, Dr. Y dictated Patient X's record and gave his office staff coding information regarding the procedures performed on Patient X. Using the code for intramedullary nailing of the tibia was straightforward. But, the only code he could find to describe the debridement he had performed was CPT Code 11044, debridement; skin, subcutaneous tissue, muscle and bone.

Ms. Z, Dr. Y's office manager, had just completed an Academy-sponsored course in CPT coding and had been hard at work learning the intricacies of the Medicare fee schedule, which is based on the resource-based relative value scale (RBRVS). Ms. Z explained to Dr. Y that under the RBRVS, the debridement procedure he had performed on Patient X was worth 2.28 relative value units (RVUs), in terms of the physician work involved. (The physician work RVUs make up almost half of the total RVUs for most orthopaedic procedures. Medicare pays about $41 per RVU, nationally. This means Medicare pays about $93.50 for the physician work involved in the procedure and about $200 total for the procedure, nationally.)

Other codes with similar RVUs were Code 23065 (biopsy, soft tissue of shoulder area, superficial) and Code 26011 (drainage of finger abscess; complicated, e.g., felon). Both Dr. Y and Ms. Z believed that 2.28 RVUs did not adequately compensate Dr. Y for the time and effort he had expended for the work done the previous night. Also, Dr. Y believed that other codes with similar RVUs are not nearly as complex as the debridement procedure (Code 11044) performed on Patient X.

Dr. Y called the Academy office to complain about this inequity. The Academy staff explained that when the RBRVS was created in 1992, the law also required the Health Care Financing Administration (HCFA) to review the physician work RVUs every five years. Dr. Y learned that this five-year review was in progress and that Code 11044 was among the many codes introduced by the Academy as having an inappropriate relative value. Academy staff explained the intricacies of this five-year review. Dr. Y offered to assist the Academy in a change in the RVU of CPT Code 11044.

HCFA had asked the AMA/Specialty Society RBRVS Update Committee (RUC) to assist in carrying out the five-year review. The RUC is an advisory committee to HCFA which recommends RVUs for physician work for new and revised CPT codes.

Undervalued codes

The RUC and HCFA set up specific criteria and a strict methodology for the five-year review. From January to March of 1995, myself, the Academy's RUC member, and representatives from each musculoskeletal subspecialty society, identified 82 codes that we believed were undervalued, including Code 11044. In the case of Code 11044, the Academy would have to show that either the original work performed for HCFA in the Harvard/Hsiao Study used to develop the RBRVS was in error or that patients or the manner by which the procedure is provided had changed over the five years since the RBRVS was developed.

During the spring of 1995, members of the Academy and the Orthopaedic Trauma Association (OTA) completed the RUC mail survey, describing the work involved in providing clinical services similar to that provided to Patient X by Dr. Y. That survey, which was done by physicians who actually perform the procedure (including Dr. Y), showed that the physician work RVU for the procedure should be at least three times higher than the current physician work RVU Code 11044.

Richard Haynes, MD, the Academy's advisor to the RUC, convinced the RUC that the debridement procedure performed on Patient X is much more complex than other procedures for which Code 11044 is used. For example, Code 11044 is used by general and plastic surgeons to describe their treatment for patients with varicose leg ulcers or paraplegics with decubitii. As a result of the Academy's efforts, the RUC recommended that the AMA CPT Editorial Panel (which manages the CPT coding system) review this issue for purposes of developing new codes.

Dr. Haynes and Dr. Morris had discussions with the Academy's Committee on CPT Coding, chaired by Blair C. Filler, MD. Dr. Filler; M. Bradford Henley, MD, representing the OTA; and other members of his committee developed three proposed new CPT codes to be used in the treatment of open fractures and dislocations, instead of Codes 11044 and 11043 (Debridement; skin, subcutaneous tissue, muscle). The first of these three new codes covered debridement of skin and subcutaneous tissue, a second code covered the debridement of fascia and muscle, and a third code covered debridement of bone.

Dr. Filler presented his committee's proposal to the AMA CPT Editorial Panel. His recommendations were accepted and three new codes were adopted.

Need survey

Another hurdle needed to be crossed. Each new or revised CPT code needed an RVU for physician work assigned to it to be paid under RBRVS payment system.* The Academy would have to do a survey of the physician work involved in these codes and present the findings to the RUC in much the same way it was done with Code 11044 in the five-year review.

To accomplish this, 33 members of the Academy and OTA completed the necessary RUC surveys for the new CPT codes. The survey respondents estimated the time taken within the 24 hours before the start of the actual procedure (pre-service), the "skin-to-skin time" as done in the operating room (intra-service) and the time required during the balance of the operative day (post-service). The respondents, who included Dr. Y, took into account other factors such as technical skill, physical effort, mental effort, judgment and stress due to the potential of iatrogenic harm.

Dr. Haynes then presented the RUC with the results of the surveys of these three codes. Dr. Haynes was assisted by Laura Tosi, MD, of the Academy's Committee on Health Care Financing and Jeffrey Anglen, MD, of OTA.

This formal presentation detailed the survey results and presented the Academy's rationale for recommending work RVUs for the three new trauma codes. Because of the accurate data supplied by Dr. Y and other orthopaedic surgeons who completed the mail survey, and Dr. Haynes' persuasive arguments, the Academy recommendations were accepted by the RUC. These physician work RVU recommendations were then reviewed and accepted by HCFA.

Now, Dr. Y and all orthopaedic surgeons will no longer have to use inappropriate codes with incorrect work RVUs for the treatment of open fractures and dislocations. (See Bulletin January 1997.)

Instead of old CPT Codes 11043 and 11044, the following three new codes now exist with significantly greater work RVUs (and greater Medicare payment levels):

11010 Debridement including removal of foreign material associated with open fractures and/or dislocations; skin and subcutaneous tissue. 1997 work RVU 4.15

11011 Debridement including removal of foreign material associated with open fractures and/or dislocations; skin, subcutaneous tissue, muscle fascia and muscle. 1997 work RVU 4.95

11012 Debridement including removal of foreign material associated with open fractures and/or dislocations; skin, subcutaneous tissue, muscle fascia, muscle and bone. 1997 work RVU 6.88

This achievement could not have been made without the help of individual orthopaedists who participated in the RUC surveys and who helped to develop more accurate CPT codes. If the Academy ever sends you an RUC survey, please help us and yourself by completing it. Also, if you believe a CPT code does not accurately reflect a given procedure, write to the Academy's health policy department with a detailed explanation.

* The other components of the RBRVS, practice cost and malpractice, have been valued by HCFA, using charge-based historic data. However, the practice cost component is currently under study in an effort to make it "resource-based" (i.e., based on actual field study).

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