AAOS Bulletin - June, 2005

AAOS prepares for Medicare five-year review

How you can help change Medicare reimbursement for orthopaedic procedures

By Daniel H. Sung, JD

The Medicare five-year review of relative value units is an important process that examines the relativity of payment rates under the Medicare physician fee schedule. The five-year review is an opportunity for the Centers for Medicare and Medicaid Services (CMS) and medical specialty societies, such as the AAOS, to identify and correct payment rates for misvalued services within the Medicare fee schedule. The AAOS will advocate for all of orthopaedics in this process, but to be effective, it will need your help in collecting data this summer.

Orthopaedic procedures

The current five-year review includes 125 orthopaedic procedures. CMS selected 27 orthopaedic procedures covering the entire spectrum of musculoskeletal care, and the AAOS nominated 98 orthopaedic procedures that it considers undervalued or in need of review.

The procedures selected by CMS for inclusion in the review (and the corresponding CPT codes) include:

• total hip and knee replacement (27130 and 27447)

• spine (22520, 22554, 22612, 22840, 63047, 63048, 63075)

• upper extremity (25447, 26055, 26160, 26600, 26951)

• joint injections (20600 and 20610)

• fracture care (27236)

• casting (29075)

• X-rays (73100, 73110, 73120, 73130, 73140)

The procedures selected by the AAOS for inclusion in the review focus on musculoskeletal tumor and fracture care codes. Each of the selected procedures had to meet specific criteria set by CMS to warrant review.

In addition to orthopaedic-specific codes, the relative values for evaluation and management (E/M) codes will be closely scrutinized during the current five-year review.

Data needed

This summer, the AAOS will be collecting data to support recommendations for changes in reimbursement rates. Because of the wide range of orthopaedic procedures that are part of the five-year review process, the AAOS is depending on all of its members to participate in the survey process.

For each set of orthopaedic procedure codes, as well as for many of the E/M codes under consideration, a survey will be sent to a random sampling of members. The AAOS will use member census data to ensure that the members surveyed will be asked about codes relevant to their practices. In addition, AAOS members will be able to volunteer for a specific survey via the Health Policy section of the AAOS Web site.

There are several key components to these surveys, which are designed to address issues such as service time, technical skill, patient severity, complexity, length of stay and other factors. For example, the surveys ask for detailed preoperative, intraoperative, and postoperative time data, as well as the number of postoperative visits (both hospital and office) associated with a procedure.

The survey also may ask you to compare the intensity and difficulty of two procedures in relation to one another. Finally, the surveys include an important question about the amount of physician work involved for a given procedure.

Members who receive the surveys must complete them as honestly and accurately as possible. Do not underestimate or overestimate any component of the survey.

Results and recommendations

Once the AAOS has collected enough data from members, the information will be used to develop recommendations that affect reimbursement rates for specific orthopaedic procedures and E/M codes. In particular, aggregate results of the survey will be used to set the Medicare reimbursement rate of the surveyed procedure relative to other procedures on the Medicare fee schedule.

If you are asked to complete a data-collection survey, remember that the information you provide is the primary method that the AAOS uses to make its recommendations on Medicare reimbursement rates for the surveyed procedures. Therefore, it is vitally important for you to complete and return the survey.

Without sufficient data, the AAOS will not be able to make compelling recommendations. The AAOS will be the most effective advocate for orthopaedics only if it can collect sufficient and reliable data from its members.

The five-year review is an extremely important process that directly affects your Medicare reimbursement. Whether you are part of the random sample or a volunteer, remember to provide the most accurate data possible.

Daniel H. Sung, JD, is a policy analyst in the AAOS department of socioeconomic and state society affairs. He can be reached at (847) 384-4320 or sung@aaos.org

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