General Surgery Coding Alert

A 1.5% increase across the board offset by some disappointing RVUs

CMS has unveiled its "Revisions to Payment Policies Under the Physician fee schedule for Calendar Year 2005," which brings higher overall reimbursement, but potentially no payments for some key new procedures.

First, the good news: CMS has increased the Medicare conversion factor to $37.8975 for 2005, up from $37.3374 in 2004 - an increase of about 1.5 percent.

Medicare payers use the conversion factor, along with the relative value units (RVUs) assigned to individual CPT codes, to determine reimbursement amounts.

For example: The fee schedule assigns 6.05 RVUs to 11043 (Debridement; skin, subcutatenous tissue and muscle). To determine payment, multiply the RVUs by the conversion factor, for a total of $229.28.

In addition, Medicare carriers adjust fees depending on the practice's geographic location according to the relative cost of providing healthcare in that area. About half of the 92 geographic areas defined by Medicare will see increases in their geographic adjustment factors (GAFs) in 2005. The rest will either not change or decrease.
 
Example: The GAF for Santa Clara, Calif., will rise 3.4 percent, from 1.184 in 2004 to 1.224 in 2005. Meanwhile, in Manhattan, the GAF will shrink 1.8 percent, from 1.225 to 1.203.
 
Therefore, in the Santa Clara area, for example, payment for 11043 would come to $280.64 ($229.28, as calculated above, multiplied by the GAF of 1.224 = 280.64).

You Could Be Out of Luck for Carrier-Priced Codes

On the downside, the fee schedule reveals disappointing news regarding new-for-2005 wound care codes.

Many general surgery coders were thrilled to hear that the AMA created two new codes to represent wound vacuum assisted closure (VAC) services this year, but the fee schedule failed to deliver any RVUs to codes 97605 (Negative pressure wound therapy [e.g., vacuum assisted drainage collection], including topical application[s], wound assessment, and instruction[s] for ongoing care, per session; total wound[s] surface area less than or equal to 50 square centimeters) and 97606 (... total wound[s] surface area greater than 50 square centimeters).

Although CPT Changes 2005 states that these procedures require "work and practice expense different than any of the procedures considered to be selective debridement in the 97000 series," the RVU Committee assigned "B" status indicators to both codes, meaning that the codes will be "carrier priced."

Expect disappointment: "A 'B' status indicator means that no separate payment will be made for the code," says Marvel J Hammer, RN, CPC, CCS-P, CHCO, president of MJH Consulting in Denver. "In most instances, I have not seen individual carriers then price these services separately."
 
In addition, the Nov. 15, 2004 Federal Register explains that, although the review board recommended 0.55 work RVUs for 97605 and 0.60 for 97606, CMS disagreed, stating that when the wound VAC service "does not encompass selective debridement, we consider this service to represent a dressing change and will not make separate payment."
 
If your general surgery practice performs a negative pressure wound therapy service that also requires selective debridement, CMS will bundle the wound VAC service into the new debridement codes 97597 (Removal of devitalized tissue from wound[s], selective debridement, without anesthesia [e.g., high-pressure waterjet with/without suction, sharp selective debridement with scissors, scalpel and forceps], with or without topical application[s], wound assessment, and instruction[s] for ongoing care, may include use of a whirlpool, per session; total wound[s] surface area less than or equal to 20 square centimeters) and 97598 (...total wound[s] surface area greater than 20 square centimeters).

Transplant Prep Codes Also Garner B Status

In a similar vein, CMS will also allow carriers to price many of the new transplant preparation codes ("Prepare Now for Backbench Transplant Preparation Codes," General Surgery Coding Alert, January 2005).

Affected procedures include preparation of donor lung and heart/lung codes 32855, 32856, 33933, 33944, removal of intestinal allograft 44137, preparation of donor intestine 44715, donor liver 47143 and 47144, and donor pancreas 48551.

Get the whole story on the Web: You can view the complete text of the 2005 fee schedule revisions at http://www.cms.hhs.gov/regulations/pfs/2005/1429fc.asp. At the same address, you can also find a complete list of RVUs for all CPT codes in "Addendum B" to the fee schedule update, as well as a complete list of geographic adjustments in "Addendum D."