General Surgery Coding Alert

The Health Care Financing Administration (HCFA) modifies its fee schedule for physicians every year. The 2001 national fee schedule Relative Value File, which contains key information about how procedures can be modified to optimize reimbursement, is now available on the HCFA Web site, and may be one of the most important documents a general surgery coder can use.

Many coders associate the HCFA fee schedule with RVUs [relative value units] and reimbursement for specific procedures. But this document contains information far more useful for general surgeons than RVUs, says Susan Callaway, CPC, CCS-P, an independent coding specialist and educator in North Augusta, S.C.

Specifically, the fee schedule addresses the following:

Does the procedure have a global period? If so, how long is it?

Can the procedure be split into professional and technical components?

Do multiple surgery guidelines apply to the procedure?

Can modifier -50 (bilateral procedure) be appended to the service?

What proportion of the procedure is considered pre-, intra- and postoperative?

For multiple endoscopic procedures, what is the base endoscopic code?

This two-part article will examine and explain the various components of the fee schedule. This months installment explains how to obtain the document, and discusses entries about modifiers, RVUs, global days and pre-, intra- and postoperative components of procedures.

Find and Download the Fee Schedule

The easiest way to access the fee schedule is to download it from the HCFA Web site, www.hcfa.gov. From the HCFA home page, select in order the links for Stats and Data, Public Use Data Files and under the heading Physician Fee Schedule Relative Value File RVU01.EXE. Scroll to the bottom of the page to accept the CPT copyright statement. To download the CY 2001 file and obtain a self-extracting copy of the fee schedule, click the file, click accept, select the directory to which you want to save the file and choose save.

When the download is complete, go to the proper directory and double click the saved file. You will be asked to select a directory for the self-extracted files. Choose the directory to which you want to save the files and click unzip. A total of seven files (comprising four documents, each of which is offered in two or more formats) will self-extract to the chosen directory.

Using the Fee Schedule

The most important document the fee schedule itself (named pprrvu01) is offered in three formats. The Excel (.xls) version is the easiest to use. If you dont have Excel software, you can also view the information (in a less user-friendly manner) as a text (.txt) file.

Note: A sample of what youll see when you open the Excel file appears on the enclosed insert. The complete file contains all available CPT and HCPCS codes.

Determining Relative Value Units. The fee schedule is most recognizable because it tells providers how much Medicare will pay for the services they perform. This information is found in 10 fields ranging from F to P in the complete schedule.

Three components physician work, practice expense and malpractice expense are added to provide the RVU total. Physician work and malpractice RVUs occupy one column each, but the practice expense for a service may vary depending on whether the service is performed in a facility (i.e., hospital) or nonfacility (i.e., office).

Additionally, both facility and nonfacility practice expense RVUs are listed two ways: transitioned and fully implemented. The difference relates to HCFA adjustments of fees paid for procedures over a four-year cycle that began in 1998. As a result, for procedures or services performed in 2001, only the transitioned column applies. In 2002, when HCFAs fee schedule changes are in place, the fully implemented column will be correct.

Fortunately, the fee schedule provides the total number of RVUs for each procedure, therefore coders do not have to waste time adding the different columns. There are four columns with this information, however, again relating to the setting (facility or nonfacility) in which the procedure or service was performed and including both transitional and fully implemented fees.

For example, the correct number of RVUs (18.17) for a laparoscopic cholecystectomy (47562) performed in a facility would be found in column P, which lists the transitioned total RVUs for services performed in a facility (see sample fee schedule on enclosed insert).

Remember, however, that the RVU information tells the provider little he or she wouldnt already know by reading an explanation of benefits. The RVUs listed in the 10 fields are not meant to guide physicians on how much to bill rather, they simply inform physicians what Medicare pays. In fact, argues Callaway, because some private carriers may exceed Medicares fee schedule, surgeons should continue to bill for procedures based on their own, in-house determinations and not embrace the habit of using Medicares fee as a baseline.

Modifiers. Additional useful information can be found starting in the Modifiers field immediately to the right of the CPT or HCPCS code. This field identifies whether the code has a professional or technical component, identified by modifier -26 (professional component) or modifier -TC (technical component). If the field is blank, this denotes that the service is global (i.e., it includes both the technical and professional components). In the sample, an abdominal x-ray (74000) is listed three times, corresponding to global, professional component or technical component. Note that the RVUs assigned vary considerably, with the global service valued the highest. By reading the fee schedule, therefore, you can determine that if the physician owns the equipment, no modifier should be used when billing for the service.

For services other than those with a professional and/or technical component, a blank will appear in this field with one exception: the presence of CPT modifier -53 (discontinued procedure) after colonoscopy code 45378 indicates that separate RVUs and a fee schedule amount have been established for this procedure should it be terminated before completion.

Global Periods. The number of global days HCFA assigns to a procedure or service can be found two fields to the right of the final RVU indicator. Most coders may be familiar with 0-, 10-, or 90-day global periods, but the fee schedule also includes procedures with XXX (the global concept does not apply to this code); YYY (the carrier is to determine whether the global concept applies and establishes the postoperative period, if appropriate, at time of pricing); and ZZZ (the code is related to another service and is always included in the global period of the other service) global periods. The XXX designation typically applies to diagnostic tests, such as the 74000 listed in our sample, while ZZZ may be listed for some add-on codes, such as 44955 in the sample. Only unlisted codes receive a YYY designation.

Pre-, Intra- and Postoperative Percentages. HCFA determines that set percentages of the fee for any procedure with a global period are apportioned for pre-, intra-and postoperative services, with intraoperative services usually taking the majority of RVUs. In the laparoscopic cholecystectomy (47562) in the sample, for instance, 9 percent of the fee applies to preoperative services; 81 percent to intraoperative; and 10 percent to postoperative. This can become important if one physician performs pre- or postoperative care and another performs the surgery. The surgeon performing the surgery (and preoperative care) would bill 47562-54 (surgical care only) and would receive 90 percent of the fee, whereas the other physician would bill 47562-55 (postoperative management only) and receive the remaining 10 percent.

Note: Next month, the remaining fields of the fee schedule multiple procedures, bilateral procedures, co/assistant/team surgery, supplies and endoscopic base codes are examined.