Neurology & Pain Management Coding Alert

Medicare's Physician Fee Schedule is a valuable resource but can be difficult to interpret. The schedule is a tabular list of all CPT Codes updated yearly by CMS. Codes are listed in rows with details arranged in columns. The most basic information included in the fee schedule is the relative value units (RVUs) assigned to each code, which determine Medicare payment. Additional columns provide detailed facts concerning modifiers, global periods and more. By using this information correctly, practices can increase coding efficiency and accuracy.
 
Fee Schedule Facts: How to Get It
 
 
The updated fee schedule is announced yearly in the Federal Register and can be downloaded from the CMS Web site at www.hcfa.gov. From the home page, select in order the links for "Stats and Data" (near the top-left of the screen), "Public Use Data Files" (at the top of the screen) and scrolling down under the heading "National Physician Fee Schedule Relative Value File" "RVU02_A.ZIP," scroll to the bottom of the page to accept the CPT copyright statement. To download, select the file, click accept, specify the directory to which you want to save the file (desktop, C-drive, auxiliary drive, etc.) and choose "save."
 
When the download is complete (this may take 20 minutes or more), use WinZip or other applicable software to open the zipped file. The Fee Schedule (file name "PPRRVU02") is offered in several formats. The Excel (.xls) version is the easiest to use. If you don't have Excel, you can view the information as a text (.txt) file. Double-click on the desired file, which will self-extract for viewing. You may choose to save this extracted file to a new location for easy access later, or you may use WinZip or other applicable software to view the file from its downloaded location each time.
 
Note: You may also contact CMS directly for a copy by calling 410-786-3000.

RVU information is helpful because it allows practices to double-check their claim forms to ensure that they are being reimbursed correctly. It can also help in the proper application of modifier -51 (Multiple procedures).
 
The total RVUs for a procedure are determined by adding the work, practice expense and malpractice expense RVUs, says Susan Callaway, CPC, CPS-C, an independent coding and reimbursement specialist in North Augusta, S.C. Amounts for practice expense and total RVUs are given for facility and nonfacility settings. If there is a facility charge for the service provided (e.g., a hospital, ambulatory surgical center or skilled nursing facility), use the facility RVUs. In all other settings (e.g., the physician's office) nonfacility RVUs are used.
 
For instance, electromyography (EMG) code 95860 ( one extremity with or without related paraspinal areas) has been assigned 0.96 work RVUs (column F of the fee schedule) and 0.05 malpractice RVUs (column J). Practice expense RVUs for this procedure are identical for facility (column I) and nonfacility (column G) settings, at 1.18 RVUs. Adding these gives a total of 2.19 RVUs (.96 + .05 + 1.18 = 2.19). The total RVUs for facility and nonfacility settings is also represented in columns L and K of the fee schedule. Using this information and the 2002 conversion factor of $36.1992 (see News Brief, this issue), neurologists can determine their payments from Medicare for all billable CPT codes. Medicare payments are tailored to geographic area, so practices must also consult the 2002 Geographic Practice Cost Indices (GPCI) published in the Nov. 1, 2001, Federal Register to determine the correct amounts.
 
Determine Medicare payments for Kentucky using the GPCI. For example, multiply work RVUs by 0.97, practice expense RVUs by 0.866 and malpractice expense RVUs by 0.877. Add the results for a new total RVUs adjusted for that geographic area. For 95860, the formulation would result as follows:

 

0.96 work RVUs x 0.97 = 0.9312 

0.05 malpractice expense RVUs x 0.877 = 0.04385   

1.18 practice expense

RVUs X 0.866 = 1.02188

 

0.9312 work RVUs + 0.04385 malpractice expense RVUs + 1.02188 practice expense RVUs = 1.99693     

1.99693 total RVUs x $36.1992 conversion factor = $72.29 payment for 95860 in Kentucky.

Payment for codes in all areas can be calculated in the same way using the applicable GPCI conversions rates. Although practices cannot calculate payment for every claim, occasional spot checks can ensure that Medicare is reimbursing your full amount.

RVUs: Modifier -51

RVU information is also useful when applying modifier -51. When required, for instance, modifier -51 is used to report multiple injections of a neurolytic substance or translaminar epidural. When billing for these services, code each injection separately with modifier -51 appended to the second and subsequent codes, Callaway says. For example, if the neurologist provides two epidural injections of a neurolytic substance one each at a cervical and lumbar level the service should be reported 62282 (Injection/infusion of neurolytic substance [e.g., alcohol, phenol, iced saline solutions], with or without other therapeutic substance; epidural, lumbar, sacral [caudal]), 62281-51 ( epidural, cervical or thoracic; multiple procedures). Documentation must support each code, outlining the dosage, location and medical necessity for each injection. Choose the highest-valued code as the primary procedure by comparing column K or L totals (as appropriate) for each code.    

Attach modifier -51 to the lesser-valued procedure(s), says Catherine Brink, CMM, CPC, president of Healthcare Resource Management Inc., a physician practice management consulting firm in Spring Lake, N.J. In the above example, 62282 is chosen as the primary procedure because it has been assigned more RVUs than 62281 (8.04 versus 7.32). If 62281 were chosen as the primary procedure, it would be paid at full value while the higher-paying procedure (62282) would be reimbursed at 50 percent of its value. This represents a loss of reimbursement for the neurologist (8.04 RVUs + 7.32/2 RVUs = 11.7 while 7.32 RVUs + 8.04/2 RVUs = 11.34).

Column N of the fee schedule lists the global period for each CPT code. By checking this information, neurology coders can be certain they are not billing for care included in the global period of a previous surgery. E/M services provided during the global period of a related procedure, although rare for neurologists, are not separately reportable. If an E/M service is provided during the global period of an unrelated procedure, attach modifier -24 (Unrelated evaluation and management service by the same physician during a postoperative period) to the E/M service.

Some procedures are a combination of a physician component and a technical component. CPT specifies that "When the physician component is reported separately, the service may be identified by adding modifier '-26' (Professional component) to the usual procedure number" or by attaching the five-digit modifier code 09926.
 
Consulting the fee schedule is the easiest way to determine if a particular code contains a professional and technical component. Check the far left-hand column that lists each code. If separate values are listed for the code with modifiers -26 and -TC (Technical component), then modifier -26 is appropriate for that code if only the professional component of the service is provided (the physician does not own the equipment that he or she uses to provide the service).
 
For example, the fee schedule shows that nerve conduction studies, such as 95900 ( amplitude and latency/velocity study, each nerve; motor, without F-wave study), include a professional and technical component. The full value of the code includes performance of the study, equipment and staff, and interpretation and report. This means modifier -26 is appropriately appended to 95900 if the neurologist performs the test using equipment owned by a hospital or other facility and provides interpretation only, Brink says.
 
However, append modifier -26 only if the physician does not own the equipment that he or she uses to provide the service. In the above example, if the neurologist performs the nerve conduction study in his or her office using his or her own equipment, 95900 may be billed with no modifiers attached. For example, it is not correct for a physician to bill 95900-26 and 95900-TC.
 
When billing Medicare, physicians can't directly bill for the technical component of a procedure even when they use their equipment in the hospital, Callaway says. For instance, if the neurologist performs EMG and/or nerve conduction studies on a hospital inpatient using his or her own machine, modifier -26 must be used because the hospital is paid a facility fee with the diagnosis related group. For Medicare, the physician must bill the institution by a separate agreement if they are to recover the reimbursement of the technical component for these studies. The only time that you don't use modifier -26 is for outpatients using your own machine. This rule does not apply to private insurers.