Neurosurgery Coding Alert

Neurosurgery may duck the harshest fee cuts

The Medicare Physician fee schedule for 2007 is beginning to take shape, and the five-year review of Medicare's relative value units holds big changes for some neurosurgical procedures.
 
Impact: The proposed fee schedule is -a mixed bag [for neurosurgery], but almost all work values have gone up, and practice expense values are mixed. Some of the increases are long overdue,- says Eric Sandhusen, CHC, CPC, director of compliance for the Columbia University department of surgery. 

Here's a look at the possible RVU changes for neurosurgery procedures in 2007.

Big RVU Bump Proposed for Craniotomy Code

The basics: The public comment period for the proposed fee schedule ended in late August, so no one knows what the final proposed RVUs for next year will be yet. But while these numbers may be revised, they do give coders and physicians a good idea of where the RVU cuts and increases may come from.

Some procedures may have drastically lower RVUs in 2007, but other procedures would have greater reimbursement if the fee schedule passes.
 
For example, last year the RVUs were 46.66 for craniotomy code 61537 (Craniotomy with elevation of bone flap; for lobectomy, temporal lobe, without electrocorticography during surgery). The proposed schedule calls for 60.75 RVUs next year. Code 61538 (... for lobectomy, temporal lobe, with electrocorticography during surgery) could go from 49.04 to 65.03. Each of these proposed changes represents about a $550 increase for the services, depending on your individual geographical adjustments, the final conversion factor, and any across-the-board RVU cuts, Sandhusen says.

Proposed Increases Please Coding Experts

The proposed RVU changes for 61537 and 61538 are welcome news to Sharon Hathaway, RHIA, CCS-P, reimbursement manager for the department of neurosurgery at the Medical College of Wisconsin.
 
-I believe that these codes were undervalued in terms of the amount of work and liability to the physician,- she says.

Another major RVU change could come with craniectomy code 61312 (Craniectomy or craniotomy for evacuation of hematoma, supratentorial; extradural or subdural).

The schedule reports that the work RVUs (wRVUs) could be pushed from 24.53 (2006) to 30.30 (2007) for the procedure. The increase is being proposed for 61312  because -the increased use of anticoagulants by these patients has increased the intensity of the intra-service work,- according to the Federal Register Volume 71, No. 125. Total RVUs might go from 45.95 to 51.71--almost $225 in added payment for the 61312 code.
 
Hathaway says that the Federal Register's reasoning on 61312 makes good sense. Other neurosurgery procedures that would enjoy a pay bump next year if the fee schedule passes include:

- 61538 (... for lobectomy, temporal lobe, with electrocorticography during surgery). Proposed wRVU increase: from 26.77 to 39.31.

- 61697 (Surgery of complex intracranial aneurysm, intracranial approach; carotid circulation). Proposed wRVU increase: from 50.44 to 63.16.

- 61698 (... vertebrobasilar circulation). Proposed wRVU increase: from 48.34 to 69.39

- 61702 (Surgery of simple intracranial aneurysm, intracranial approach; vertebrobasilar circulation). Proposed wRVU increase: from 48.34 to 59.80.

Increases for 61697 and 61698 -are long overdue, as they were about the same value for the -complex- intracranial aneurysm repair as for the simple.

-Also, 61702 got increased because it is in a much more difficult location, which was not previously reflected,- Sandhusen says.

Remember: Final RVUs Not Yet Set

If CMS does improve RVUs for these procedures, the RVUs may not increase to the full, proposed amount: The RVU increases will be finalized after Medicare considers recommendations from various specialty societies and input from the RVU Update Committee (RUC).

So, for example, 61702 could enjoy increased RVUs next year, but the code may not end up being worth the proposed 59.80 units.

Check Out the Big Picture 

When the resource-based relative value system (RBRVS) was implemented in 1992, many procedure codes- relative value units were -gap-filling- approximations. To improve these approximations--and to account for changes in technologies and relative costs--CMS conducts a comprehensive review every five years,   Sandhusen says.

-In theory, these changes should be budget-neutral (i.e., not adding to overall program expenditures), because population-adjusted total relative values should remain steady,- Sandhusen says. But because more RVUs will increase than decrease under this review, CMS is considering an across-the-board 10 percent reduction in all RVUs to maintain budget neutrality, he says.
 
In addition, when the total volume of services increases, RBRVS is designed to limit or reduce the conversion factor, which is what led to the payment decreases in the beginning of 2006, before Congress overrode the reduction in February, Sandhusen says. (Many specialty societies are pushing for a greater decrease in the conversion factor, in the expectation that it will be easier for Congress to override this than perform an across-the-board RVU adjustment.)

But a congressional override might not come next year, because skyrocketing healthcare costs have fueled the feds- desire to tighten up payouts and cut about 5 percent from their Medicare budget in 2007.

Providers got a first look at the changes CMS might make when the proposed physician fee schedule for 2007 premiered in June. The final fee schedule will be set in November, according to the Federal Register.

-Our current system is not sustainable, either from the standpoint of rising costs or quality of care,- CMS administrator Mark McClellan said of the need for a cut in overall payments.