Neurosurgery Coding Alert

Greater payer scrutiny would certainly accompany higher RVUs

In the recent 2007 proposed physician fee schedule, the relative value units (RVUs) for many procedures were reduced, though neurosurgery practices could enjoy RVU increases for several surgeries.

There are two reasons for the drastic cuts in procedure RVUs, according to the Centers for Medicare & Medicaid Services (CMS):

- Medicare desperately needs to lower costs and is shooting to trim about 5 percent from its overall payments in 2007.

- CMS wants to assign higher RVUs to -cognitive- services like evaluation and management.

Not all healthcare professionals are thrilled with the move to make E/M codes more profitable. -The problem with this is it gives with one hand (increased E/M RVUs), and it takes with another (decreased procedure RVUs),- says Barbara McAneny, a physician in Albuquerque, N.M., and member of the Practicing Physicians Advisory Council (PPAC).

And the increased E/M RVUs will likely mean that payers will be watching your high-level E/M claims carefully. Read on for a breakdown of the proposed E/M increases and some instruction about making your claims stand up to increased attention from insurers.

99213 Nominated for Big RVU Bump

One of the E/M services the proposed schedule sets for an RVU boost to is the level-three established patient office visit (99213, Office or other outpatient visit for the evaluation and management of an established patient, which requires at least two of these three key components: an expanded problem-focused history; an expanded problem-focused examination; medical decision-making of low complexity).

In 2006, the RVUs for 99213 were 0.94. According to the proposed Physician fee schedule, 99213 in a hospital facility could be worth 1.23 RVUs in 2007, more than 30 percent higher (23 percent higher in a physician's office).

However, the increased RVUs may come wrapped in red tape, experts say. Whenever RVU levels are increased, intensified payer scrutiny is sure to follow. If your office already observes strict guidelines about reporting the appropriate E/M level, you should have nothing to worry about.

But if your neurosurgery office has had problems with E/M coding in the past -- especially upcoding -- you may want to review your practices before 2007. -As always, just make sure the medical necessity and operative report support the criteria for the code,- says Rena Hall, CPC, coder for the Kansas City Neurosurgery Group in Missouri.

Try this: Make your 99213 claims audit-proof by satisfying all of the requirements of a level-three visit and proving medical necessity via excellent ICD-9 coding. And never, under any circumstances, file a claim with an inflated E/M level.

Example: A patient who had a cervical fusion a year ago is seen for recurrent neck pain. The surgeon reviews MRI findings, which show an intact fusion with no dislocation, then prescribes a mild pain medication and muscle relaxant, and schedules a follow-up visit. On the claim, be sure to attach ICD-9 code 723.1 (Cervicalgia) to 99213 to prove medical necessity for the level-three visit.

Other E/M RVU changes: In addition to upping RVUs for 99213, the proposed schedule also calls for significantly increased RVUs for these E/Ms:

- 99204 -- Office or other outpatient visit for the evaluation and management of a new patient, which requires these three key components: a comprehensive history; a comprehensive examination; medical decision- making of moderate complexity. Proposed RVU increase: 2.83 (2006) RVUs to 3.13 (2007) in a facility, 3.62 to 3.91 in a physician office.

- 99205 -- ... a comprehensive history; a comprehensive examination; medical decision-making of high complexity. Proposed RVU increase: 3.77 to 4.06 facility, 4.60 to 4.94 office.

- 99214 -- ... a detailed history; a detailed examination; medical decision-making of moderate complexity. Proposed RVU increase: 1.56 to 1.91 facility, 2.18 to 2.57 office
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- 99215 -- ... a comprehensive history; a comprehensive examination; medical decision-making of high complexity. Proposed RVU increase: 2.50 to 2.69 facility, 3.17 to 3.47 office.

Perhaps most dramatic will be the increases in inpatient E/M services, all of which could see RVU increases ranging from 7.9 percent for 99255 (Initial inpatient consultation for a new or established patient, which requires these three key components: a comprehensive history; a comprehensive examination; and medical decision-making of high complexity) to 43.2 percent for 99251 ( ... a problem-focused history; a problem-focused examination; and straightforward medical decision-making).

Best bet: Be sure to bill all appropriate E/M services, especially when allowed during the global period -- but your documentation must support the services. If you observe this rule, your E/M coding patterns should not be so skewed as to trigger a payer audit.