Otolaryngology Coding Alert

2007 fee schedule still raises cognitive services- work RVUs

The 2007 Medicare Physician Fee Schedule's increased values for 99213 may not provide your bottom line with a substantial boost, but at least you won't see that bottom line shrink due to the previously scheduled payment cuts.

1. Applaud Probable Rate Freeze

Congress heard your cries and froze the payment cut for 2007. -There was an outcry from numerous physicians and physician associations to the planned 5 percent cut to the conversion factor (CF),- says Russ Still, executive vice president of Medical Management Associates in Atlanta. To increase values for cognitive services like 99213 and 99214 while maintaining mandated budget neutrality, CMS had planned to cut the CF across the board.

The numbers: To keep the reimbursement rate the same, Congress passed a freeze on Dec. 9 that, if enacted, will keep the CF at the current 2006 rate of 37.8975 instead of decreasing it to the proposed 2007 rate of 35.9848. -President Bush is expected to sign the measure in the next week,- says Robert B. Doherty, senior vice president of governmental affairs and public policy for the American College of Physicians.

2. Calculate Fees With Transitional RVUs

A freeze, however, does not mean CPT code payments will remain the same in 2007. Because of the five-year review, the CF tells only part of the story, Still says. To calculate a CPT code's payment, you also need to look at any changes to the code's work and practice expense (PE) relative value units (RVUs).

Do this: When determining a code's payment rate, make sure to choose the total RVU that represents the current year. -The transitional columns [P and R] indicate the current values that apply,- Still says. To get a long-range look at what you can expect those values to ultimately become, look to the code's fully implemented total RVUs (columns Q and S), which will become effective in 2010.

3. Expect Cognitive Work Hike Despite Objections

Higher RVUs for some E/M services make a difference for some ENTs, but the hike won't matter much, says Andrew Borden, CCS-P, CPC, reimbursement manager in the department of otolaryngology and communication sciences at the Medical College of Wisconsin in Milwaukee. -The majority of our income is from surgical and procedural coding.-

Example: CMS assigned an additional 0.25 work RVUs to 99213 (Office or other outpatient visit for the evaluation and management of an established patient ...). That increase, plus a slight PE raise, will result in more than an additional $9-10 for level-three visits as noted below:
    
*Note: 2007 values, except work, listed in this article are all transitional and use the 2006 CF of 37.8975.

The American Academy of Otolaryngology -- Head and Neck Surgeons (AAO-HNS) objected to these increases for two reasons when CMS proposed them:

Reason 1: -- the proposed increases are excessive and unsupported by a careful analysis of the data, including an analysis of the [intra-service work per unit of time] IWPUT,- according to CMS-1321-FC page 546-548.

Reason 2: The IWPUTs that result -are illogical within families of codes and exceed the levels of many complex surgical procedures.-

CMS agreed with primary-care physicians that there was a need for a change to the current work RVUs. -There has been a change in the complexity of the patient population resulting in more diagnoses per encounter and more ambitious management goals,- according to CMS-1321-FC page 548. CMS addressed the concerns expressed by the AAO-HNS in the final rule as follows:

Explanation 1: -We are not yet convinced about the validity of the IWPUT analysis when applied to such -cognitive- services, particularly if such an analysis were to be used to negate the findings of acceptable surveys,- CMS explained in the final rule.

Explanation 2: If the increases would cause some rank order anomalies, the relative update committee (RUC) and the specialties involved should instead handle this.

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

4. Expect Same ENT Bottom Line

Otolaryngology emerges from the five-year review even across the board. -There is some question as to the accuracy of the 0 calculation,- says Charles F. Koopmann Jr., MD,MHSA, AAO-HNS coordinator for practice affairs and professor and associate chair at the University of Michigan's department of otolaryngology in Ann Arbor.

According to CMS calculations in the final rule, you can expect 0 percent more work RVUs in 2007 than in 2006. Plus, you-ll receive no total increase or decrease to your PE RVUs in 2007 or by 2010. Your grand combined total allowed charge impact for work and PE RVU changes for the 2007-2010 period will be a flat 0 percent.

Audiology services will take a major hit with an overall PE and work change decrease of 4 percent. This is due to the elimination of the nonphysician work pool, under which audiology services are reimbursed.