Pulmonology Coding Alert

Watch out: 2007 fee schedule cuts $750 from 31730 to prevent double-billing
 
You'll receive a welcome hike to your frequently billed high-level office visit, hospital and critical care codes. The 2007 Medicare Physician Fee Schedule will deliver anywhere from almost an additional $10 to more than $18 for 99291.

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 5.1 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 on cutting the CF across the board.

The numbers: To keep the reimbursement rate the same, Congress approved a freeze on Dec. 9 that if passed will keep the CF at the current 2006 rate of 37.8975 instead of decreasing it to the scheduled 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.

If the scheduled CF reduction occurs, you would have still benefited from a slight overall gain in 2007. Averting the pay cut will mean the increase in payment to pulmonologists next year will be around 6 percent, not 1 percent, says Alan L. Plummer, MD, professor of medicine, Division of Pulmonary, Allergy, and Critical Care at Emory University School of Medicine in Atlanta.

2. Calculate Fees With Transitional RVUs

A freeze, however, does not mean 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 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. Cheer for Gain From Review

Pulmonary medicine emerges from the five-year work and PE review with more RVUs -- and will continue to experience increases. You can expect 6 percent more work RVUs in 2007 than in 2006. You'll receive an initial boost of 1 percent to your PE RVUs. Those values will go up an additional 1 percent by 2010. Your grand combined work and PE RVU total for the 2007-2010 period will be an increase of 8 percent.
 
Here are the percentage changes you can expect in other areas:

4. Welcome More Cognitive Credit

Look forward to more RVUs for problem-related E/M services. CMS is "implementing substantial increases in payments for 'evaluation and management services' such as office visits so that physicians can spend more time with their patients to manage their care and achieve better outcomes -- to reduce complications and avoid unnecessary tests and procedures," says a November 2006 press release from the CMS Office of Public Affairs. "This includes critical services that can help to prevent or detect early the underlying conditions for the top causes of death in women such as heart disease, stroke, diabetes, and pulmonary disease."

Because pulmonologists frequently bill high-level office visit codes (99213-99215), RVU hikes to those codes mean more money. "Pulmonologists use 99213-99215 most frequently for office visits, as well as new patient codes, consult codes, and hospital visit and ICU critical care codes for their patient evaluation codes, so an increase in payment for these codes will increase the payment to pulmonologists," Plummer says. "The combination of increases in E/M codes and no cut in overall payments is really good news for pulmonologists."

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,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 ...). That increase plus a slight PE expense raise results in an additional $10.23 ($7.05 without freeze) in office level-three visits or a $9.86 ($7.56 without freeze) increase for facility 99213s.
 
*Note: 2007 values, except work, listed in this article are all transitional. Numbers in parentheses indicate amounts without CF freeze.

Perhaps the most dramatic change you will notice is the increases in inpatient E/M services. For instance, level-one initial hospital care code 99221 (Initial hospital care, per day, for the evaluation and management of a patient ...) will gain 0.63 RVUs for a total of 2.43 up from 1.80 or more than $19 ($87.44 in 2007 compared to the 2006 national rate of $68.22).

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:

5. Applaud Critical Care Work Gain

Be grateful for increased work RVUs for adult critical care code 99291 (Critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes). "Critical care providers would have faced a cut had the Five-Year Review not been positive," says the Society for Critical Care Medicine (SCCM). If the CF reduction isn't stopped, billing 99291 in the facility would amount to a national rate of $208.44 in 2007, compared to $207.68 in 2006.

While this is only a slight increase, without the work increase the PE decrease would have resulted in a decreased payment rate. A CF freeze will pop these gains up to $273.24 in an office and $225.87 in a facility. Changes for 99291 include:
 
6. Avoid Losing $750 With 31730

The fee schedule reduces the physician expense RVUs for 31730 (Transtracheal [percutaneous] introduction of needle wire dilator/stent or indwelling tube for oxygen therapy) to account for the separately billable fast track supply tray contents. "The following supplies will be removed from the inputs for CPT 31730 because they are already contained in the fast track tray: alcohol pads, 6-cc syringe with needle, 27G needle and 4x4 gauze pads," according to page 135 of CMS-1321-FC.

CMS had accepted the $750 price that the association representing pulmonary physicians had recommended in its documentation specifying the contents of the fast track supply tray for 31730. But when CMS accepted that value codeable with SA091, it "did not remove the duplicated supply items from the PE database at that time."

Important: When performing 31730 in an office, make sure you code the tray separately with SA091 (Tray, scoop, fast track system tray). "The payment for 31730 to the nonfacility is $190.29, and $146.88 for the facility for 31730, far less than the $750 allowed for the fast track tray," Plummer says.

Private offices will get reimbursed directly for the supply, whereas outpatient hospitals are reimbursed through APCs, says Carol Pohlig, BSN, RN, CPC, ASC, senior coding and education specialist at the University of Pennsylvania department of medicine in Philadelphia. "Typically, trays and supplies are only paid by DMERCs for expenses that are directly incurred by the physician/group."