Pulmonology Coding Alert

The Health Care Financing Administration (HCFA) has promised to eliminate the 10 percent reduction in reimbursement for critical care that was instituted in 2000. As of January 2001, rates will return to their 1999 levels. Walter J. ODonohue Jr., MD, FCCP, representative to the American Medical Association CPT advisory committee for the American College of Chest Physicians and chief of pulmonary/critical care at the University Medical Center in Omaha, Neb., brings this good news from a meeting with the HCFA CPT editorial panel.

Some history helps explain why this is good news for pulmonary physicians. In 1999, the American Medical Association (AMA) made editorial changes to the explanatory notes describing critical care in the CPT manual . This change was necessary because the notes were vague, leading to varying interpretations by Medicare Part B carriers. ODonohue cites examples like critically ill and unstable. Like others, he asked what these terms really mean theyre all ambiguous. Although the revisions were not complete, they were approved in 2000.

The revisions were considered editorial only, by both the CPT editorial panel and the AMAs RUC (Relative Value Update Committee, the committee of practicing physicians from different specialties that recommends to HCFA what the physician work values should be). As a result of the determination that the changes were editorial, no change in work values was recommended by the RUC. ODonohue says, HCFA arbitrarily reduced compensation by 10 percent. A comprehensive home visit had more value than critical care by a physician.

HCFA Responds to the Medical Community

To answer the dissatisfaction of the medical community, HCFA listened to recommendations from representatives of the American College of Chest Physicians (ACCP), the National Association for Medical Direction of Respiratory Care, the Society of Critical Care Medicine, and the American Thoracic Society, as well as others in the medical community. As a result, at the May CPT editorial panel meeting, HCFA and the medical community agreed on changes to the CPT explanatory notes. The changes will be effective Jan. 1, 2001.

You can expect to see the 10 percent critical care reductions go away. ODonohue says there are studies that show critical care has higher value than the 1999 rates, but the RUC didnt elect to raise the rates above 1999 levels.

When the code descriptions were written in 1999, HCFA sent transmittals to the carriers about critical care reimbursements. ODonohue describes these transmittals as not friendly. HCFA promises to reissue transmittals to carriers with revised guidelines.

Patricia Booth, principal of the Government Representation with Quality (GRQ) healthcare consulting group in Chevy Chase, Md., also participated in the negotiations to return the rates to the 1999 levels. She says the compromise is a change that HCFA and the medical community could live with.

She tells of problems created when some carriers denied critical care after two days. Some carriers disagreed with the medical community about the term stable. As the carriers defined it, the patient was stable if vital signs are consistent, even if those readings were the results of medical interventions.

Booth says, Because of frequent denials of critical care billings, some physicians have been reluctant to submit claims for critical care. Some will downcode to hospital visits at lower rates. To illustrate how serious this is, Booth cites critical care at a relative work value of 3.6 and a hospital visit at 1.51. Sometimes a physician bills for a patient consultation, with a relative work value of 3.65, but he or she can get paid for only one consultation. After January 2001, the accurate critical care codes should result in fewer denials.