Wiki 45388 Fee

[ccosta]

Fellow Members,

Wondered if you could enlighten me as to why CMS has decided that Code 45388:Colonoscopy, flexible; with ablation of tumor(s), polyp(s), or other lesion(s) (includes pre- and post-dilation and guide wire passage, when performed); is worth $3,000.00 + and any other code within the same range [family] is only valued around $400.00 - $600.00?
I have been contacted by my C-team when they noticed the GI cost was extremely high. Contacted the local MAC First Coast Service Options, they did research and had to rely on the files they received from CMS for the fees, not knowing why it was so out of alignment, or if they knew of the increase. I was referred to the Final Rule for November 2015 which had the Fee schedule changes, nothing relating to the substantial increase in code 45388.
This doesn't seem correct?
We are considering the data input of the RVU is incorrect, however when looking at other MACs they have the same RVU with fees similar to local MAC.
I find it highly irregular that CMS would increase the fee for the same procedure performed in 2014 [45383] from $400.00 +/- to well over $3,000.00 +/- in 2016??

Any assistance with the reasoning behind this would be very helpful and put my administrators [including CMO, and CEO] at ease. If the increase was justified, they would like to know reasoning behind it, if it is an error, we could then proceed to make corrections.

Thank you in advance for your assistance.

Carl W. Costa RHIT, CPC, CDIP
Holly Hill, FL

 

[helenadutoit@comcast.net]

Maybe it is because the instrument - laser is so expensive to purchase. I have often come across incorrect coding when I have read the op report closely. Sometimes physicians get confused with ablation and removal. It is generally accepted that if the CPT code 45388: Colonoscopy, flexible; with ablation of tumor(s), polyp(s), or other lesion(s) (includes pre- and post-dilation and guide wire passage, when performed); is being utilized, the polyp(s), tumor(s), or other lesion(s) are ablated with laser. Nothing is left over to be removed. If a physician states in the op note that he ablated polyps, tumors or other lesions and removed them via snare, that is technically not 45388, but 45385. Laser equipment is extremely expensive. That is only my opinion why CMS has such a high fee for this code.

Fellow Members,

Wondered if you could enlighten me as to why CMS has decided that Code 45388:Colonoscopy, flexible; with ablation of tumor(s), polyp(s), or other lesion(s) (includes pre- and post-dilation and guide wire passage, when performed); is worth $3,000.00 + and any other code within the same range [family] is only valued around $400.00 - $600.00?
I have been contacted by my C-team when they noticed the GI cost was extremely high. Contacted the local MAC First Coast Service Options, they did research and had to rely on the files they received from CMS for the fees, not knowing why it was so out of alignment, or if they knew of the increase. I was referred to the Final Rule for November 2015 which had the Fee schedule changes, nothing relating to the substantial increase in code 45388.
This doesn't seem correct?
We are considering the data input of the RVU is incorrect, however when looking at other MACs they have the same RVU with fees similar to local MAC.
I find it highly irregular that CMS would increase the fee for the same procedure performed in 2014 [45383] from $400.00 +/- to well over $3,000.00 +/- in 2016??

Any assistance with the reasoning behind this would be very helpful and put my administrators [including CMO, and CEO] at ease. If the increase was justified, they would like to know reasoning behind it, if it is an error, we could then proceed to make corrections.

Thank you in advance for your assistance.

Carl W. Costa RHIT, CPC, CDIP
Holly Hill, FL

 

[CodingKing]

I can't access the in depth RVU breakdown from 2014 (i use find a code and there is a ton of cost basis info behind the RVU calculation) but for instance with today's codes:

45388 requires use of "radiofrequency generator, endoscopy" w/ average purchase price of $108,000 w/ 5 years of equipment life which is additional to say what is needed equipment wise w/ the snare. There is an additional direct supplies expense for "catheter, RF ablation, endoscopic" which on average costs $1,700 on top of supplies for snare removal.

I attached PE RVU breakdown of 45385 (snare technique) vs 45388 (RFA technique)

 

[thomas7331]

CodingKing, would you be willing to share your source as to where to find the information on details of the RVU PE calculation? I've looked for this information on the CMS and CFR sites without success and it would be very helpful for me. Thanks!

 

[CodingKing]

CodingKing, would you be willing to share your source as to where to find the information on details of the RVU PE calculation? I've looked for this information on the CMS and CFR sites without success and it would be very helpful for me. Thanks!

I have a subscription to findacode.com professional for my encoder which includes the information. I'm not sure what the underlying source is. I can backdate but only as far back as I have been a subscriber.

 

[ccosta]

Maybe it is because the instrument - laser is so expensive to purchase. I have often come across incorrect coding when I have read the op report closely. Sometimes physicians get confused with ablation and removal. It is generally accepted that if the CPT code 45388: Colonoscopy, flexible; with ablation of tumor(s), polyp(s), or other lesion(s) (includes pre- and post-dilation and guide wire passage, when performed); is being utilized, the polyp(s), tumor(s), or other lesion(s) are ablated with laser. Nothing is left over to be removed. If a physician states in the op note that he ablated polyps, tumors or other lesions and removed them via snare, that is technically not 45388, but 45385. Laser equipment is extremely expensive. That is only my opinion why CMS has such a high fee for this code.

Thank you for this information, now the fee associated with this code starts to make sense. Will convey to administration so we can make adjustments.
Thanks
Carl

 

[ccosta]

I can't access the in depth RVU breakdown from 2014 (i use find a code and there is a ton of cost basis info behind the RVU calculation) but for instance with today's codes:

45388 requires use of "radiofrequency generator, endoscopy" w/ average purchase price of $108,000 w/ 5 years of equipment life which is additional to say what is needed equipment wise w/ the snare. There is an additional direct supplies expense for "catheter, RF ablation, endoscopic" which on average costs $1,700 on top of supplies for snare removal.

I attached PE RVU breakdown of 45385 (snare technique) vs 45388 (RFA technique)

View attachment 2926

Coding King,

Thank you for all the information including the file with RVU breakdown, this was very helpful as sometimes visuals are the best form of communication. This really shows why the fee is so high.
Thanks
Carl