By Lucian Newman III, MD
In reality, 2014 is little different from the past in terms of Current Procedural Terminology (CPT) code changes. Each year, the American Medical Association (AMA) releases updates to reflect changes in the way physicians report the work they perform via the CPT reporting system. Initially developed in 1966 as a way to report work done by providers, it was modified in 1970, and by 1983 was mandated by Medicare as the system to be used to report the work performed by physicians and non-physicians alike.
The original intent was not meant to be a vehicle to bill insurance carriers, but it is the basis now. This year, the AMA announced 335 changes to the CPT that include roughly 9,700 entries. The changes involve code additions, deletions and revisions. As a historical comparison, in 2010 there were 219 new codes, 141 revisions and 63 deletions. In 2012, there were 278 new codes, 139 revisions and 98 deletions.
Each modification is intended to reflect changes in the way we practice adopting new approaches accordingly. The immense undertaking is broken down annually to address the items needing critical attention. Nearly 25% of the 2014 CPT update is devoted to upper endoscopy, while lower gastrointestinal (GI) procedures will be addressed in 2015.
It would be prudent for all to understand the process by which these changes occur. The CPT exists to create a consistent system to report work to Medicare and Medicaid as well as most private third-party payors. In this manner, a fee schedule is produced for reimbursement.
The CPT is maintained by a committee that includes 11 physicians who are nominated by the representative medical societies. As changes in practice require CPT changes, the work group reviews these ideas to make recommendations to the Relative Value Scale Update Committee (RUC). This committee is composed of 31 members, 21 of whom are nominated by a broad cross section of medical specialty societies (Table).
The criteria for review are known as screens and include site of service anomalies, fast-growing procedures and new technologies, among others. The reviews may look at low value/high frequency codes, bundling issues and unused codes, as well as any codes that influence the balance of the CPT process.
The resource-based relative value scale (RBRVS) system is also pertinent to discuss. In the RBRVS system, payments for services are determined by the resource costs needed to provide them. The cost of providing each service is divided into three components: physician work, practice expense and professional liability insurance. Payments are calculated by multiplying the combined costs of a service by a conversion factor (a monetary amount that is determined by the Centers for Medicare & Medicaid Services). Payments are also adjusted for geographic differences in resource costs (www.ama-assn.org).
Specifically, 2014 includes changes as mentioned to upper endoscopy, abscess drainage with image guidance, breast biopsies with image guidance, radiological and cardiology embolization procedures, and molecular pathology diagnostic codes. As expected, when changes occur, there are intended and unintended consequences.
The American Society of Breast Surgeons and the Society of Breast Imaging have opposed the reductions that will affect physicians in non-facility settings. The new payment bundling system will include the biopsy and the localization service together, resulting in a lower total reimbursement. If insufficient reimbursement is the result, the fear is that more invasive open biopsies will be done. Imaging service, in general, is the recipient of substantial cuts in 2014. It is anticipated that radiation therapy centers will be cut by approximately 13%, radiation oncology by 5%, diagnostic testing by 7%, interventional radiology by 3% and nuclear medicine by 3%.
The gastroenterology code changes include new codes, revised codes and the addition of sedation options. The focus on upper GI procedures separates rigid and flexible approaches to therapeutic interventions. Newer therapeutic options are described. As always, the exact description by the physician is required to bill the specific code. All too often, the report produced by the proceduralist is not specific enough to distinguish between the CPT codes.
The take-home message is that as medicine changes, our ability to differentiate between approaches becomes more difficult. We are moving to ICD-10 in 2014, and similarly, the diagnostic specificity is paramount. ICD-10 PCS [procedure coding system] is the facility analog to the physicians’ CPT. It also has requirements that documentation must accommodate to generate accurate reimbursement. Adopting a strategy to survive professionally in the future seems imperative. Software solutions are being developed to help in these endeavors.
Dr. Newman is founder and CMO of ComplyMD (complymd.com), a company that provides procedural documentation solutions. He is a general surgeon in Gadsden, Alabama.