Regulatory changes that affect coding for immunotherapy

Here Comes the Sun: Medical Professionalism and the Implications of the Sunshine Act for Gastroenterology Practice

My Head is Spinning: An Overview of Reimbursement and Balance Disorders

Revision total knee arthroplasty for infection is challenging. Septic revisions, whether 1-stage or 2-stage, may require more time and effort than comparable aseptic revisions. However, the burden of infection may not be reflected by the relative value units (RVUs) assigned to septic revision compared with aseptic revision. The purposes of this study were to compare the RVUs of aseptic and septic revision total knee arthroplasties and to calculate the RVU per minute for work effort. The American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) database was analyzed for the years 2006 to 2017. The Current Procedural Terminology (CPT) code 27487 and the International Classification of Diseases, Ninth Revision (ICD-9) code 996.XX, excluding 996.6X, were used to identify all aseptic revision total knee arthroplasties (n = 12,907). The CPT code 27487 and the ICD-9 code 996.6X were used to determine all 1-stage septic revision total knee arthroplasties (n = 891). The CPT codes 27488 and 11981 were used to identify the first stage of a 2-stage revision (n = 293). The CPT codes 27447 and 11982 were used to identify the second stage of a 2-stage revision (n = 279). After 4:1 propensity score matching, 274 cases were identified per septic cohort (aseptic single-stage: n = 1,096). The RVU-to-dollar conversion factor was provided by the U.S. Centers for Medicare & Medicaid Services (CMS), and RVU dollar valuations were calculated. The septic second-stage revision was used as the control group for comparisons. The RVU per minute for the aseptic 2-component revision was 0.215, from a mean operative time of 148.95 minutes. The RVU per minute for the septic, 2-component, 1-stage revision was 0.199, from a mean operative time of 160.6 minutes. For septic, 2-stage revisions, the first-stage RVU per minute was 0.157, from a mean operative time of 138.1 minutes. The second-stage RVU per minute was 0.144, from a mean operative time of 170.0 minutes. Two-component aseptic revision total knee arthroplasty was valued the highest. Despite the increased complexity and worse postoperative outcomes associated with revision total knee arthroplasties for infection, the current physician reimbursement does not account for these challenges. This inadequate compensation may discourage providers from performing these operations and, in turn, make it more difficult for patients with periprosthetic joint infection to receive the necessary treatment. Therefore, the CPT code revaluation may be warranted for these procedures.

What Acute Care Nurse Practitioners Should Understand About Reimbursement

You have accessThe ASHA LeaderBottom Line1 May 2008Auditory Implants: Coding and Reimbursement Issues Steven C White Steven C White Google Scholar More articles by this author https://doi.org/10.1044/leader.BML.13062008.3 SectionsAbout ToolsAdd to favorites ShareFacebookTwitterLinked In The topic of cochlear implants, middle-ear implants, and brain-stem implants is an active one in the coding and reimbursement of audiology and speech-language pathology evaluation and treatment services. Specific Current Procedural Terminology (CPT) codes are related to testing and rehabilitation for prospective implant patients and patients who have received an implant. Robert Fifer and other members of ASHA’s Health Care Economics Committee have drafted and defended CPT proposals to the American Medical Association CPT Editorial Panel to ensure that appropriate codes are available to audiologists and speech-language pathologists to report auditory implant device-related procedures. These questions and answers focus on coverage and procedural coding of these services. Q: I am an audiologist and am seeing a Medicare beneficiary for auditory rehabilitation following a cochlear implant. Can I bill Medicare for CPT 92633 (auditory rehabilitation; postlingual hearing loss)? No. Medicare covers only diagnostic audiology services. The Medicare statute needs to be amended to permit audiologists to bill for rehabilitation services. ASHA is working to accomplish that goal. Q: I am an SLP and work in a hospital. Can the hospital bill Medicare for CPT 92633 (auditory rehabilitation; postlingual hearing loss) when I provide the procedure? No. Although SLPs can provide Medicare rehabilitation services, the Centers for Medicare and Medicaid Services (CMS) made the decision not to cover 92633—and also not to cover CPT 92630, auditory rehabilitation; prelingual hearing loss—to clarify that audiologists could not bill for the procedure. CMS instructs SLPs providing auditory rehabilitation to Medicare beneficiaries to use CPT 92507 (treatment of speech, language, voice, communication, and/or auditory processing). Q: Can the hospital, my employer, bill a private health plan (e.g., an employer-sponsored health plan) for CPT 92633 when I provide the service? I’m an SLP. The hospital definitely can bill a private health plan for CPT 92633. Only Medicare disallows CPT 92633. You may want to check the health plan’s Web site to ensure that 92633 is included in its medical policy. For example, Cigna has a Healthcare Coverage Position (0180) that specifically lists 92630 and 92633 as covered procedures when medically necessary (search “aural rehabilitation” on Cigna’s Web site). The summary of the Cigna coverage position states, “AR is indicated for the treatment of such impairment and is a medically necessary component of the management of cochlear device and auditory brainstem implantation.” Q: As an audiologist in private practice, can I bill a private health plan (e.g., an employer-sponsored health plan) for CPT 92633 when I provide the service? Yes, you can bill a private health plan for CPT 92633. Only Medicare disallows CPT 92633. As stated above, you may want to check the health plan’s Web site to ensure that 92633 is included in its medical policy. The Cigna policy is a good one for you to review to see how private health plans view AR. Q: I am a private-practice audiologist and have a Medicare provider number. What CPT code should I use when seeing a 15-year-old patient who has just had a cochlear implant? The code for this situation is CPT 92603 (diagnostic analysis of cochlear implant, age 7 years or older; with programming). For follow-up services you can use CPT 92604 (subsequent reprogramming). Q: I recently took a position as an audiologist in an auditory implant center. Is there a code for programming an auditory brainstem implant? I know Medicare covers the surgery. The correct code is CPT 92640 (diagnostic analysis with programming of auditory brainstem implant, per hour). Author Notes Steven C White, director of health care economics and advocacy, can be reached at [email protected]. Advertising Disclaimer | Advertise With Us Advertising Disclaimer | Advertise With Us Additional Resources FiguresSourcesRelatedDetails Volume 13Issue 6May 2008 Get Permissions Add to your Mendeley library History Published in print: May 1, 2008 Metrics Downloaded 443 times Topicsasha-topicsleader_do_tagleader-topicsasha-article-typesCopyright & Permissions© 2008 American Speech-Language-Hearing AssociationLoading ...

Psychiatric Collaborative Care for Patients With Respiratory Disease

Research Type: Level 3 - Retrospective cohort study, Case-control study, Meta-analysis of Level 3 studies Introduction/Purpose: The fee-for-service model in the United States healthcare system relies on work Relative Value Units (wRVUs), established by the Centers for Medicare and Medicaid Services (CMS). wRVUs are assigned to various clinical activities, including procedures and office visits, serving as a key metric for physician reimbursement and procedural valuation. While the number of wRVUs is reflective of multiple factors, physicians’ work such as effort, time, and technical expertise remain the primary determinants. Many orthopaedic foot and ankle (FA) procedures require substantial technical expertise, yet the adequacy of their compensation remains largely unexplored. This study evaluates whether orthopaedic FA surgeries are fairly compensated compared to other orthopaedic procedures. Methods: The National Surgical Quality Improvement Program (NSQIP) database from 2020 to 2022 was utilized for this study. Orthopaedic procedures performed by orthopaedic surgeons were identified using Current Procedural Terminology (CPT) codes. The CMS RVU dollar conversion factor was obtained from the 2025 CMS fee schedule. Identified procedures were categorized into orthopaedic FA group and non-FA group based on CPT codes. Compensation adequacy for FA procedures was assessed by comparing wRVUs, operative time, wRVU per hour (wRVU/h), and reimbursement rates ($/hour). We also analyzed the relationship between operative time and wRVU/h in FA procedures through polynomial regression analysis. Since a nonlinear relationship was identified in the linear regression analysis, polynomial regression analysis was performed. Additionally, perioperative complications, including mortality, readmission, and reoperation, were analyzed, along with secondary complications such as infections, thromboembolic events, respiratory complications, renal failure, transfusion, cardiac events, and sepsis, to compare procedural risk profiles between the two groups. Results: Twenty-three CPT codes for orthopaedic FA procedures accounting 8,684 cases were identified from 164 orthopaedic CPT codes. Compared to non-FA procedures, FA procedures demonstrated longer operative time (96.66 minutes Vs. 89.27 minutes, P<.001), and lower mean wRVU number (11.35 Vs. 17.68, P<.001). The mean wRVU/h and the reimbursement ($/h) were significantly lower in FA procedure group (8.77 Vs. 16.88, P<.001 and 283.53 Vs.539.44, P<.001, respectively). After adjusting for the effect of perioperative complication, the mean wRVU/h remained significantly (P <.001). Further, there is a tendency for wRVU/h to decrease as operative time increases in orthopaedic FA procedures: P<.001, R2=0.69, wRVU/h = 29.25 – 0.32*(operative time) + 0.000096*(operative time)2. The perioperative complication rate was higher in non-FA procedure group (11.88% Vs. 13.50%, P<.001). Conclusion: The current wRVU scale may not adequately compensate for orthopaedic FA procedures. Compared to non-FA orthopaedic procedures, FA procedures have lower wRVU/h despite longer operative times. Furthermore, a significant trend shows a decline in mean wRVU/h as operative time increases in orthopaedic FA procedures. These findings suggest a potential undercompensating of FA procedures. Are Orthopaedic Foot and Ankle Surgeries Undercompensated? Assessment of Work Relative Value Units in Orthopaedic Foot and Ankle Procedures Compared to Other Orthopaedic Procedures

Family Physicians Sue to Shine Light on RUC Deliberations, Claim Specialists Skew Reimbursement Against Primary Care

Facet injection trends in the Medicare population and the impact of bundling codes

ObjectiveInjection laryngoplasty (IL) is performed to correct glottic insufficiency. There has been a purported shift away from operative techniques in favor of awake, in‐office procedures, but no studies comparing utilization include updated current procedural terminology (CPT) coding. We analyzed the usage of operative versus awake injections CPT codes over 2 decades, recognizing that these encompass a broad array of injection procedures.Study DesignRetrospective database study.SettingUnited States Medicare Population from 2001 to 2022.MethodsUtilization and reimbursement data compiled by the US Centers for Medicare & Medicaid Services were queried for CPT codes encompassing awake injections (31513, 31573, 31574), operative ILs (31570, 31571), and operative medialization laryngoplasties (31588, 31591).Results10,186 injections were performed in 2022, a 195% increase from 2001. Awake injections grew by 412.77%, while operative injections grew by 134.75%. Operative injections are still more common (79.4% in 2001; 64.24% in 2022) and population‐adjusted use of 31571 grew between 2001 and 2021, while 31570 decreased. Since its adoption in 2017, awake IL code 31574 increased by 66.6%. From 2001 to 2006, the annual growth rate of awake injections was significantly lower than that of operative IL (P < .0001). From 2017 onwards, the awake IL growth rate was significantly higher than operative injections (P = .020).ConclusionsAwake injection utilization increased over the 22‐year period, as introduction of code 31574 coincided with a relative decline in operative and an increase in awake IL. Otolaryngologists may be implementing awake injections due to reduced recovery time and introduction of more specific CPT codes.

The Medicare Prescription Drug, Improvement, and Modernization Act and Centers for Medicare and Medicaid Services affirmation enabled pharmacists to use Current Procedural Terminology (CPT) codes for documentation and billing of clinical services. Despite legislative support and potential availability of pharmacists' clinical services, a gap may exist between the reported availability and actual prevalence of these services in real-world settings. The objective was to assess the prevalence of selected CPT codes (99605-99607, 98966-989968, and 99211-99215) in documenting and billing potential pharmacists' clinical services using recent available data. This retrospective study utilized the Merative MarketScan Medicare database from the period January 1, 2016, to December 31, 2020. The dataset included deidentified patient information and CPT codes. Patients with CPT codes for face-to-face medication therapy management (MTM) services (99605-99607), codes for telephonic assessment and management (A/M) services (98966-98968), and/or codes for evaluation and management (E/M) services (99211-99215) were identified from outpatient claims. Descriptive statistics, including prevalence rates, were calculated. This study was approved by an institutional review board and followed STROBE guidelines. There were claims data for 2,784,629 enrollees from 2016 through 2020. Prevalence rates varied during this period, with lower rates for MTM face-to-face CPT codes (0.06%) and telephonic A/M codes (0.58%), while E/M CPT codes showed higher prevalence rates (87%). Study findings exhibited a limited adoption rate for MTM CPT codes for billing pharmacists' clinical services. Future research may focus on assessing pharmacists' perceptions and identifying facilitators and barriers to using CPT codes in billing clinical services.

In the next version of International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) and Physicians’ Current Procedural Terminology (CPT®), you no longer will be able to wait until April 1 to start filing claims with new CPT codes and January 1 to start filing claims for ICD-9-CM codes. The Health Insurance Portability and Accountability Act of 1996 requires health care professionals to use the standard code sets in effect on the date of service noted on the claim. Therefore, CPT codes will be effective January 1, and you no longer will have the 90-day grace period. ICD-9-CM codes will be effective October 1. This change is supposed to make it easier for physician offices and payers to adjust their payment systems. The challenge will be making sure physician offices know what the new, revised, and deleted codes are, so they can start reporting them on the effective dates. Be on the lookout for the updated ICD-9-CM codes, which are published in the Federal Register in April or May each year, and the American Medical Association CPT coding book, which is published yearly in October.

Outcomes of open and endovascular repair for ruptured and nonruptured internal iliac artery aneurysms

A Rose by Any Other Name: A Brief Review of <i>ICD-9-CM</i> Diagnosis Coding

There is a paucity of data regarding financial trends for procedural reimbursements in otolaryngology. The purpose of this study was to evaluate monetary trends in Medicare reimbursement rates for the 20 most commonly billed otolaryngology procedures from 2000 to 2019. Analysis of physician reimbursement. The American Academy of Otolaryngology-Head and Neck Surgery database was queried to determine the 20 most performed otolaryngology procedures. Next, the Physician Fee Schedule Look-Up Tool from the Centers for Medicare and Medicaid Services was utilized to assess each of the top 20 most utilized Current Procedural Terminology (CPT) codes in otolaryngology, and reimbursement data was extracted. All monetary data was adjusted for inflation to 2019 U.S. dollars using changes to consumer price index. Average annual and total percentage change in reimbursement were calculated based on adjusted values for all included procedures. After adjusting for inflation, the average reimbursement for the total 20 procedures decreased by 37.63% from 2000 to 2019. The greatest single mean decrease was seen in CPT code 61782 for stereotaxis procedures on the skull, meninges, and brain (-59.96%), whereas the smallest mean decrease was in CPT code 30520 for septoplasty (-1.50%). From 2000 to 2019, the adjusted reimbursement rate for the combined procedures decreased by an average of 2.33% each year. Medicare reimbursement for included procedures has decreased from 2000 to 2019. Increased awareness and consideration of these trends will be important for policy makers, hospitals, and surgeons in order to assure continued access to meaningful otolaryngology care in the United States. 4 Laryngoscope, 131:496-501, 2021.