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AUA Coding and Reimbursement Committee

May 2010 Report

Respectfully submitted by David H. Kauder, MD., FACS

This is my report as the New England Section representative to the AUA’s Coding and Reimbursement Committee (CRC) meeting that was held during the annual meeting in San Francisco.  Some of the committee’s business is proprietary and not up for publication at this time.  The charge of the committee is to review requests from membership or industry for  new procedures and technologies to see if they deserve a CPT code.  Once the proposals have met the criteria established by the American Medical Association, the AUA will support the creation of a new Category I CPT code or if criteria are not met, a Category III CPT code.  Category III Tracking codes are essentially data collection codes.  Category III CPT codes are carrier priced.    The American Medical Association has established criteria and the CRC has aligned their review process with AMA CPT Panel criteria.  If a procedure or technology passes a rigorous process, it may be granted a  Category I CPT code. The Category I CPT code is necessary for any procedure or new technology to receive reimbursement from insurers.  After the CPT code has been approved, it then it passed through the rigorous AMA Relative Value Update Committee (RUC) process.  During the RUC process,  a CPT code is assigned the RVU or relative value units for the physician work involved in the service/procedure, practice expense and professional liability that help determine YOUR FEES.  The RVUs are then sent to the Centers for Medicare and Medicaid Services (CMS) for final approval and publication in the Federal Register in November 2010.  The AMA CPT Panel and RUC meets three times per year and if new codes or re-review, surveys will be sent out for completion by our members. 

Every five years the AMA “asks” us to survey our members on codes considered mis-valued by CMS.   The fourth Five Year Review occurs in2010 and thirteen common urologic procedures listed below. There were an additional 9 codes surveyed in 2008 where some questions on the site of service were questioned and the AUA was asked to comment on the codes to determine if they were valued correctly.  All codes during this survey cycle will be reviewed at the October 2010 RUC meeting.  The results of the survey may  have significant effects on the RVUs and thereby the fees you receive.

How does the AUA get survey information?  Exactly as it sounds – The AUA will send out a survey request and a link to the online survey.  It is extremely important that you help if you are asked to fill out a survey.  The AUA needs 30 responses to validate a survey.  To get to this they send out 1,400 emails and it is a struggle to get to the 30. The surveys are the key to the data needed for the RUC to determine your fees.  Stephanie Stinchcomb from the AUA spoke to the MAPU annual meeting regarding surveys last year.

It is important that the survey respondents answer all questions as accurately as possible.  Consideration should be given to the time pre-operative time, intra-service time and post-operative times.    If you get a request from the AUA, PLEASE ANSWER AND HELP OUT.

Diagnosis coding for cancer versus history of cancer

If you are treating a patient for a malignancy, you should be using the usual ICD-9 diagnosis code for that malignancy.  However, if the cancer is no longer present and you are following the patient, using the V-code diagnosis which is personal history of cancer X is appropriate.  This would be true even for the patient that is undergoing a surveillance cystoscopy and no tumor is found.  The diagnosis should be the V-code for personal history of bladder cancer.  Using a v-code should have no effect on the reimbursement by any payors.  The official guidelines for ICD-9-CM are listed below:

ICD-9-CM Official Guidelines for Coding and Reporting Effective October 1, 2009

Primary malignancy previously excised

When a primary malignancy has been previously excised or eradicated from its site and there is no further treatment directed to that site and there is no evidence of any existing primary malignancy, a code from category V10, Personal history of malignant neoplasm, should be used to indicate the former site of the malignancy. Any mention of extension, invasion, or metastasis to another site is coded as a secondary malignant neoplasm to that site. The secondary site may be the principal or first-listed with the V10 code used as a secondary code.Admissions/Encounters involving chemotherapy, immunotherapy and radiation therapy or Episode of care involves surgical removal of neoplasm

When an episode of care involves the surgical removal of a neoplasm, primary or secondary site, followed by adjunct chemotherapy or radiation treatment during the same episode of care, the neoplasm code should be assigned as principal or first-listed diagnosis, using  the standard ICD-9 codes that have been used not the “V-code” for history of cancer.

PQRI - Eligible professionals who successfully report in 2010-11 would receive a one percent bonus and 2012-14 would receive a 0.5 percent bonus.  However, PQRI will become mandatory in 2015 and those who fail to participate will face a 1.5 percent penalty, which will increase to 2 percent in 2016 and thereafter

Legislative Leadership Conference
 
On March 24th, 2004 several MAPU Board Members participated in the Massachusetts Medical Society’s Legislative Leadership Conference held at MMS Headquarters.
 
Drs. Jeffrey Steinberg, Susan Pursell and Jerry Rittenhouse represented the state’s urologists in this interactive workshop to improve advocacy efforts at the state and federal levels.
 
Skills building sessions included challenging role-playing scenarios on various topics including:

“ How to Testify: When You Have Two Minutes to Tell Your Story and No One Seems to be Listening”

“ Black and White and Read All Over: Making Your Case To the Media and the Public”
 
“ Making It Happen: Grassroots Strategies for Your District,Alliance and Specialty Societies”

In addition, attendees met with State Senator Robert Havern (D-Arlington) to get first hand feedback on how to communicate effectively with legislators.
 
In summary, your MAPU colleagues gained valuable skills to further our important legislative agenda with our elected officials – a very worthwhile experience!

Printable version of Newest Health Legislation

Here is a list of legislative issues from the past several years and a collection of position papers compiled by the American Urological Association.

http://www.auanet.org/govtaffairs/