BACKGROUND.doc

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BACKGROUND.doc

  1. 1. REPORT OF THE BOARD OF TRUSTEES B of T Report 8 - I-00 Subject: Appropriate Use of Component Codes in Current Procedural Terminology (CPT) Presented by: D. Ted Lewers, MD, Chair Referred by: Reference Committee H (Eugenia Marcus, MD, Chair) ----------------------------------------------------------------------------------------------------------------------- 1 2 3 4 5 6 7 8 9 10 11 12 13 14
  2. 2. B of T Rep. 37 - A-99 -- page 2 Resolution 816 (A-00) “Support for Component Coding” from the Society of Cardiovascular and Interventional Radiology called on the American Medical Association (AMA) to support development of educational materials designed to encourage appropriate use of CPT codes, such as the appropriate use of component coding, by payors. The House of Delegates adopted a substitute resolution that contained stronger language to reinforce the importance of appropriate use of CPT codes. The following substitute resolution was adopted: “That the AMA aggressively pursue the appropriate use of coding through development of educational materials on component coding with a report back to the House for I-00” In response to this resolution, the following report has been prepared. It discusses the origin and intention of component coding, current educational resources, existing AMA policy and the source of problems. Finally, recommendations are made. BACKGROUND In the most general terms, component coding is the use of more than one CPT code to describe a service. Typically a single CPT code inclusively describes all aspects of a single service performed by a single health care professional. Exceptions to this involve the use of modifier -62 for co- surgeons and modifier -66 for a team of surgeons. Also, in instances where more that one service is performed, modifier -51 and or applicable add-on codes without the modifier are used to describe multiple procedures performed at the same session by the same physician. The rules for component coding are an exception to typical CPT coding of one code for one service. However, they exist because the services provided as component codes are a combination of distinct services often delivered by different physicians, but required to perform a single therapeutic intervention. Component coding is used in cardiology and interventional radiology services to describe the radiologic supervision and interpretation (S&I) that is needed to perform a therapeutic procedure which also may require the use of more than one CPT code. Prior to 1992 and the adoption of the Resource Based Relative Value Scale (RBRVS) by the Health Care Financing Administration (HCFA) CPT contained two methods for describing interventional radiology services. There were “complete procedure” codes where the therapeutic intervention and the S&I were combined in one code and there were “component codes” where procedure codes were used in conjunction with appropriate S&I codes that were oriented around the types of procedure and anatomy. With the advent of the RBRVS, the two methods were abandoned for a more uniform component approach which was believed to be more equitable for physicians who perform S&I apart from the therapeutic service and more efficient for payors by eliminating confusion caused by having two systems. Component coding is a method of coding that allows radiologic S&I codes to be used in conjunction with procedural codes. The coding for cardiology and interventional radiology services is arranged in this manner to accommodate the common occurrence of one physician performing the therapeutic intervention and another doing the S&I. If a single physician does both, the procedure code and the S&I code can be reported. In addition, some interventional services also use catheter placement codes since there are multiple diagnostic and therapeutic interventions that are possible after the catheter is inserted (i.e. balloons or stents). The multitude of possible percutaneous interventions to describe each order of vessels in a family (i.e. first order brachiocephalic) would require several hundred unique codes if all services, catheter placement, intervention and S&I, were included in a single service. For example, the therapeutic intervention transluminal balloon angioplasty, percutaneous; venous (35476) may use code 36011, Selective 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49
  3. 3. B of T Rep. 37 - A-99 -- page 3 catheter placement, venous system; first order branch (eg renal vein, jugular vein) for the placement of the catheter and code 75978, transluminal balloon angioplasty, venous (eg, subclavian stenosis), radiological supervision and interpretation, for the S&I. DISCUSSION Resolution 816 pertains to the development of education material as a means to induce compliance with CPT guidelines on component coding. Instructions for component coding are relatively simple and are explicitly contained in a number of publications including the CPT Book, CPT Assistant, Principles of CPT Coding, CPT Changes 2001: An Insiders View, Coding Guide for: Radiology (Coding Strategies Incorporated, 1999), Interventional Radiology Coding Users’ Guide (Society of Cardiovascular and Interventional Radiology, the American College of Radiology, the Radiology Business Management Association and the American Healthcare Radiology Administrators, 1995) and HCFA’s Medicare Carrier Manual. Guidelines for use of component codes are made very clear in the CPT Book. The Supervision and Interpretation section of the Radiology Guidelines states: When a procedure is performed by two physicians, the radiologic portion of the procedure is designated as “radiological supervision and interpretation.” When a physician performs both the procedure and provides imaging supervision and interpretation, a combination of procedure codes outside the 70000 series and imaging supervision and interpretation are to be used. In addition, CPT uses cross references following procedure codes to direct users to the correct S&I code and cross references following each S&I code directing users to the different procedure codes. The arteries and vein subsections of the cardiovascular section and the cardiac catheterization subsection of the Medicine section provide guidelines for use of catheter placement codes. CPT Assistant, August 1996, reviews noncoronary angioplasty services and states that “in addition to the codes for the intervention aspect of the procedure, codes for catheter placement and the radiologic supervision and interpretation should also be reported”. This issue of the Assistant explains why component coding was developed and offers a clinical vignette to illustrate the correct application of CPT codes and guidelines. Additional issues of the CPT Assistant from Fall 1993 and April 1998 explain catheter placement with respect to selective vessel ordering. Principles of CPT Coding a new AMA publication for 2000, was designed as a guide for learning and using CPT, not as a substitute to the CPT book. The rules for coding interventional radiology services are reviewed in detail as well as the rationale for the component approach. Anatomy is also discussed since appropriate coding for catheter placement depends on a through understanding of the vascular system. Principles of CPT Coding makes use of anatomic illustrations and clinical vignettes to demonstrate correct application of CPT component coding guidelines. CPT Changes 2001: An Insider’s View was a new AMA publication for 2000. This book explains in great detail all the changes for CPT in any given year. It contains illustrations, clinical vignettes, and rationales for why the codes were developed. CPT 2001 has new codes for endovascular repair of abdominal aortic aneurysm. Since this new procedure is reported using component codes, the book reviews component coding. Also, the use of parenthetical statements or instructions following codes is highlighted as a method of directing users to the correct S&I codes. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49
  4. 4. B of T Rep. 37 - A-99 -- page 4 The Coding Supervision and Interpretation Services section in Coding Guide for: Radiology includes the above language from the CPT guidelines and adds an example of cardiac procedures that require both a radiologist and a cardiologist to be present. In this case the radiology portion is billed as a separate S&I code. The Guide also describes HCFA policy on the use of S&I codes and gives examples. The Interventional Radiology Users’ Guide goes into great detail describing 54 common interventional procedures and how they should be coded using component codes. It also reviews commonly asked questions and responses. This guide provides anatomic definitions and procedure explanations. Another detailed explanation of component coding is available in the Medicare Carrier Manual. The following excerpt is from HCFA’s Medicare Carriers Manual, Part 3, Chapter 15, FEE SCHEDULE FOR PHYSICIAN SERVICES E. Supervision and Interpretation (S&I) Codes and Interventional Radiology.-- 1. Physician Presence.--Radiologic S&I codes are used to describe the personal supervision of the performance of the radiologic portion of a procedure by one or more physicians and the interpretation of the findings. In order to bill for the supervision aspect of the procedure, the physician must be present during its performance. This kind of personal supervision of the performance of the procedure is a service to an individual beneficiary and differs from the type of general supervision of the radiologic procedures performed in a hospital for which intermediaries pay the costs as physician services to the hospital. The interpretation of the procedure may be performed later by another physician. In situations in which a cardiologist, for example, bills for the supervision (the "S") of the S&I code, and a radiologist bills for the interpretation (the "I") of the code, both physicians should use a -52 modifier indicating a reduced service, e.g., the interpretation only. Pay no more for the fragmented S&I code than you would if a single physician furnished both aspects of the procedure. 2. Multiple Procedure Reduction.--Make no multiple procedure reductions in the S&I or primary nonradiologic codes in these types of procedures, or in any procedure codes for which the descriptor and RVUs reflect a multiple service reduction. For additional procedure codes that do not reflect such a reduction, apply the multiple procedure reductions set forth in §15038. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37
  5. 5. B of T Rep. 37 - A-99 -- page 5 The instructions for use of component codes under the Medicare program are quite explicit and HCFA has correctly exempted component codes from the multiple surgical reduction, but allows for the S&I portion to be split between physicians. They also specified criteria to assist in determining if a physician can bill for S&I. According to Medicare, the physician must be present to bill the S&I portion of a procedure with a separate S&I code. This distinguishes S&I as part of a therapeutic service from general radiologic S&I performed as a service to a hospital. Policy The issue of correct use of CPT component codes involves compliance with well established CPT coding guidelines on the use of S&I codes. Significant AMA policy exists on bundling and use of CPT Guidelines. The AMA Policy Database includes:  Policy H-70.949 which calls on the AMA to (1) advocate and take steps to ensure that public and private payors do not bundle services inappropriately by encompassing individually coded services under other separately coded services unless specifically addressed in CPT guidelines; and (2) enhance and fully coordinate its activities to prevent the inappropriate bundling of CPT codes (and other coding systems for supplies, injections, etc) used for payment by both public and private payors.  Policy H-70.937 states that the AMA: (1) vigorously opposes the practice of unilateral, arbitrary downcoding and/or bundling by all payers; (2) makes it a priority to establish national standards for the appropriate use of CPT codes, guidelines, and modifiers and to advocate the adoption of these standards; (3) should formulate a national policy for intervention with carriers or payers who use unreasonable business practices to unilaterally downcode or inappropriately bundle physician services, and support legislation to accomplish this; and (4) along with medical specialty societies, call on its members to identify to our AMA specific CPT code bundling problems by payers in their area and that our AMA develop a mechanism for assisting our members in dealing with these problems with payors.  Policy H-70.954 calls on the AMA to (1) continue to seek endorsement of Current Procedural Terminology (CPT) as the national coding standard for physician services; in collaboration with state and specialty societies, urge the Secretary of HHS and HCFA and all other payers to adopt CPT as the single uniform coding standard for physician services in all practice settings; and will oppose the incorrect use of CPT by insurers and others, taking necessary actions to insure compliance with licensing agreements, which include provisions for termination of the agreement; (2) work with the American Academy of Pediatrics and other specialty societies to support state and federal legislation requiring insurers to follow the coding as defined in the Current Procedural Terminology Manual and interpreted by the CPT Assistant for all contracts in both the public and private sectors, as long as the CPT process is simple, user friendly, and does not undergo frequent changes; and (3) seek legislation and/or regulation to ensure that all insurance companies and group payors recognize all published CPT codes including modifiers.  Policy H-70.962 states that the AMA introduce or support legislation or regulation that would require that managed care plans be monitored and prohibited from the arbitrary and inappropriate bundling of services to reduce payment to participating physicians; and that the medically indicated patient services such as consultations and diagnostic procedures provided by physicians on the same day be paid on a separate basis in conformity with the AMA Current Procedural Terminology (CPT) coding policy and not inappropriately bundled as they currently are by managed care plans. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47
  6. 6. B of T Rep. 37 - A-99 -- page 6 Conclusion The CPT guidelines for component coding are relatively simplistic and directly addressed in the CPT Book, other AMA coding resources, specialized coding products, and in HCFA’s Medicare Carrier Manual. Since the rules for component coding are well documented and distributed in a variety of educational publications, it appears that the problem of appropriate use of component coding is not a matter of developing educational materials. The central issue is compliance with established CPT guidelines. Current AMA policy on the importance of following CPT guidelines as laid out in the CPT Book and other AMA coding resources adequately speaks to the need to follow CPT, but does not effectively address methods to remedy existing problems of inaccurate code bundling and failure to use CPT Guidelines. Although the resolution calls for development of education material to help inform payors of proper coding, current difficulties associated with acceptance of component coding by private payors is not a problem of a lack of understanding or availability of adequate information regarding rules for component coding. Payors are using computerized editing packages to bundle codes and ignore CPT rules including component coding. In order to aggressively pursue the appropriate use of CPT codes and effectively impact the claims review practices of payors, the AMA needs to influence the development of computerized edits so that they reflect CPT guidelines. The Board of Trustees Recommends: 1. That policies H-70.949, H-70.937, H-70.943, H-70.954, and H-70.962 be reaffirmed. (Reaffirm AMA policy). 2. That the AMA pursue methods of wide distribution for existing coding products and services developed by national specialty societies in cooperation with the AMA and the CPT Editorial Panel. (Directive to take action). 3. That the AMA advocate that the Department of Health and Human Services (DHHS) designate CPT guidelines and instructions as contained in the CPT Book and approved by the CPT Editorial Panel as the national implementation standards for CPT codes. (Directive to take action). 4. That the CPT Editorial Panel consider developing CPT coding combinations that comply with CPT coding rules and guidelines and that could serve as a basis for payor software programs. (Directive to take action). 5. That the remainder of this reprint be filed. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40
  7. 7. B of T Rep. 37 - A-99 -- page 6 Conclusion The CPT guidelines for component coding are relatively simplistic and directly addressed in the CPT Book, other AMA coding resources, specialized coding products, and in HCFA’s Medicare Carrier Manual. Since the rules for component coding are well documented and distributed in a variety of educational publications, it appears that the problem of appropriate use of component coding is not a matter of developing educational materials. The central issue is compliance with established CPT guidelines. Current AMA policy on the importance of following CPT guidelines as laid out in the CPT Book and other AMA coding resources adequately speaks to the need to follow CPT, but does not effectively address methods to remedy existing problems of inaccurate code bundling and failure to use CPT Guidelines. Although the resolution calls for development of education material to help inform payors of proper coding, current difficulties associated with acceptance of component coding by private payors is not a problem of a lack of understanding or availability of adequate information regarding rules for component coding. Payors are using computerized editing packages to bundle codes and ignore CPT rules including component coding. In order to aggressively pursue the appropriate use of CPT codes and effectively impact the claims review practices of payors, the AMA needs to influence the development of computerized edits so that they reflect CPT guidelines. The Board of Trustees Recommends: 1. That policies H-70.949, H-70.937, H-70.943, H-70.954, and H-70.962 be reaffirmed. (Reaffirm AMA policy). 2. That the AMA pursue methods of wide distribution for existing coding products and services developed by national specialty societies in cooperation with the AMA and the CPT Editorial Panel. (Directive to take action). 3. That the AMA advocate that the Department of Health and Human Services (DHHS) designate CPT guidelines and instructions as contained in the CPT Book and approved by the CPT Editorial Panel as the national implementation standards for CPT codes. (Directive to take action). 4. That the CPT Editorial Panel consider developing CPT coding combinations that comply with CPT coding rules and guidelines and that could serve as a basis for payor software programs. (Directive to take action). 5. That the remainder of this reprint be filed. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40

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