We should thank our congressional representatives for adopting H.J. Res. 2, the Republican-suggested “permanent fix” to the obvious problem in the flawed Medicare fee schedule. The 4.4% decrease was deleted and a 1.6% increase added to the conversion factor for 2003. This is estimated to increase the “projected payments” to physicians by $54 billion over the next 10 years.
However, the complicated payment formula will be used to determine future conversion factors, and one source has suggested that we could see a decrease in 2004.
The new fee schedule has been surrounded by confusion for months, resulting in the delay and continued uncertainty. The blame has been placed on a flawed formula. In reality, that is only the tip of the iceberg. The fee schedule was built on a “beautiful theory that was murdered by the cold, hard facts of life.” The idea of a “resource-based” relative value system was abandoned early in its development. The payment rules are, in some cases, unfair, more complex than necessary, and based on cost control instead of good patient care.
The laws creating the system, including the formulas, are flawed, making it impossible to fix. Add the problems associated with the practice expense relative value units and payments for services in the office versus the hospital, and you begin to see the picture. Unfortunately, we have allowed our private contracts to be based on the same flawed system.
I am concerned we are on the verge of drastic reforms that will destroy the health care system as we know it. In the meantime, we must work with the tools we are given.
A number of changes in the 2003 system require your immediate attention. As of this writing, I assume that the new CPT codes and relative values were implemented on March 1 as planned. If so, follow the recommendations below. If implementation of the 2003 Medicare fee schedule (new codes and relative values could be implemented independent of the new conversion factor) was delayed for any reason, then I recommend putting this article aside and referring to it when the new codes and relative value units are implemented.
We had four catheterization codes in 2002: the P9612-catheterization for specimen; G0002-office catheterization with a Foley catheter for a Medicare patient in acute retention; 53670-catheterization for all other situations, except for 53675-a complicated insertion.
The last three codes above have been deleted. The new catheterization codes and their use are as follows:
P9612 (the only holdover) should be used when you are catheterizing a Medicare patient for a specimen in the office. Do not use this code for private patients unless you have been specifically advised by your private payer to use the HCPC codes from Medicare. Do not use it for any other catheterizations.
51701 (insertion of non-indwelling bladder catheter such as straight catheterization for residual urine). This is the code you would use any time you insert a non-indwelling catheter for any reason except as stated for the P code above.
51702 (insertion of temporary in-dwelling bladder catheter, simple-such as a Foley catheter). You would use this code in the office and in the hospital. It is used for both acute and chronic retention problems.
51703 (complicated-such as altered anatomy, fractured catheter, or a balloon). This code should be used when there is difficulty inserting the catheter. If you use this code, I would suggest your documentation back up your coding.
If you have to use manipulations of the urethra because of the altered anatomy or catheter guide or other means of inserting the catheter, it may have been “without difficulty” for you, but if you document it properly, an auditor will agree that it was complicated. Always be sure that your coding accurately reflects your documentation.
The code, G0050, use of ultrasound to check for residual urine in a Medicare patient, has been deleted. The new code is 51798 (measurement of post-void residual urine and/or bladder capacity by ultrasoundnon imaging).
This change is interesting. This ultrasound code is now located in the urodynamics section, making it a surgical code. Code 51798 has bundling edits and would require a modifier (if appropriate) when performed with another procedure. However, it has a global indicator of “XXX,” which means the global concept does not apply. (This is also the global designation for most radiological codes, including 76775).
Theoretically, 51798 could be charged in post-op global period without a modifier, and the 25 modifier would not be required on an E&M service performed on the same day. This means that we should be able to continue to use the ultrasound for residual checks to determine if patients are voiding appropriately after major surgery.
Also interesting is that the definition of the new code specifically states that it is to be used for “non imaging.” Therefore, it would be incorrect if you used this code for an imaging-producing ultrasound examination.
The Federal Register, in discussing the deletion of G0050, indicated that the 51798 was to replace the G0050. However, the 51798 definition does not match the G0050 definition. Herein lies the conflict.
Here is my recommendation for coding:
Use 51798 if you are using a “non-imaging” ultrasound machine to check residual on any patient, whether Medicare or private. (This is now CPT code, not a Medicare HCPC code). If your machine prints out the volume, draws a graph to the bladder, or performs any other type of reporting other than a true ultrasound image, this is the code you would be required to use.
The good news is that, if you are using an ultrasound machine with true ultrasound image documentation, then you should use the 76775, even if you are checking for residual urine in a Medicare patient.
I am not sure if this was the intent of the comment in the Federal Register, but this would be correct coding. Until something is written in your local carrier’s manual or sent out by CMS indicating otherwise, this is the code that I would use.
If local medical review policies are engendered by the new codes, you need to abide by those policies when published. Stay tuned.
The information in this column is designed to be authoritative, and every effort has been made to ensure its accuracy at the time it was written. However, readers are encouraged to check with their individual carrier or private payers for updates and to confirm that this information conforms to their specific rules.