Changes in coding and reimbursement are on tap for 2006, some of which are known and some of which are uncertain.
We do know that there will be a number of new CPT codes, including all new injection codes, which are to be implemented on Jan. 1. We also know that the Competitive Acquisition Program (CAP) has been delayed until July, and that Medicare Part B drug payments will again change on Jan. 1. The 2006 fee schedule includes a 4.4% decrease in the conversion factor.
Expect minimal changes in Medicare relative values and no major payment rule changes. Medicare Part D implementation and Medicare Advantage will become realities.
The unknown revolves around the key question: “Will Congress pass a law to increase the conversion factor?” Included in the category of “unknown but almost certain” are pay for performance and continued pressure by all payers on physician fees.
The unknown: Conversion factor
Let’s look first at the “unknown.” The 2006 fee schedule includes a 4.4% decrease in the conversion factor. This could still change, but only by an act of Congress.
My prediction as of this writing is that we will receive no increase in the conversion factor. However, I think Congress will have acted and we will avert a 4.4% decrease. If we do receive an increase of 1%, that will be a bonus.
Unfortunately, I am concerned that the legislation to correct the flawed sustainable growth rate formula that determines the Medicare conversion factor will be history instead of law. The proposed 1.5% increase in our conversion factor this year with corrected values in the future will have been blown away by the hurricane and forgotten during the discussions of Supreme Court justices.
I also feel certain that pay for performance (P4P) will be implemented by some private payers this year and, eventually, by Medicare. The American Medical Association, American College of Surgeons, AUA, and many other organizations and societies are working hard to prevent this or to ensure the program uses accurate data and is fair.
Pay for performance, physician transparency on quality-of-care issues, and publication of statistics on our practices are being touted as changes that will lead to a higher quality of care. These measures are being recommended by some of the same think tanks and individuals who brought us HMOs and are being demanded by big business. We will see variations on the theme in the private sector as well as Medicare. Those demanding these changes feel that the public is not getting the quality of care they are paying for and deserve.
My recommendation would be that you bypass the urge to pass judgment and to try not to determine whether the program is of value. Learn the rules and play the game by those rules. The quicker you do, the better off you will be.
What we do know:
Medicare has left the “P” out of “P4P” and is implementing a series of G codes and requesting that physicians voluntarily submit the codes related to quality of care without additional payment. Only a few will apply to urology, and you will need to play the game.
The following are the CPT changes that are relevant to most practicing urologists, although there are many more.
Consultations.
The confirmatory consult has been eliminated. Any patient or family member who requests a consultation or second opinion should be reported using a new patient or established patient code. If a third-party payer mandates a consultation, then modifier -32 should be attached to the appropriate consult code.
Follow-up inpatient consults.
The follow-up inpatient consultation codes also have been eliminated. These services should be reported using the subsequent visit codes.
Codes for nursing facility services.
There have been many changes to the nursing facility codes, including additions and deletions to the series of codes 99304 to 99318. However, as a urologist, most of your visits will be charged using the appropriate inpatient codes (consults, subsequent care, etc.) for those patients who reside in a nursing facility. Those patients seen in your office who are not residents of a skilled nursing facility should be charged with your outpatient consult codes as well as your established patient visit codes.
Some codes for home rest or custodial care services (99324 to 99340) also have changed significantly. If your office provides one of these services, you would use these codes. Otherwise, continue to use your outpatient consult and your outpatient established patient codes.
Urology-specific codes:
A number of new codes have been introduced for renal pelvis catheter procedures (50382 to 50389). There is also a new code, 50592, for percutaneous radiofrequency ablation of renal tumors.
Our injection codes have undergone major changes. As you remember, in 2005, all of our injection and infusion codes were replaced by G codes for Medicare. This year, all of the G codes and the original CPT injection codes are being replaced with new CPT codes. As of Jan. 1, you should use the new CPT codes for both private and Medicare patients.
For example, 96402 (antineoplastic hormonal injection therapy) is the code for all LHRH agonist drugs—such as triptorelin pamoate (Trelstar), leuprolide (Lupron, Eligard, Viadur), goserelin acetate (Zoladex), histrelin (Vantas), and others—instead of codes 90765 to 90779 or the corresponding “G” codes.
Medicare Part D, HMOs:
Medicare Part D is an insurance program for drugs. Many plans will be available. A patient should compare prices, based on formulary and co-payments, because the amounts they pay for their drugs may vary considerably from plan to plan. You can obtain brochures from CMS or refer patients to the Medicare hotline, 1-800-Medicare, or to the web site, http://www.medicare.gov/. Remember, Part D will not pay for drugs that are paid for by Part B Medicare.
Medicare HMOs are Back in a big way. For now, be prudent in your contracting. There is a lot of money to be made by organizing the care of high-risk Medicare patients. You do not want to do the work without sharing the profits.
Urologist Ray Painter, MD, is president of Physician Reimbursement Systems, Inc., in Denver and is also publisher of Urology Coding and Reimbursement Sourcebook
Disclaimer:
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.
