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As many of you may remember the early 90's brought us the FESS mess. Your society played a pivotal
role in salvaging the sinus CPT codes. Through this experience we learned valuable lessons about
coding and reimbursement, at times, more than we ever wanted to know. We learned what components
make up the Relative Value Units (RVU's) for any given code and what a laborious task it is to value
a new code (a process called 'surveying a code') once agreement has been reached that a new code is
needed to adequately describe a service. We learned that requesting a new CPT code is a process not
to be entered into lightly. It requires justification and must be agreed to by the AMA CPT Editorial
Panel; once accepted as necessary to describe a new service, it must then be assigned a relative value
by the RUC (the Relative Value Update Committee of the AMA). This value is usually determined by
surveying at least 50 members of the specialty who will use the code to describe their services.
The process involves writing a scenario for the service, justifying the pre-service and post-service
time and comparing the amount of work involved in the new code to other established procedure codes,
which involve similar work and complexity that are familiar to those being surveyed. This last part
is sometimes called 'crosswalking' the codes.
The relative value units (RVU's) for any code are made up of three components: 1) Work Value Units, 2)
Practice Expense Value Units and 3) Malpractice Value Units. Work RVU's are the primary thing surveyed.
One other key piece of information is that HCFA, for whose benefit most of this work is done, has a
defined pool of money with which to pay its claims for a given year. The amount of reimbursement for
a given code relative to other codes is determined by the relative value assigned and by the 'conversion
factor', i.e. how many dollars per unit of value HCFA pays and by a geographic modifier. Consequently
any new code dilutes the pool of money available for all other codes and specialties, unless it is "new
technology". (it might seem logical that if we eliminate some codes that their RVU's could be put back
into the pool; however, that does not happen.)
In addition, HCFA allows every specialty to have a 5-year review of its codes to determine whether they
are properly valued relative to other codes. Our Academy recently submitted a 5-year review of some of
our codes and had them turned down. Due to difficulty they had getting enough people to respond to the
surveys, they had to resort to a consensus panel method of determining the relative values, and the RUC
turned this down as invalid. This was a major loss. Now the General Surgeons and the Orthopedists
appear to have received approval for significant increases in some of their codes by just this same
method. This will negatively affect everyone else's reimbursement including yours, because HCFA will
have to take something from everyone to pay for these changes. If this tends to raise your blood
pressure, don't let it, just let it stimulate you to become involved for your own benefit. The days
of being able to sit back and let someone else do it are over.
The Academy says this process is expensive, costing about $6,000.000 per code surveyed. The turn around
time is short, a matter of days from notification to deadline and the process is somewhat difficult to
understand and follow; yet it is critical to your future reimbursement. The Academy is requesting help
from all of the specialty societies to contribute financially and to provide trained volunteers who will
be willing at a moment's notice to provide answers to the surveys. I can attest that they never come at
a convenient time; however, if we do not help or do it correctly we will not get the requested RVU.
This just happened with Revision of the Nasal Valve, a code requested by the AAFPRS, due to lack of
input (the ARS was not consulte.).
Consequently, I am requesting 50 - 60 volunteers from diverse geographic locations and practice types
who are willing to be trained and to be ready to fill out surveys expeditiously when asked. We also
need people who are willing to be the watchdogs of our reimbursement process. Please contact me by
letter or through the ARS web site to let me know of your willingness to serve. This will become more
important as reimbursement declines and as other specialties encroach on the limited pool of resources.
As you might expect if we have to supplement the Academy financially this may require a dues increase,
particularly in light of having unilaterally funded the legal fight to restore CPT #61795 and the
FESS MESS.
Fred Kuhn, M.D. , President, American Rhinologic Society
Georgia Nasal & Sinus Institute
Savannah, GA
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