November 2005: CMS Denies Coverage of +61795 in an ASC Setting


Michael Setzen, MD, FACS
Chair, Patient Advocacy Committee

Well, good news and bad news on the interim rule for ASC covered services.

Good news: 31233, 31235, 31237, and 31238 will NOT be deleted from the ASC list. Medicare has accepted our arguments that removing these would cause harm to beneficiaries who may need the additional services rendered in a facility.

Bad news: they did not accept our position on +61795. They said that this CPT code was for coding the use of equipment, not a surgical procedure, and therefore was not appropriate for the ASC list.

The interim final rule was published in the Federal Register on May 4. We had 60 days from that date to comment but both the ARS and AAO-HNS Boards elected not to challenge this denial in spite of their disapproval. There was concern that in so doing one might irritate CMS and they may request a review of other FESS Codes. Furthermore they did include the Physician Component of reimbursement for +61795.

Many Carriers in different states around the country are challenging Otolaryngologists with respect to Evidenced based need for IGS.

It has been suggested when challenged that you meet with the involved Carrier and present the Academy's Guidelines for the use of IGS.

It is suggested that you respond as follows when questioned about Evidenced Based documentation for IGS:

In general, there is mostly expert opinion, namely Level 5 evidence, demonstrating that IGS makes FESS "safer." In order to prove it is safer with level I or grade A evidence, we would need to perform a randomized study placing half of the patients in the IGS group and the other half in the non-IGS group and see who has more complications. Given the low occurrence of serious complications (less than 1%), this would require tens of thousands of patients to be enrolled to demonstrate any difference between the groups. This is a practical impossibility for two reasons:

  1. Can't do a study like this enrolling >30,000 patients
  2. Ethical considerations - would you be willing to serve as a surgeon (or a patient) in such a study based on our current experience with IGS?

Another great analogy applies to parachute use. There is no Evidenced Based Documentation to prove that one does better with or without a parachute when jumping out of a plane because no study would subject half the jumpers to this randomized trial and so it is with IGS.

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Revised 11/2005
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