2019 HSC Section 2 - Practice Management

Ann Thorac Surg 2017;103:373 – 80

QUALITY REPORT JACOBS ET AL VALUATION OF PHYSICIAN WORK

outpatient of fi ce visits that occur during the designated number of days after the operation. Category II CPT codes are for reporting quality per- formance measures. Category II codes were created in response to the CPT Editorial Panel ’ s belief that for CPT to effectively serve as a national set of codes, a coding category to assist in reporting quality measures was necessary. Category III CPT codes primarily represent a set of temporary codes for the purpose of tracking new pro- cedures and technologies not yet meeting the stringent Category I criteria. Category III codes are useful in tracking the extent and frequency of use nationally of a particular procedure or service. Category III codes are not referred to the RUC for recommendations about valua- tion. Category III codes are approved for a 5-year time frame, by which time they either possess suf fi cient data for conversion to Category I status or are sunsetted. Oc- casionally, Category III status is extended beyond 5 years. In 1977, the U.S. Department of Health, Education, and Welfare created the Health Care Financing Administra- tion (HCFA). This federal agency, later to be known as the CMS, was charged with the administration and oversight of Medicare. Historically, critical to the adoption and continuation of CPT in reimbursement were several de- cisions by the HCFA and the U.S. Congress [7] : 1. 1983: included CPT in the HCFA Common Procedure Coding System 2. 1986: CPT was a required part of the Medicaid Man- agement Information System 3. 1987: Congress required CPT to be used for reporting outpatient surgical procedures 4. 2000: U.S. Department of Health and Human Services designated CPT as the national coding standard for reporting physician and other health care profes- sional services and procedures under the Health In- surance Portability and Accountability Act of 1996. Services included are: a. physician services b. physical and occupational therapy services c. radiologic procedures d. clinical laboratory tests e. other medical diagnostic procedures f. hearing and vision services g. transportation services, including ambulances Nongovernmental insurers also use CPT almost exclusively. Insurers and large health care systems on occasion have developed “ local codes ” to deal with spe- ci fi c procedures, and CMS has now sanctioned the In- ternational Classi fi cation of Diseases, 10th Revision, Procedure Coding System (ICD-10-PCS). (CMS con- tracted with 3M Health Information Systems in 1993 to design and then develop ICD-10-PCS, a procedure clas- si fi cation system to replace Volume 3 of ICD-9-CM. ICD- 10-PCS was initially released in 1998 and has been updated annually since that time [9] .) Nevertheless, CPT remains the standardized coding nomenclature for fi ling

reimbursement [4] . Other roles include administrative management, tracking new and investigational proced- ures, and the evolving area of pay for performance. CPT allows for comparison of local, regional, and national utilization for medical education and research [4] . Three categories of CPT codes exist. Category I repre- sents the vast majority of CPT codes. The creation of a new Category I code requires that the new procedure or service: 1. is approved by the U.S. Food and Drug Administra- tion (when devices or drugs are involved in the pro- cedure or service), 2. is consistent with contemporary medical practice, 3. is in widespread use (performed by many practi- tioners in multiple locations), and 4. is supported with abundant peer-reviewed literature. The initial step in the process to obtain a new CPT code is for the code to be presented and evaluated by the AMA CPT Editorial Panel, which approves the code as being a reasonable physician/provider service with an appro- priate description. Category I CPT codes that are approved by CPT are then forwarded on to the RUC for valuation recommendations. Inclusion or exclusion of a procedure or service in CPT does not imply any policy about health insurance coverage or reimbursement [8] . The Category I section of the CPT is subdivided into six subsections: Evaluation and Management (E/M), Anesthesiology, Surgery, Radiology, including nuclear medicine and diagnostic ultrasound, Pathology and Laboratory, and Medicine (except for anesthesiology). A detailed discussion of these subsections is far beyond the scope of this article. A brief review of the E/M subsection is warranted, however, because the E/M subsection is one of the largest and is used by many different providers. The E/M sub- section is divided into broad categories such as of fi ce visits and hospital visits, new patients, established patients, and consultations, among others. The sub- categories are important because the work represented by these subcategories varies by the type of service, place of service, and condition of the patient. Individual E/M codes have within them well-de fi ned components as well as time estimates typically required for performing a particular E/M service. The CPT descriptors for the Sur- gical subsection are not as detailed as for E/M codes. Nonetheless, the CPT codes representing an identi fi able surgical procedure often include a variety of services. Which services are included in a given CPT code are broadly determined by the surgical global periods (0-day, 10-day, and 90-day) but also vary on a procedure-by- procedure basis. Of note, E/M visits are often included in the 10-day and 90-day global surgical codes [8] . Therefore, the RVU associated with a CPT code for a surgical procedure that is a 0-day, 10-day, or 90-day global surgical code will include the value of the work associated with a variety of E/M services during that speci fi c global period, including critical care in the intensive care unit, hospital visits on the ward, and all

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