Practice expense code changes requested
In addition to the broad, generic questions of how HCFA should design and construct its proposed relative value-based practice expense formula, the public comments it received also asked it to reconsider its proposed direct practice expense RVUs for a number of specific codes.
Among the RVU changes in specific codes recommended to HCFA:
31625 Bronchoscopy with biopsy should have a higher practice expense RVU than diagnostic bronchoscopy (31622) because biopsies use more equipment and supplies. In addition, sending a biopsy out for a pathology report and receiving that information will increase administrative staff costs. For many colonoscopy procedures, the difference in PE-RVUs due to a biopsy is 0.06 RVUs. For this procedure there is no difference at all.
43239 Upper GI endoscopy with biopsy should have a higher practice expense RVU from diagnostic upper GI endoscopy (43235) because biopsies use more equipment and supplies. In addition, sending a biopsy out for a pathology report and receiving that information will increase administrative staff costs. For many endoscopy procedures, the difference in PE-RVUs due to a biopsy is 0.06 RVUs. For this procedure there is no difference at all.
45378 There are two listings for a diagnostic colonoscopy in the proposed rule and they are not clearly differentiated. The second listing with the lower work values is for a discontinued procedure and should be listed with a modifier -53. The in-office PE-RVUs are consistent with other colonoscopy procedures, but the out-of-office PE-RVUs for this service are much lower than other colonoscopy codes. For example, 45380 (colonoscopy and biopsy) has a work value of 4.01 RVUs, direct practice expense of 3.66 RVUs, malpractice expense of 0.40 RVUs, a direct out-of-office practice expense of 0.14 RVUs, and a total out-of-office practice expense of 1.14 RVUs.
These values are very similar to 45378 except for the total out-of-office practice expense value. 45378 has a work value of 3.70 RVUs, direct practice expense of 3.55 RVUs, malpractice expense of 0.39 RVUs, direct out-of-office practice expense of 0.14 RVUs, and total out-of-office practice expense value of only 0.41 RVUs. If the other values for 45378 are correct, then the resulting out-of-office practice expense value should be 1.08 RVUs, not 0.41 RVUs.
71010 Chest X-ray, single view, has the same proposed direct practice expenses in and out of the office. CPEP data indicate that labor and supplies are substantially less in the out-of-office setting. Therefore, the out-of-office direct practice expense RVUs should be reduced.
71015 Chest X-ray, stereo frontal view, has the same proposed direct practice expenses in and out of the office. CPEP data indicate that labor and supplies are substantially less in the out-of-office setting. Therefore, the out-of-office direct practice expense RVUs should be reduced.
71020 Chest X-ray, two views, has the same proposed direct practice expenses in and out of the office. CPEP data indicate that labor and supplies are substantially less in the out-of-office setting. Therefore, the out-of-office direct practice expense RVUs should be reduced.
90918 The Renal Physicians Association indicated that the monthly 90922 capitated payment (MCP) for end-stage renal disease (ESRD) services is undervalued in the proposed rule. The services indicated by the MCP for ESRD services do not represent a single procedure, but rather a series of evaluation and management (E/M) services provided over a month’s time in conjunction with the administration of the patient’s dialysis prescription. Every E/M service that has historically represented a "building block" component code of the MCP experienced an increase in the proposed rule. Therefore, the PE-RVUs for the MCP should be adjusted upward, as well.
93350 Echo transthoracic has the same proposed direct practice expenses in and out of the office. CPEP data indicate that labor and supplies are substantially less in the out-of-office setting. In turn, the out-of-office direct practice expense RVUs should be reduced.
99239 Hospital discharge day services should not have an in-office practice expense value. This appears to be a typographical error because the other hospital discharge day code (99238) and hospital visit codes do not have in-office practice expense RVUs. Also, many procedures have the same direct in-office PE-RVUs and out-of-office RVUs. HCFA is requested to re-examine these procedures to determine if indeed the in-office and out-of-office RVUs should be the same.
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