DRG Coding Advisor
RVU review also looks at families of services
Medicare acts on Committee’s recommendations
Medicare has proposed adopting the relative value units (RVUs) recommended by the American Medical Association’s Specialty Society Relative Value Update Committee (RUC) to maintain code relativity for families of services. Here are Medicare’s answers to RUC recommendations related to specific families of services:
• Lymphadenectomy. The RUC recommended an increase in work RVUs for the fully surveyed code 38745 (Axillary lymphadenectomy; complete) from 8.84 to 11.0 RVUs based on comparisons with codes 60210 (Partial thyroid lobectomy, unilateral, with or without isthmusectomy) and 32100 (Thoracotomy, major with exploration and biopsy).
Medicare’s response: Assigned the median survey RVUs of 13.00 to code 38745. To maintain relativity within this family, it extrapolated the 47% increase in work RVUs of code 38745 to codes 38740 (Axillary lymphadenectomy; superficial) and 38760 (Inguinofemoral lymphadenectomy, superficial, including Cloquets node (separate procedure)) for proposed work RVUs of 10.02 and 12.94, respectively.
• Colectomy. The RUC recommended no change in the work RVUs for this family of codes.
Medicare’s response: "If the RVUs for procedures in this family are not changed, the procedures will be significantly undervalued com- pared to other general surgery codes and vascular surgery codes." Medicare, in turn, proposed the following work RVUs for the codes in this family:
| Proposed Colectomy-related RVUs | |
| Code | Work RVUs |
| 44140 | 21.00 |
| 44143 | 22.99 |
| 44144 | 21.53 |
| 44145 | 26.42 |
| 44146 | 27.54 |
| 44150 | 23.95 |
| 44151 | 26.88 |
| 44152 | 27.83 |
| 44153 | 30.59 |
| 44155 | 27.86 |
| 44156 | 30.79 |
• Intestine Repair. The RUC recommended an increase of 14% for all work RVUs in this family based on a recommended increase in fully surveyed code 44604 (Suture of large intestine (colorrhaphy) for perforated ulcer, diverticulum, wound, injury or rupture (single or multiple perforations); without colostomy) from 14.28 work RVUs to 16.03 work RVUs.
Medicare’s response: Agreed with the increase in work RVUs for code 44604, while noting that there are several rank-order anomalies currently in this family of codes that would be exacerbated by an across-the-board increase in work RVUs.
Therefore, it is also proposing to correct the rank-order anomalies as follows:
— Valuing code 44602 (Suture of small intestine (enterorrhaphy) for perforated ulcer, diverticulum, wound, injury or rupture; single perforation) at 16.03 work RVUs. The work RVUs for code 44602 are identical to the work RVUs for code 44604 because they describe the same procedure, except code 44604 is for the large intestine.
— Valuing code 44605 (Suture of large intestine (colorrhaphy) for perforated ulcer, diverticulum, wound, injury or rupture (single or multiple perforations); with colostomy) at 19.53 work RVUs. The work RVUs for code 44605 are identical to the work RVUs for code 44604, except that code 44605 includes creating a colostomy, with the attendant increase in postoperative wound care. The intraservice work of creating a colostomy is captured by subtracting the work RVUs for code 44140 from code 44143, which leaves 1.99 RVUs. In addition, there is one extra postoperative visit required for code 44605. Medicare believes 44605 is equivalent to 99233, which has 1.51 work RVUs. Therefore, the agency added 1.99 and 1.51 work RVUs to the work RVUs for code 44604 to arrive at 19.53 work RVUs for code 44605.
— Valuing code 44603 (Suture of small intestine (enterorrhaphy) for perforated ulcer, diverticulum, wound, injury or rupture; multiple perforations) at 18.66 work RVUs. The additional work required for code 44603 as compared to code 44602 is similar to the additional work required for code 44605 as compared to code 44604, except, because there is no actual colostomy, the additional postoperative visit is comparable to code 99231, with 0.64 work RVUs. Therefore, the agency added work RVUs of 1.99 and 0.64 to the work RVUs of code 44602 to arrive at 18.66 work RVUs for code 44603.
Medicare also said the current work RVUs for codes 44640 (Closure of intestinal cutaneous fistula), 44650 (Closure of enteroenteric or enterocolic fistula), 44660 (Closure of enterovesical fistula; without intestinal or bladder resection), and 44661 (Closure of enterovesical fistula; with bowel and/or bladder resection) are rank-order anomalies, as they are undervalued compared to code 44604.
As a result, it proposed assigning 22.27 work RVUs to code 44650. To keep the current relativity with the other codes, Medicare also proposed 21.65 work RVUs for code 44640, 21.36 work RVUs for code 44660, and 24.81 work RVUs for code 44661. Medicare also wants to accept the RUC recommendations for the remaining codes (44615, 44620, 44625, 44626, 44680, 44700, and 44850).
• Anus/rectum — Hemorrhoids/fistula. The RUC extrapolated a 14% decrease in work RVUs to all codes in this family based upon a decrease in work RVUs for the fully surveyed code 46262 (Hemorrhoidectomy, internal and external, complex or extensive; with fistulectomy, with or without fissurectomy).
Medicare’s response: It agreed with the RUC recommendation for the surveyed code, but disagreed with the extrapolation to the anal fistula repair codes and the anal abscess treatment codes. Instead, it proposed maintaining the current RVUs for codes 46270, 46275, 46280, 46288, 45000, 45020, 45100, 45108, 46040, 46045, and 46060. It also agreed with the RUC’s recommendations to decrease the work RVUs for other codes in this family of codes (46250, 46255, 46257, 46258, 46260, 46261, 46262, 46934, 46936, 46945, and 46946).
• Abdomen, peritoneum, omentum. The RUC recommended an increase for the fully surveyed code 49020 (Drainage of peritoneal abscess or localized peritonitis, exclusive of appendiceal abscess; open) from 16.79 work RVUs to 20.73 work RVUs.
Medicare’s response: It disagreed, proposing a work RVU valuation of 22.84.
Obstetrics/gynecology
The American College of Obstetrics and Gynecology referenced 35 codes for review by the RUC.
RUC recommendation: Increases in the RVUs for the following codes: 56515 (2.76), 56740 (4.57), 57100 (1.20), 58152 (20.60), 58260 (12.98), 58262 (14.77), 58263 (16.06), 58275 (15.76), 58280 (17.01), 58267 (17.04), 58285 (22.26), 58600 (5.60), 58605 (5.00), 58700 (12.05), 58740 (14.00), 58825 (10.98), 58920 (11.36), 58951 (22.38), 59812 (4.01), and 59870 (6.01).
Medicare’s response: It accepted the RUC’s recommendations.
Cardiology
The American College of Cardiology recommended review of three procedure codes: 93350, 33234, and 33235.
RUC recommendation: It supported an increase in the work RVUs for code 93350 to account for the increased work and more complex conditions of the patient population and proposed increasing the work RVUs to 1.48.
Medicare’s response: It accepted the RUC’s recommendations.
Radiology
The American College of Radiology identified three codes they believe are undervalued: 76065, Radiologic examination of an infant, and two mammography procedure codes (76090 and 76091).
RUC recommendation: It recommended work RVUs of 0.70 for code 76065. For the mammography procedure codes, the RUC recommended work RVUs of 0.70 for code 76090 and 0.87 for code 76091.
Medicare’s response: It accepted the RUC’s recommendations.
Ophthalmology
The American Academy of Ophthalmology requested review of nine codes, including one code for evaluation of the global period.
RUC recommendation: The RUC agreed to change the global period from 90 days to 10 days for code 65855 (Laser surgery of eye) and also reduced the work RVUs to 3.85 to account for this reduction in the global period. For code 67218, the RUC recommended work RVUs of 18.53. For code 92018, the RUC recommended that the work RVUs be increased to 2.50, with the understanding that the code would be sent to the CPT Editorial Panel for clarification.
Medicare’s response: It accepted all of the RUC recommendations.
Orthopedic surgery
The American Academy of Orthopaedic forwarded 42 codes for review it felt were undervalued.
RUC recommendation: The RUC recommended increasing the work RVUs for the following codes: 29883 (11.05), 29450 (2.08), 28299 (9.18), 28705 (18.80), 23472 (21.10), 26562 (15.00), 20245 (8.50), 27075 (35.00), 27077 (40.00), 27284 (23.45), 27286 (23.45), 27822 (11.00), 27823 (13.00), 28445 (15.62) and 27724 (18.20).
Medicare's response: It accepted all of the RUC's recommended hikes except for orthopedic surgery code 20245 (Biopsy, bone, excisional; deep (eg, humerus, ischium, femur).
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