Caloric codes change for 2016

I am a bit behind the times posting this information two weeks into 2016, but it just seems sort of anticlimactic. We have been working to change the incorrect valuation of the caloric irrigation codes for about five years. Well, we got a change, but it isn’t what we hoped for. It also isn’t correct, or the result of transparent discussion, or in the best interest of our patients, or based on any type of logical or defensible formula. Go ahead and look at the table below provided by the American Academy of Audiology. I will do the math for you. It’s about a 27% decrease in reimbursement compared to 2015.

Here is the “need to know” info. CPT code 92543 has been deleted. It has been replaced by two codes. When you do 4 irrigations, you bill 92537. When you do 2 irrigations, you bill 92538. These are single unit codes, meaning that you only bill them once in a day. You no longer bill multiple units based on the number of irrigations performed. So, if that’s all you want to know, stop here.

Estimated Payment Rates for New Caloric Codes in 2016

*New CPT codes 92537 and 92538 will replace CPT code 92543 in 2016.

If you want a taste of how this code was valued, read on. First, and I have stated this before, we have to sign a confidentiality agreement when we enter AMA meetings. So, the methods used to value your health care, which is the single largest line item on the 2016 federal budget, are held in secret. How crazy is that? I believe it leads to a mindset of lack of accountability. As I watched the recent excellent movie, The Big Short, I saw some parallels on the consequences of lack of accountability. I have pieced together some public information below, with short set ups and summaries to tie them together.

The values suggested by the AMA were based on surveys by over 100 Audiologists, Otolaryngologists and Neurologists. All three specialty societies agreed on the proposed values, they were scrutinized and agreed to by the Relative Value Update Committee (RUC) of the American Medical Association (AMA), which has a vested interest in making sure procedures are not overvalued.

Medicare (CMS) decided these values were too high and that they overestimated the work involved in performing the caloric irrigation test. The decision was made by a mysterious panel, repeatedly referred to as “we” in the Federal Register. I was intimately involved in this process, met face to face with Medicare representatives in Baltimore, and along with Paul Pessis, AuD  presented and defended the values at the AMA RUC meeting. I am still not clear on who “we” is.  If I did, I would like the opportunity to ask them how they would present and defend their values.

Medicare’s Explanation

Below, you will find an excerpt taken directly from the Medicare Physician Fee Schedule Final Rule. For the sake of expediency, I have bolded the pertinent lines:

For CY 2016, the CPT Editorial Panel deleted CPT code 92543 (Assessment and

recording of balance system during irrigation of both ears) and created two new CPT codes,

92537 and 92538, to report caloric vestibular testing for bithermal and monothermal testing

procedures, respectively. The RUC recommended a work RVU of 0.80 for CPT code 92537 and

a work RVU of 0.55 for CPT code 92538. In the proposed rule, we stated that we believed that

the recommendations for these services overstate the work involved in performing these

procedures. Due to similarity in service and time, we proposed that a direct crosswalk of CPT

code 97606 (Negative pressure wound therapy, surface area greater than 50 square centimeters,

per session) to CPT code 92537 accurately reflects the total work involved in furnishing the

service. To establish a proposed value for CPT code 92538, we divided the proposed work RVU

for 92537 in half since the code descriptor for this procedure describes the service as having two

irrigations as opposed to the four involved in CPT code 92537. Therefore, for CY 2016, we

proposed work RVUs of 0.60 to CPT code 92537 and 0.30 to CPT code 92538.

The following is a summary of the comments we received on our proposals.

Comment: Several specialty societies stated their disappointment that CMS did not

accept the RUC-recommended work RVUs for CPT codes 92537 and 92538. Commenters stated

their objection to the rationale CMS used, stating that the rationale ignored the cogent,

methodical, and thorough approach utilized by the RUC.

Response: We appreciate the commenters’ feedback. However, we reiterate that CPT

code 67606 has nearly identical intra-service and total times as CPT code 92537 and given the

similarity in services we continue to believe the direct crosswalk from CPT code 97606 to CPT

code 92537 to be the most accurate. Also, CPT code 92538 describes two irrigations which is

half the work involved in furnishing the service of CPT code 92537. For that reason, we

continue to believe it is appropriate to establish 92538 with half of the work RVUs of 92537.

Therefore, for CY 2016 we are finalizing a work RVU of 0.60 for 92537 and 0.30 for 92538.

(20) Instrument-Based Ocular Screening (CPT Codes 99174 and 99177)

Academy of Audiology Response

Next, here is an excerpt from a letter, prepared by the Practice Policy Advisory Council (PPAC), signed by American Academy of Audiology president Larry Eng, and sent to CMS. The full letter is available on the Academy website.

In the final rule, CMS maintained their decision to utilize this crosswalk, reiterating that “CPT code 97606 has nearly identical intra-service and total times as CPT code 92537” and also referencing “the similarity in services.” CMS’ response addresses parallels in the time components of the two codes, but fails to acknowledge the concerns the specialties raised regarding the selection of CPT code 97606 as a comparison code.  As noted in our proposed rule comments, utilizing CPT code 97606 as a direct crosswalk for CPT code 92537 is inherently problematic. CPT code 97606 was last valued in 2003, more than 12 years ago. The survey for this code only yielded 16 respondents, far below the standard set by the RUC and CMS. We find this comparison incongruous, as CPT code 97606 is a low volume code (12,000) compared with the data for CPT code 92543 with much higher utilization (400,000/4= 100,000).

Letter from AAA President, Larry ENG, AuD

Insightful Summary and Sustainable Resolution

I wish.