Last week we reviewed the structure of CPT codes, developed and valued by the American Medical Association, as a primer to discuss the reasons behind recent reductions in valuation and reimburseent for vestibular procedures.
Let’s start with the new “bundled” code. The CPT code 92540 (Basic Vestibular Exam) was created to combine four of the CPT codes that make up a large part of the ENG/VNG exam battery. The bundled code was created at the directive of CMS (Centers for Medicare and Medicaid Service). Medicare has instituted a policy to combine codes that are frequently billed together. In other words, we did not have a choice in bundling the four codes listed below:
92541 – Gaze, spontaneous nystagmus test
92542 – Positional nystagmus test
92544 –Optokinetic nystagmus test
92545 –Oscillating tracking test
The idea behind bundling is that when you do multiple procedures in one visit, let’s say four procedures, you don’t meet and greet four times. You don’t review records four times, etc. Using this logic, the value should have been reduced by the adding the total pre and post time for the four procedures, and reducing that value to 25%, leaving the intra time and values intact (refer to last week’s post for an explanation of pre, intra and post time). Well, that didn’t happen. Because the four individual codes listed above had never been surveyed, it was decided that the new bundled code should be surveyed. The results of that survey determined the current value of the new code, which was far lower than if only the pre and post times were addressed.
A second major issue involving vestibular procedure valuation is the “elimination of the non-Physician work pool.” This is a complex subject, but I will attempt to simplify it at the expense of leaping over some steps along the way. There was a time when audiology procedures were largely considered as “practice expense” to the billing physician. Now that Audiologists can bill Medicare directly, there has been a move to convert the value of our procedures from “expense” to “work.” Again, last week’s post explains these terms. There has been a pool of money that has been used over the past decade or so to pay a significant amount for the practice expense portion of these procedures because little to no work value had been assigned. That pool of money is being eliminated over a five year period, ending in 2014. So any value assigned to practice expense will essentially disappear. The only way to maintain adequate reimbursement is to increase the work component value of these codes through the AMA valuation process.
The current economic and political climate makes fair valuation difficult, if not impossible. There has been massive fraud and overutilization of some vestibular codes. There are political and professional turf battles that play into the valuation process. There is the highly publicized need to reduce the cost of Medicare to reduce the federal deficit. We are still facing the possibility of an additional dramatic cut in the Medicare conversion rate, currently estimated at about 29%, as part of the sustained growth rate (SGR) policy.