Understanding How You Get Paid: Part 1

It might seem as if the Centers for Medicare & Medicaid Services (CMS) arbitrarily makes payment cuts with little explanation or rationale. The AAN believes knowledge is power and recognizes the importance of its members understanding how their payment rates are established. In this first in a series of four articles, you will learn how CMS and the American Medical Association (AMA) identify CPT codes to be reviewed and the role the AAN plays in that process.

There is not a single mechanism that identifies a given procedure or CPT code for review; rather, several utilization screens that apply to all medical specialties and identify “misvalued codes” are available. In some instances, these screens have ultimately led to major cuts in reimbursement for procedures for many specialties. For example, in 2013, dermatology saw a nearly 30-percent reduction to three of their most highly utilized codes; in 2016, ophthalmology saw significant cuts to reimbursement for glaucoma surgery codes. Both CMS and the AMA monitor code utilization―the AMA via the Relative Value Scale Update Committee (RUC). The intent is to identify potentially misvalued services using objective mechanisms for reevaluation. The RUC recommends relative values for CPT codes to CMS, and CMS determines the final values.

The AMA workgroup that monitors utilization trends was formed following comments from the Medicare Payment Advisory Commission (MedPAC) urging CMS to be more diligent in the identification of both potentially over- and under- valued services within the payment schedule. Screens that would flag a code include (but are not limited to) the following:

• Bundled CPT services: services often billed together
• Site-of-Service anomalies: services with site of service shifts (e.g., services that were typically in the inpatient setting and are now typically performed in the outpatient setting or physician office)
• Shift in specialty: services originally performed by one specialty but are now predominantly performed by a different specialty
• High Volume Growth: services with a utilization increase of 100 percent or more in a three-year period
• Services with low work RVUs that are billed in multiple units per patient
• Services with low work RVUs that have high utilization
• High Expenditure Procedural Codes: codes under the Medicare Physician Payment Schedule that have not been reviewed in the last five years with the highest payments per specialty

Examples of neurology codes that have been identified for review include needle electromyography and nerve conduction studies (2010 ‒ Bundled CPT services screen) and long-term EEG monitoring code 95951 (2016 ‒ High Volume Growth screen).

Once a service has been flagged, the medical specialty society (the AAN in this case) responds with an action plan which includes an explanation of the utilization and a recommendation. The AMA RUC will review the recommendation of the specialty society and either remove the code from the screen, recommend updating the CPT code language to further clarify the service, or recommend the code be reviewed for updated valuation.

CMS also monitors code utilization and identifies potentially misvalued services with similar screens. The actions of CMS are driven by law; for example, the Affordable Care Act requires the agency to periodically identify potentially misvalued services and to review and make appropriate adjustments to the relative values for those services.

Watch for Part 2 in this series of AANnews coding articles, which will focus on what happens after a code has been identified and the role the AAN plays.