Understanding How You Get Paid: Part 2

In part one of this series published in the May AANnews you learned how CPT codes are identified by the Centers for Medicare & Medicaid Services (CMS) and the American Medical Association (AMA) for review and potential changes in reimbursement. This article focuses on what happens after a code has been identified and the role the AAN plays.

If a CPT code reported by neurologists is identified as potentially misvalued, the AAN will carefully look at the utilization history for an explanation. In many cases, there is a reasonable explanation for an increase, such as a new technology or a new service that health care providers are adopting as part of their practice. In this instance, the AAN will propose the code be removed from the screen and no action is required. Another explanation might be outdated CPT code language which has led to incorrect coding and increased utilization. The appropriate recommendation is this case would be review by the CPT Editorial Panel to update the code language to reflect current practice.

Unfortunately, an increase in utilization could be due to mis-coding or inappropriate use, in which case the medical specialty society may propose a delay in review to allow member education to correct the mis-coding. Alternately, the specialty may be directed to survey the CPT code for updated valuation.  The survey process occurs via the AMA Relative Value Scale Update Committee (RUC) which recommends relative values for physician work and direct practice expense to CMS.

To put this process in context, we can look to long-term EEG monitoring code 95951 which was identified by CMS in 2017 due to a rapid increase in utilization (more than 100 percent in a five-year period). The AAN (in collaboration with the American Clinical Neurophysiology Society and National Association of Epilepsy Centers) proposed revisions to 95951 and other long-term EEG monitoring codes to more accurately describe the services provided. The AMA CPT Editorial Panel established a new code set which was reviewed by the RUC and will be effective January 1, 2020. The values the RUC recommended for the new long-term EEG code were submitted to CMS, which will publish its proposed payment rates in the Medicare Physician Fee Schedule Proposed Rule in July of 2019 this year. Following publication of the Proposed Rule, the AAN will have the opportunity to submit comments specific to the new code set values.

New and revised codes remain under AMA embargo until the release of the next calendar year’s code set, typically in September each year. Part three in this series of AANnews coding articles will introduce new codes for 2020.