Look for these coding, reimbursement changes in 2006

December 1, 2005

Changes in coding and reimbursement are on tap for 2006, some of which are known and some of which are uncertain.

We do know that there will be a number of new CPT codes, including all new injection codes, which are to be implemented on Jan. 1. We also know that the Competitive Acquisition Program (CAP) has been delayed until July, and that Medicare Part B drug payments will again change on Jan. 1. The 2006 fee schedule includes a 4.4% decrease in the conversion factor.

Expect minimal changes in Medicare relative values and no major payment rule changes. Medicare Part D implementation and Medicare Advantage will become realities.

The unknown: Conversion factor

Let's look first at the "unknown." The 2006 fee schedule includes a 4.4% decrease in the conversion factor. This could still change, but only by an act of Congress.

My prediction as of this writing is that we will receive no increase in the conversion factor. However, I think Congress will have acted and we will avert a 4.4% decrease. If we do receive an increase of 1%, that will be a bonus.

Unfortunately, I am concerned that the legislation to correct the flawed sustainable growth rate formula that determines the Medicare conversion factor will be history instead of law. The proposed 1.5% increase in our conversion factor this year with corrected values in the future will have been blown away by the hurricane and forgotten during the discussions of Supreme Court justices.

I also feel certain that pay for performance (P4P) will be implemented by some private payers this year and, eventually, by Medicare. The American Medical Association, American College of Surgeons, AUA, and many other organizations and societies are working hard to prevent this or to ensure the program uses accurate data and is fair.

Pay for performance, physician transparency on quality-of-care issues, and publication of statistics on our practices are being touted as changes that will lead to a higher quality of care. These measures are being recommended by some of the same think tanks and individuals who brought us HMOs and are being demanded by big business. We will see variations on the theme in the private sector as well as Medicare. Those demanding these changes feel that the public is not getting the quality of care they are paying for and deserve.

My recommendation would be that you bypass the urge to pass judgment and to try not to determine whether the program is of value. Learn the rules and play the game by those rules. The quicker you do, the better off you will be.

What we do know

Medicare has left the "P" out of "P4P" and is implementing a series of G codes and requesting that physicians voluntarily submit the codes related to quality of care without additional payment. Only a few will apply to urology, and you will need to play the game.

The following are the CPT changes that are relevant to most practicing urologists, although there are many more.

Consultations. The confirmatory consult has been eliminated. Any patient or family member who requests a consultation or second opinion should be reported using a new patient or established patient code. If a third-party payer mandates a consultation, then modifier -32 should be attached to the appropriate consult code.

Follow-up inpatient consults. The follow-up inpatient consultation codes also have been eliminated. These services should be reported using the subsequent visit codes.

Codes for nursing facility services. There have been many changes to the nursing facility codes, including additions and deletions to the series of codes 99304 to 99318. However, as a urologist, most of your visits will be charged using the appropriate inpatient codes (consults, subsequent care, etc.) for those patients who reside in a nursing facility. Those patients seen in your office who are not residents of a skilled nursing facility should be charged with your outpatient consult codes as well as your established patient visit codes.