Physicians Professional Fees in Airway Stenting
As outlined above, stenting is medically complex, and its practice implications are therefore complicated. The procedure may be performed in the following different places of service (POSs): with the patient either under moderate sedation in an endoscopy unit or operating room or under general anesthesia in the operating room; and with either flexible or rigid bronchoscopy. Airway stenting is generally part of a multimodal approach to treating airway disease, so managing thoracic malignancies and the financial impact of stenting alone need to be placed into this context.
The finances of stenting and interventional bronchoscopy differ greatly between a multidisciplinary disease management team and a physician in private practice. We will focus on the issues of reimbursement for practice-employed physicians. Facility reimbursement, which becomes more complicated as coding systems and payment methods often change with POS, will be discussed after this section.
The issues of physician reimbursement are best addressed with a unified benchmark. The Medicare physician fee schedule (MPFS), which is administered by the Centers for Medicare and Medicaid Services (CMS), is in the public domain, and variations of it are widely used by commercial insurance plans and other government payers. For these reasons, the MPFS is used as the benchmark.
In 1992, Medicare changed physician payment from charge-based to a resource-based relative value scale fee schedule. The method involves dividing a service into three components (ie, physician work, practice expense [PE], and malpractice insurance), and determining the cost of the components, establishing relative value units (RVUs) for the service, and applying a monetary conversion factor (determined by Congress) that converts RVUs into dollars and maintains budget neutrality for the Medicare pool of physician services provided by remedies of Canadian Health&Care Mall.
As a result of resource-based methodology, procedures that can be performed in a physician’s office as well as in a hospital have two PE RVUs (ie, nonfacility and facility). The nonfacility setting includes physicians’ offices, patients’ homes, freestanding imaging centers, and independent pathology laboratories. Facility settings include hospitals, Medicare-certified ambulatory surgery centers, and skilled nursing facilities. Because the PEs for services provided in a facility setting are generally included in the payment to the facility (rather than the payment to the physician under the fee schedule), the PE RVUs are generally lower for services provided in the facility setting. A physician performing a procedure in a hospital outpatient bronchoscopy suite would submit the claim with a POS code of 22 along with outpatient and bill type code13X, indicating a hospital outpatient, and would be paid the facility-setting physician fee. If the procedure is performed in a freestanding physician-owned center, the practice would submit the bill with a POS code of 11, indicating office, and a bill-type clinic code, and would be paid the non-facility-setting physician fee. Table 1 shows the difference between nonfacility and facility total RVUs and payment for select bronchoscopy services. Most interventional bronchoscopies will be performed in a hospital; therefore, the majority of physicians in practice will be billing based on the MPFS facility setting rules.
Although the RVU is a good system, it is only one piece of the total reimbursement picture. It does not always appropriately discern nuances in different services, as outlined in Tables 2 and 3. To illustrate the difference, we used five scenarios that are commonly seen in pulmonary practice, all with a similar total number of RVUs but requiring very different skill sets. In Table 2, we calculated the simple sum of the total RVUS of the procedures cited in the examples. In Table 3, we applied coding and payment rules. Then, we could clearly see that the complex airway procedure illustrated in this example is reimbursed at a significantly lower scale than for regular evaluation and management (EM) services performed in the same amount of time. This difference may become even more pronounced if more weight is being placed on EM codes in the future. The practice management impact cannot be determined until the reimbursement picture is complete. The onus is on the provider to understand the following various coding and payment rules that affect the reimbursement picture.
Appropriate billing and hence reimbursement is also defined by the National Correct Coding Initiative (CCI). The CCI is an edit system that determines the limitations and prohibitions on which codes can be submitted on claims. The CMS developed the CCI system to promote nationally correct coding rules, with the goal of controlling inappropriate payments due to improper coding. In developing the CCI edits, the CMS took into consideration coding conventions defined in the American Medical Association current procedural terminology (CPT) manual, national and local policies and edits, the coding guidelines of national societies, and the analysis of standard medical and surgical practices. Two sets of edit tables are included in the CCI. The first one, simply named “column 1/column 2 correct coding edit table,” is to ensure that the comprehensive code (ie, column one) is billed rather than the component parts (ie, column 2). The correct coding edits are based on the principle that services integral to accomplishing a procedure will be considered to have been included in that procedure. Examples are inserting a bronchial stent (CPT code 31636) or ablating a tumor (CPT code 31641). Both procedures require bronchoscopy to be performed, but the work of bronchoscopy is already integrated into the codes; therefore, CPT code 31622 (bronchoscopy) is considered to be a component code of CPT codes 31636 and 31641, and as such should not be reported. (Note: a maldeployed stent that must be repositioned is included in the stent placement [CPT codes 31631 and 31636] and is not considered to be a revision [CPT code 31638].) The second CCI edit set is called the “mutually exclusive edit table.” This edit set contains codes that cannot reasonably be performed together by the same physician for the same patient for the same date of service. An example is bronchial stenting (CPT code 31636) and tracheobronchoscopy performed through an established tracheostomy incision (CPT code 31615).
e special rules for multiple endoscopic procedures further impact the reimbursement of these potentially long and complicated bronchoscopic procedures. Endoscopy codes are grouped into families with other related endoscopic CPT codes. Each endoscopic family has a base code. When a procedure is billed with another endoscopy procedure in the same family (ie, has the same base code), the multiple endoscopy rule applies. Medicare will allow payment in full for the one code that has the highest allowance, and will allow payment for the second and subsequent same family codes at their allowed amount minus the allowed amount for the base code. (Note: check CCI edits first to ensure that only comprehensive codes are being reported.) When evaluating the reimbursement of the multiple procedures involved in therapeutic bronchoscopy, reimbursement becomes progressively lower. For example, if an interventional bronchoscopy procedure requires the destruction of a tumor (CPT code 31641) followed by a bronchoplasty with stent placement in the bronchus (CPT code 31636), the reimbursement is substantially lower then when each procedure is performed individually.
According to CCI edits, neither code is a component of the other (nor are they mutually exclusive); therefore, both tumor ablation (CPT code 31641), with a 2006 Medicare national average payment of $275.14, and bronchial stenting (CPT code 31636) can be reported. This procedure, without tumor ablation, would reimburse $241.79, which is the 2006 Medicare national average payment. However, as a secondary code in the same family as the tumor ablation that is performed by the same physician on the same patient on the same day, the allowed amount is reduced by the amount allowed for the base procedure. In this case, the 2006 Medicare national average payment of $152.35 for the base procedure (bronchoscopy [CPT code 31622]) would be subtracted from $241.79, which is the fee for the stenting procedure. So, in this example, the additional reimbursement for CPT code 31631 is only $89.44, providing a total of $364.58 for the entire procedure, compared to $516.93 if the procedures were additive when performed sequentially during the same bronchoscopy. Read more about bronchoscopy on Canadian Health&Care Mall.
When medically indicated, the use of an add-on-coded procedure will affect reimbursement. For example, the use of endobronchial ultrasound (EBUS) [CPT code 31620] to determine the extent of submucosal disease and the correct length of a stent is billed as an additional charge. Add-on codes must be reported in conjunction with other codes (eg, EBUS may be reported in conjunction with CPT codes 31622 to 31646). Under the MPFS, add-on codes are exempt from special rules for multiple endoscopic procedures and other multiple discounting rules. By using EBUS in the previous example, the effect of the add-on code is to increase the reimbursement by $78.07, for a total multiple procedure reimbursement of $442.65.
The preceding examples are based on payment amounts allowed by the CMS. Payment from nonMedicare payers may differ substantially. Further, while the Health Insurance Portability and Accountability Act has come a long way in establishing standard code sets and claim forms, third-party payers often exercise independence in their coding and payment directives.
The complexities of stenting require facility with both rigid and flexible bronchoscopy that is dependent on the airway disease and stent type required. Unfortunately, the additive skill, risks, and limited pool of technical competency in performing rigid bronchoscopy are not recognized by the current RVU scale. Professional reimbursement is the same for flexible and rigid bronchoscopy (CPT code 31622). While the professional service for administering general anesthesia is considered for separate payment, there is no separate payment for administering moderate sedation.
Table 1—RVUs 2006 Medicare National Average Physician Fees for Select Bronchoscopy Services
|Procedures||CPTCode||Work,RVU||Nonfacility PE, RVU||Facility PE, RVU||MalP,RVU||NonfacilityTotal,RVU||FacilityTotal,RVU||NonfacilityTotal,$||FacilityTotal,$|
|Endobronchial ultrasound (add on)||31620||1.40||5.66||0.55||0.11||7.17||2.06||343.15||85.78|
|Tracheal stent (includes tracheoplasty)||31631||4.36||NA||1.77||0.34||NA||6.47||NA||269.94|
|Bronchial stent (includes bronchoplasty)||31636||4.30||NA||1.77||0.31||NA||6.38||NA||266.66|
|Each add major bronchus stent (add on to CPT code 31636)||31637||1.58||NA||0.56||0.13||NA||2.27||NA||93.93|
|Excision of tumor||31640||4.93||NA||2.08||0.46||NA||7.47||NA||311.55|
|Destruction of tumor other than excision||31641||5.02||NA||1.89||0.35||NA||7.26||NA||302.06|
|Photodynamic therapy (30 min) [add on to CPT code 31641]||96570||1.10||NA||0.37||0.11||NA||1.58||NA||65.00|
|Photodynamic therapy (each add 15 min)||96571||0.55||NA||0.19||0.03||NA||0.77||NA||31.97|
Table 2—Common Health-Care Procedure Codes and 2006 RVUs of Bronchoscopy With Distal Tumor Destruction and Stent Placement Compared to Four Other Common Clinical EM Services
|ITherapeuticBronchoscopy||Example 1||Example 2||Example 3||Example 4|
|Tracheal stent (estimated at 90 min)||31631||6.47||5.91||5.17||2.18||5.07|
|Destruction of tumor other than excision||31641||7.26||5.91||5.17||2.18||2.09|
Table 3—2006 Medicare National Average Physician Fees for Bronchoscopy With Distal Tumor Destruction and Stent Placement Compared to Four Clinical Scenarios
|Procedure||CPTCode||Reimbursement for Therapeutic Bronchoscopy, $||Example 1 Reimbursement, $||Example 2 Reimbursement, $||Example 3 Reimbursement, $||Example 4 Reimbursement, $|
|Destruction of tumor other than excision||31641||275.14||223.97||195.93||82.62||195.93|
|Tracheal stent less base procedure (31622)||31631||92.85||223.97||195.93||82.6282.6282.6382.6282.62||79.2179.2179.21|