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Genesis of a CPT Code
The scope of pediatric anesthesia and pain control continue to expand as witnessed by the number of attendees and the quality of presentations at the recent Winter SPA/AAP Meeting. The presentations and abstracts demonstrated respect for the past, continued improvement of the present and a challenge to expand the boundaries of our capabilities for the future. However, like all medical specialties, we must overcome the obstacles that lie in our path. The obstacles today are not only related to our clinical responsibilities, but also the environment in which we practice. The leadership of the organizations representing pediatric anesthesia on a national level obviously understand these issues as evidenced by sessions on malpractice, quality, risk, and relationships to hospitals during the recent meeting. We must not consider these issues resolved simply because we have heard these presentations because this is just the beginning of the journey attempting to effectively overcome these obstacles. Also, we must not ignore the subtle issue that a surgeon and a lawyer, not a pediatric anesthesiologist, presented much about the current state of affairs. There are truly many obstacles that challenge our efforts to provide the best and safest care for our children. While malpractice insurance rates soar, governmental agencies use ridiculously low per unit reimbursement, and states eliminate the mechanisms that adjust for deteriorating health and emergent conditions in patients. One measure of this is that state agencies pay at an average 70% discount for our services and a high of 88% discount for one payer. (State Medicaid rates per anesthesia unit, 10/2002)
Representation, strong representation, by pediatric anesthesiologists on the diverse forums developing policy is the only method we have to have a meaningful impact on how we will practice in the future. These forums are those that engage in the formation of policies regarding state and national legislation, risk management, and economics and are vital to our ultimate success. I would like to use this opportunity to discuss one of these forums. For the past 6 years I have been a member of the Committee on Economics (COE) for the American Society of Anesthesiologists (ASA). The COE develops policies regarding economics and reimbursement, interprets these policies for questions arising from third party payers and anesthesiologists, maintains a dialogue with Community Medical Services (CMS) which manages Medicare, and publishes the popular Relative Value Guide (RVG), which contains the codes and values for all the procedures performed by anesthesiologists including pain relief procedures.
The Relative Value Guide is universally used by anesthesiologists to guide their billing. The codes listed in the RVG are actually licensed and maintained by the American Medical Association through the Current Procedural Terminology (CPT) section. The process of placing a numerical code on a medical procedure was first published in 1966 as a result of calls from the country's health insurers for standardization to track procedures and reimbursement. The RVG actually predates the CPT, another example of anesthesiology leadership in health care. In 2000, the CPT Code Set was designated under the Health Insurance Portability and Accountability Act (HIPPA) by the Department of Health and Human Services as the standard mechanism for reporting all health care professional services nationwide. The addition or revision of an anesthesia code requires submitting a Code Change Request form - a case report including peer reviewed references that clearly delineate the need for change. This change is then presented in person by the requester to the CPT Editorial Panel, a group of physicians and allied health care professionals, including third party payers, for approval. The exercise to create codes is essentially an effort to equate the amount of work different physicians put into their various tasks and put some comparative value on that work.
The CPT process is the first in a two step process that will eventually result in a code that will be published and given a work value. The second step is presentation of the code as approved by CPT to the Relative Update Committee (RUC). At this point, the committee work and final publication is under the auspices of the federal government (CMS). The determination of the value of the new code occurs after presentation by the sponsoring specialty, including data that indicates the work entailed in performing the procedure. This is a complex and difficult process that uses the zero sum principle. For work value to be assigned to a new code, another code must be devalued to the same extent.
This process finally yields a code that is assigned a base unit value in the RVG. This code is used by all payers reimbursing anesthesia work. Having been the ASA representative to the CPT Advisor Panel for the last three years, I have submitted 76 anesthesia and pain relief codes for addition, revision or deletion. 74 of these requests have been approved by the CPT and successfully presented by the ASA-designated RUC representatives and are currently listed in the RVG. The COE has accomplished a monumental task of revising over 20% of all the codes we commonly use, including a thorough overhaul of the pain management codes. Just as importantly, the ASA has been extraordinarily successful in finding its way through an incredible bureaucratic process and obtaining higher values for the work we all do.
The success of the ASA's Committee on Economics is possible only with support that extends far beyond the realm of anesthesiology. The approval of the many CPT codes and the valuation of work that benefits all anesthesiologists is the result of working closely as a team with many allied specialties. Of particular interest to pediatric anesthesiologists is the support our colleagues in pediatrics and many of the pediatric surgical specialties have offered. We have also developed welcomed support from our neurosurgical and radiology colleagues. In my next article, I will discuss some of the recent increases in codes that are designed specifically for anesthesiologists caring for children.
In this world of competing economic forces and constituencies, pediatric anesthesia has become an effective, strong, and welcomed voice. At least for the next three years, we will have a voice in the COE and CPT committee to push for issues related to pediatric care. I welcome any input you have regarding economic policies or codes that will benefit all of us and our the children we care for.
H. J. Przybylo, MD
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