At the root of my professional skills is that of a certified coder, which I have been since 1998. Anyone worth anything knows that coding, reimbursement and compliance are inextricably linked. I often tell colleagues in the coding realm that if you are not making a gradual transition towards compliance within two years of becoming a certified coder, you more than likely have chosen the wrong career.
The biggest problem I tend to have in this line of work is the volume of knowledge. I say “problem” because any person that I know in my personal circles who doesn’t happen to be connected to the healthcare field usually has absolutely no clue as to what is happening in health care until they themselves need treatment. That treatment moment usually becomes the time when I am called in to remold their medical bills from the origami crane shapes in which they now appear.
This post is specifically about a payment paradox that exists on a few CPT codes. It is something I discovered a few weeks ago, but am only now getting to due to travel schedules and hours on the telephone in a professional capacity.
Let’s talk about soft tissue tumors. These are little deposits that creep up in the subcutaneous skin layer that are removed most often by either dermatologists, plastic and reconstructive surgeons or general surgeons. The codes for the removal can be found under the Musculoskeletal section of CPT based on body area, and they are normally split into two codes based on the size of the tumor.
Having stated that, there is a catch. In most cases, due to CPT code reseqencing, the numerical code for the removal of a larger tumor is lower than that for the smaller tumor. Unfortunately, the problem doesn’t end there.
As an example, let’s use CPT code 24075, which is for the removal of a subcutaneous soft tissue tumor of the upper arm or elbow measuring less than 3 centimeters. The code that follows it in CPT is 24071, which is for a tumor of 3 centimeters or greater from the same body area.
Now, go to this link for the Medicare Physician Fee Schedule Search. Choose the bubble that says “List of HCPCS Codes”, and then the one somewhat below it that states “Specific Carrier/MAC”. Put 24075 in the box that says “HCPCS Box 1″, then place 24071 in the box that says “HCPCS Box 2″. Below that, choose the drop-down stating “All modifiers”, and then select your Carrier/MAC from the last drop-down. After that, click “Submit”.
The next screen shows you two disturbing things. The website has not only re-ordered your codes to show 24071 as the first code, but (and this should make the surgeons and dermatologists out there furious) the allowance for the larger tumor is roughly $100 less than that for the smaller tumor, depending on your MAC locality.
This pattern will repeat itself no matter which area of the body has subcutaneous soft tissue tumors. What I think is happening is that Medicare set the Work RVUs based on numerical order, rather than the actual amount of work involved with the procedure. CMS is not recognizing CPT resequencing, which is leading to providers being underpaid for their large soft tissue tumor removal expertise.
Appendix N of the CPT code book contains the entire list of resequenced codes. I am a simple blogger with a lot on my plate right now, so I’m not going to go through all 100 codes on that list to find similar payment inconsistencies. I shall leave that up to an enterprising reader out there. The larger point here is that Medicare is the straw that stirs the drink with regard to reimbursement for services. If Medicare makes a mistake in setting reimbursement, that error is compounded by every commercial carrier who uses Medicare allowances as a baseline for setting a fee schedule.
At the very least, I hope dermatologists take to the streets with their scalpels and benzoyl peroxide and demand change. At most, I’d like to point out that just because Medicare happens to be the Irish Wolfhound in a room full of Pomeranians doesn’t necessarily mean that they always have the first and only correct answer.