Legislative Update From
SAGES
REPORT FROM THE RUC
Michael Edye, MD
SAGES Representative to the RUC Advisory Committee
The process by which a procedure is assigned a standard code for reimbursement
is lengthy at best. First a procedure must be presented to the AMA CPT
(current procedural terminology) Panel to be assigned a code and a category.
A procedure can receive a Category I, II or III.*
Upon receiving a Category I, a code must be presented to the AMA RUC
Advisory Committee (Relative Value Update Committee) to be assigned a
value. Both the CPT and the RUC report to the CMS (Center for Medicare
and Medicaid Services) which makes the final determination as the value
of the code.
This past Spring Dr. Eric Weiss, SAGES representative to the AMA CPY
Advisory Committee, and Dr. Bill Richards presented on what is commonly
referred to as the Stretta procedure. (Upper gastrointestinal endoscopy
including esophagus, stomach, and either the duodenum and/or jejunum
as appropriate; with delivery of thermal energy to the muscle of lower
esophageal sphincter and/or gastric cardia, for treatment of gastroesophageal
reflux disease.) We were joined in this effort by the AGA and the ASGE.
Ultimately the procedure was assigned a Category I code to take affect
in 2005.
Over the summer, with the help of an expert consultant, SAGES developed
and circulated a survey to “stretta” users, along with the
AGA and the ASGE. The surveys results were complied and a final recommendation
was arrived upon.
Joel Brill (AGA), Mike Levy (ASGE) and I presented the STRETTA proposal
to the RUC Saturday September 20, 2003. The prefacilitation committee
accepted our rationale for the revised RVU with minimal comment. After
presentation to the RUC, the chairman of the prefacilitation committee
stated the committee had no more to add, discussion/questions were minimal
and both Work RVUs and Practice Expense were passed immediately.
The work value arrived upon is fair in comparison with a host of other
procedures. Some may feel we could have obtained a higher value although
that view would not be supported by closer scrutiny of similar codes,
comparable in-service times and intensities. This RVU level may serve
as a benchmark for the other endoscopic anti-GERD procedures that make
it through CPT.
The value assigned the code cannot be discussed outside of the RUC Committee,
so those details will not be disclosed here. The AMA will not formally
submit the recommendation to CMS until May 2004, when they submit the
entire year's recommendations. CMS will not publish anything until the
final rule in fall 2004 about this code. In any event, no one can do
anything about or with the results until CMS puts their stamp on the
recommendation next fall - or they choose to change the recommendation
(which is not likely).
This was SAGES first time presenting in front of the RUC. We had a positive
outcome and it was a good prelude for what may be coming down the pike
-namely the 6 bariatric codes that are to go to CPT in November. Good
survey data based on an adequate sample and then submission of an RVUs
which honestly reflect the work done should go a long way to expediting
this complicated process.
* A Category I is generally based on the procedure being consistent with
contemporary medical practice and being performed by many physicians
in clinical practice in multiple locations.
Category II codes are intended to facilitate data collection by coding
services and/or test results that are agreed upon as contributing to
positive health outcomes and quality patient care.
Category III designates a code as a temporary tracking code for new
and emerging (NOT experimental) technologies. Category III CPT codes
are intended to facilitate data collection on and assessment of new services
and procedures.
For more details please contact Colleen Elkins in the SAGES office:
colleen@sages.org
To receive updates by email on issues such as the above
and on other projects the Society is involved in, please subscribe to
our free monthly newsletter using the form below.
|
