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Acupuncture Today
April, 2005, Vol. 06, Issue 04
 
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AIMS Conducts Analysis of New CPT Codes

By Shane Burras, LAc

After reading David Wells' article published in the February 2005 issue of Acupuncture Today, and after a thorough review of available relevant material, Acupuncture and Integrated Medicine Specialists (AIMS) has significant questions and concerns regarding the process leading to the publication of the new Current Procedural Terminology (CPT) codes for acupuncture.

AIMS also has a number of questions regarding the new codes themselves.

The new CPT codes still require some clarification, and there is significant work to be done to protect both our profession and our value as health care providers in the commercial insurance industry. While we applaud the work necessary to obtain new codes, diligence, collaboration and unity are required in order to secure the future of our profession. The new codes and the issues they raise will affect every practice - cash-based or insurance-based - as the codes will help to determine acceptable rates for our services.

Were the Old CPT Codes Scheduled for Termination?

Although the original codes were considered "provisional" in the sense that they had no established relative values, we can find no evidence of a scheduled or published termination date for the codes themselves. Dr. Wells' article suggests that had the American Association of Oriental Medicine (AAOM) failed to take action, the codes would have been cancelled, and acupuncture would have been taken out of the CPT code set. We have examined the American Medical Association's CPT code review process and can find no basis for the termination, without replacement, of a code set for procedures in current use.

The article also noted that the old CPT codes had no valid "work value" assignment. The most recent schedule published by Center for Medicaid/Medicare Services (CMS), the agency responsible for publishing the relative value units (RVU) for the CPT codes, shows incorrectly calculated relative value units for acupuncture. Information from the AOM Alliance indicates that the new relative value units may soon be "zeroed out." This would leave the profession with essentially the same problem as it had with the last set of codes!

Why Is the Relative Value Unit Important?

The new CPT codes are indeed time-valued, but they were intended to provide an appropriate work value so the insurance industry would have a basis for deciding how to pay for our services. After substantial research, and as more information becomes available, it now seems that the new CPT codes present significantly more reimbursement and time-value challenges than did the previous codes.

The insurance industry uses CPT codes and their respective relative value units to determine what they deem to be an appropriate level of reimbursement. The relative value units assigned to a CPT code indicate the amount of money the CPT code is worth nationally.

Even though Medicare does not reimburse for acupuncture services, the RVUs reported by CMS are the insurance industry benchmarks for calculating the value of our services.

The "physician practice value," or the cost of running and maintaining a medical office - the largest portion of our overhead - was absent from the CMS RVU calculation. Through error or oversight, this has caused our codes to be valued far below the values insurance carriers and contracted network entities have historically used.

Dollars and Cents: How Much Are the CPT Codes Worth?

CPT code 97180 was assigned an RVU of 0.60 by CMS. When this is compared to a 15-minute office visit performed by any other physician (for example: 99213, a mid-level office visit, which was assigned an RVU of 1.39), the new codes are less than half the value for the same amount of time spent with a patient.

The conversion factor, used by CMS to calculate the actual reimbursement amount per procedure, varies based upon geographic location. In other words, the reimbursed amount varies by location, but the RVU remains constant. For example, the RVU is the same in Los Angeles and in West Virginia; what changes is the dollar conversion based upon the geographic location of the provider. A simple way to think of this is: [CPT code RVU] x [Geographic Money Conversion] = [total maximum reimbursement for the CPT code].

For example: The conversion factor for physician services in Los Angeles is approximately $37.00 per unit. In this case, the actual reimbursement amounts would be calculated as follows:

CPT Code RVU Conversion Factor Reimbursement
97810 0.60 x $37.00 = $22.20
99213 1.39 x $37.00 = $51.43

How This Has Affected Our Financial Lives

At least one large acupuncture network has - effective Jan. 1, 2005 - adopted reimbursement values that were drastically below previous reimbursement rates for acupuncturists. This particular network is almost 30 percent below what Medicare would have calculated. On average, the new rates for this network reimburse $17.00 per 15-minute increment.

The February 2005 article stated that the new codes represent an "excellent valuation for our services and represents a real triumph for the profession." Is this truly what the AAOM had in mind when these codes were created?

Some Alarming Facts

Among the most disconcerting aspects of the new CPT codes is the apparent lack of broad and diverse inputs into the CPT development process. Our understanding is that AAOM assembled a coalition of four associations, only two of which represent practitioners with acupuncture as their primary educational focus and medical scope. This coalition acted in the name of all acupuncturists across the nation during the negotiation of these new codes, yet we can find no evidence that the coalition solicited representation or input from any state-level associations. Requests for more detailed information regarding this process have so far gone unanswered. At the time of this article's writing, the AAOM has informed AIMS that our questions and concerns would be merged into a pool of questions from individual practitioners and that no responses would be provided for at least two months.

Additionally, the CPT code descriptions are problematic. Some of the acupuncture codes require "re-insertion" of a needle, but offer no definition of "re-insertion." If interpreted literally as the reuse of needles, this requirement is in direct conflict with the profession's generally accepted standards of asepsis.

Finally, an analysis of the time requirements for an "average visit" unveils a discrepancy in how much time is accounted for in an acupuncture procedure. A primer published by the AOM Alliance indicates that the pre-service, intra-service and post-service times included in an acupuncture visit total 21 minutes, not the 15 minutes established by the code. This additional time effectively cuts the already low reimbursement rates by nearly a third.

Cash - and Insurance-Based Practices Will Be Affected

Reimbursement fees in the world of commercial insurance influence fees for cash-based practices. As the commercial insurance market's valuation of our service decreases, cash patients will be willing to pay less out of pocket, driving down fees for all types of patients.

The continued participation of our profession in the commercial insurance industry is in jeopardy unless we see dramatic changes in reimbursement levels. As participation in provider networks decreases, the networks will be forced either to change their tactics or to lose their managed care contracts. Without an adequate number of providers in a given geographic location, the managed care industry will begin to have difficulties administering the acupuncture benefit, and the cost of this benefit will rise. As the costs of the benefits rise, more insurance policies will exclude coverage for acupuncture in order to control premium costs.

What Do We Do Now?

First, we need to identify and fix the issues with the new codes. In the long term, these codes may prove to be advantageous to our profession, but we will need to overcome significant deficiencies in the short term.

Second, we'll need to address the process for development of major national policies in our profession. These new codes impact more than 18,000 practitioners nationwide. AIMS is deeply concerned that apparently, a small number of individuals representing only two national Oriental medical associations negotiated these codes without substantial input from state associations or from meaningful numbers of individual stakeholders. AIMS is eager to assist the AOM profession in efforts to improve both the codes and the process that produced them. To this end, we call on the AAOM to clarify the outstanding questions around these codes so that AIMS can proceed with its analysis, and urge the AAOM to seek broader and more diverse inputs both in addressing the deficiencies of the new codes and in the formulation of major national policies of the future.

Finally, we all need to get active and stay connected. Professional unity is essential to our success. AIMS is working hard to get answers to the many questions and concerns we have with respect to the new codes. We will share information as we get it. Interested practitioners can sign up to receive this and other vital information at the Web site below.


Editor's note: To learn more about AIMS and to receive updates on the CPT codes and other important issues, visit www.aimsaction.org/keepmeposted.

 

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