2009 Cataract Coding Change Information

We value all our members input and want to take this opportunity to explain the process in hopes that you understand the many issues we face in valuing all services.

The AMA Specialty Society RVS Update Committee (RUC) and the Centers targeted code 00142 for Medicare and Medicaid Services (CMS) for review as a potentially misvalued service, as the model used to obtain the increase to the Medicare conversion factor in 2008 did not confirm the base unit value for this code. (The other codes flagged as potentially misvalued were 00210 and 00562.) To translate – this means that the RUC and CMS questioned whether this service was overvalued in relation to other anesthesia services. Therefore, we had to survey this code. This process is standard for all specialties for any potentially misvalued code.

ASA surveyed code 00142 in the summer of 2007 and sent the survey to 300 ASA members. We must send the survey in a random fashion. We needed a broad pool of respondents for a code that is performed over 1.5 million times a year. We needed to demonstrate that the responses represent individuals that have done the service and can value the work in relation to other anesthesia services. For commonly performed procedures, handpicking anesthesiologists who only do cataracts would not be a random survey, is a violation of RUC and CMS survey policy, and would have likely invalidated the survey.

Our survey results valued code 00142 at 4 base units. That value represented both the 25th percentile and the survey median. The RUC often accepts the 25th percentile response value; a specialty society must have a very strong argument for acceptance of the 50th percentile. The RUC rarely accepts a value over the 50th percentile relative value estimation. It is also important to remember the RUC and CMS concerns about potential misevaluation were based upon 4 base units. Our surveys supported maintaining this value.

Work for any anesthesia service must be in rank order with other anesthesia services. The anesthesia work associated with services that have 6 base units must represent more anesthesia work than those with base unit values of 4. Other anesthesia codes with base unit values of 6 include:

  • 00320 - Anesthesia for procedures on the esophagus, thyroid and trachea
  • 00520 - Anesthesia for closed chest procedures
  • 00840 - Anesthesia for Intraperitoneal procedures in the lower abdomen

All the above are typically performed with general anesthesia in intubated patients. Survey respondents were asked to compare the work of an anesthesia service for a cataract with other anesthesia services. Our participants did that and the responses demonstrated that anesthesia for a cataract typically performed as MAC should be valued lower compared to the work of other anesthesia services with a base unit value of 6.

We addressed the valuation concerns about codes 00210 and 00562 by carving out some of the anesthesia cases encompassed in these codes into separate CPT® codes. That was not a viable option for cataracts. In order to justify two codes we would have had to verify that the work was substantially different. All codes/vignettes/work descriptions are submitted with the understanding they represent typical work in a typical patient. Typical means more than 50 percent of the time. Cataracts are rarely done with general anesthesia. That would leave breaking the code down into separate codes: one with topical and one with a retrobulbar block. We have no evidence that retrobulbar blocks are typically (greater than 50 percent of the time) performed by the anesthesiologist. Ophthalmology has a RUC member as well and that person would need to support the argument that anesthesiologists typically perform a retrobulbar block. A separate code would not have helped with the valuation and it is unlikely that the CPT Editorial Panel would have approved such a proposal.

Finally, two codes would have likely raised the issue of budget neutrality. CMS currently allows 4 base units for a code reported over 1.6 million times a year to Medicare. If that code is divided into two separate codes with one of the new codes representing more work than the other, one code must have a lower base unit value than the other so that the total money paid is budget neutral. The budget neutrality concept was applied to code 00540 (Anesthesia for thoracotomy procedures). In 2003, a new code was created to report anesthesia for thoracotomy procedures performed using one lung ventilation. The new code (00541) was valued at 15 base units. Prior to 2003, code 00540 had 13 base units. The value was changed to 12 units due to the requirement that the codes be budget neutral. A similar result would be expected if two codes had been created.

Why did we change the value published in the Relative Value Guide®? The change to 00142 was made because the code was surveyed by anesthesiologists and those survey results clearly pointed to 4 base units. The survey was solid, met all required criteria and resulted in a value that is defensible. The RVG must remain a credible document for it to continue to be used by payers. Using survey-supported values is one very important way to maintain credibility.