Healthcare Economics Committee | ASCRS
The Healthcare Economics Committee is responsible for presenting information on issues affecting the colon and rectal surgeon to Congress and agencies of the federal government. The committee's responsibilities include keeping members informed on these issues and tracking developments in managed care, regulatory, legislative, and other issues that impact coding, billing, and reimbursement for colorectal services.
The Medicare Access and CHIPS Reauthorization Act of 2015 (MACRA) repealed the Sustainable Growth Rate (SGR) and established the Quality Payment Plan (QPP), which is intended to promote greater value within the healthcare system. The QPP consists of two distinct programs that will determine physician payments beginning in 2019, the Merit-based Incentive Payment System (MIPS) and the Advanced Alternative Payment Models (APMs). MIPS will consolidate components of three existing programs—the Physician Quality Reporting System (PQRS), the Physician Value-based Payment Modifier (VM), and the Medicare Electronic Health Record (EHR) Incentive Program, commonly referred to as “Meaningful Use.” Almost all colorectal surgeons will participate through MIPS.
MIPS is a budget-neutral payment system, meaning that there will be winners and losers starting in 2019. The good news is that CMS estimates that 90% of physicians will have a neutral or positive adjustment in the first year. The bad news is that you need to learn now what to do in 2017 in order to avoid penalties in 2019. Adjustments, up or down, to CMS payments will be made based on your MIPS composite score. The score is based on four domains but only three will be utilized in 2017, which is considered a “transition year.”
How to Ask Questions about Coding and Reimbursement
Reimbursement and the correct ICD-10 coding to support it are extremely important for every physician’s practice. This long and often cumbersome process can be complicated.
ASCRS provides the following new forms that allow ASCRS members to ask questions from expert surgeons on the Healthcare Economics Committee who will be able to tell you why your payment has been denied or which CPT code to use for specific procedures. Please complete the following forms and return them to email@example.com for review.
Frequently Asked Questions
The following is a selection of questions ASCRS members have recently asked the Healthcare Economics Committee:
Q: Why was the procedure “Fistula Plug Repair” (CPT Code 46707) denied as “experimental?”
A: Code 46707 Repair of anorectal fistula with plug (e.g., porcine small intestine submucosa [SIS])
This code was converted from a CPT Category III code to a Category I code and was first published in the 2010 Current Procedural Terminology, the only official CPT codebook, copyright American Medical Association (AMA). CPT 46707 has a Work RVU of 6.39, and is well-placed in the family of codes under the category of repair of anorectal fistula.
However, since it has become a Category I code, the American Society of Colon and Rectal Surgeons’ (ASCRS) Health Economics Committee has received many inquiries and complaints from members that insurance companies have denied payment. Key Point: just because a procedure has a Category I code, it does not guarantee payment. The majority of our procedures require prior authorization from the insurance company before we perform a procedure. This prior authorization also does not guarantee payment.
A reasonable approach for the surgeon to receive payment is to speak to the medical director of the insurance company and discuss the clinical problem in advance of the standard preauthorization process. This conversation allows the surgeon to support the decision to utilize the 46707 code for the patient, while discussing the alternative procedures that would have to be utilized if the 46707 code is not authorized: for example, endoanal advancement flap or LIFT procedures, both of which have a higher morbidity and cost. This dialogue will educate the medical director on the complex decision making for treating anorectal fistula and possibly “insure” reimbursement.
Q: What is the correct coding for the minimally invasive Transanal Total Mesorectal Excision (TaTME)?
A: As with any procedure performed, physicians want to be reimbursed for their work. The issue is what are the correct codes for billing for this procedure?
The following figures and tables will explain correct coding for this technically demanding procedure. The following tables are a compilation of the Category I CPT codes utilized for open and minimally invasive approaches to low/ultra low rectal resection with anastomosis and APR with colostomy. The following are the open CPT Codes with the long descriptors from the CPT Professional Edition.
Figure I: Laparotomy Codes (Open Codes)
44145 Colectomy, partial; with coloproctostomy (low pelvic anastomosis)
44146 Colectomy, partial; with coloproctostomy (low pelvic anastomosis) with colostomy
44147 Colectomy, partial; abdominal and transanal approach
45112 Proctectomy, combined abdominoperineal, pull-through procedure (e.g., colo-anal anastomosis)
45119 Proctectomy, combined abdominoperineal pull-through procedure (e.g., colo-anal anastomosis), with creation of colonic reservoir (e.g., J-pouch), with diverting enterostomy when performed
45110 Proctectomy; complete, combined abdominoperineal approach, with colostomy
|CPT Category I Code||Last Review by RUC||WRVU||CMS Reimbursement ($)||
|Primary Provider (%)|
Figure II: Laparoscopic Codes (Minimally Invasive Codes: Pure Laparoscopic, Hand Assisted and/or Robotic applications)
44207 Laparoscopy, surgical; colectomy, partial, with anastomosis, with coloproctostomy (low pelvic anastomosis)
44208 Laparoscopy, surgical; colectomy, partial, with anastomosis, with coloproctostomy (low pelvic anastomosis) with colostomy
44395 Laparoscopy, surgical; proctectomy, complete, combined abdominoperineal, with colostomy
44397 Laparoscopy, surgical; proctectomy, combined abdominoperineal pull-through procedure (e.g., colo-anal anastomosis), with creation of colonic reservoir (e.g., J-pouch), with diverting enterostomy, when performed
CPT Category I Code
|Last Review by RUC||WRVU||CMS Reimbursement ($)||
|Primary Provider (%)|
*Key: The columns defined in both Table I & II: CPT code, the last time it was reviewed by the AMA/Specialty Society Relative Value Update Committee (RUC), the current Work RVU, CMS reimbursement (this will vary by region of US) the number of times it was utilized in the Medicare population and the primary provider (GS is General Surgery, CRS).
- The following open codes 44147, 45112, 45119, 45110 and laparoscopic codes 44395 & 44397 have the term “combined abdominoperineal” approach, this means that the code cannot be “unbundled” in to two separate procedures, nor billed separately even if two separate surgeons do a particular part. The first assistant codes apply.
- Adding a 62 Modifier to a code does not permit separate billing of an already “bundled” procedure. The first assist codes apply.
- Unbundling is considered “billing fraud.”
Billing Recommendations for the TaTME Procedure:
Utilize the existing Laparoscopic CPT Codes in Table II, for billing the utilization of this procedure.
Q: What is the correct code to use for billing a TAMIS procedure?
A: The correct code is 0184T, a temporary code developed for the TEM procedure. Although TAMIS carries a different name, it is essentially the same procedure, just performed with non-proprietary instruments and a slightly different access device.
45172 Excision of rectal tumor, transanal approach; including muscularis propria (i.e. full thickness) is an accurate description of the TAMIS procedure except that it carries the note “excludes transanal endoscopic microsurgical tumor excision (TEMS) (0184T)”
The frustration is that many insurance carriers will not reimburse 0184T, tempting many surgeons to use the 45172 code. Other carriers will reimburse for 0184T but only for specific ICD-10 codes, such as T1 cancer, benign polyp or benign carcinoid. This makes accurate documentation by the surgeon and pathologist critical to the prospect of reimbursement.
45300 or any of the proctosigmoidoscopy codes would not be accurate and would dramatically undervalue the procedure.
45123 is not accurate, as it describes a perineal approach rather than transanal.