Medical Tuesday Blog

Current Procedural Terminology – CPT Codes

May 22

Written by: Del Meyer
05/22/2017 3:29 AM 

CPT coding is similar to ICD-9 and ICD-10 coding, except that it identifies the services rendered rather than the diagnosis on the claim. ICD code sets also contain procedure codes but these are only used in the inpatient setting.[5]CPT is currently identified by the Centers for Medicare and Medicaid Services (CMS)[6] as Level 1 of the Health Care Procedure Coding System.

Using a numbered code for each medical or surgical procedure helps define the procedure for greater consistency. These are the CPT codes, Current Procedural Terminology, which define the time and work involved with each procedure required for the diagnosis and management of each recorded ICD code. These have been spelled out with E & M (Evaluation and Management) descriptions for all medical and surgical procedures.

The CPT coding system describes how to report procedures or services. These formerly included a Relative Value Scale. Then physician could use a conversion factor to determine all their fees in proportion to each other based on the number assigned. This was known as the 1964 RVS Medical Codes. These were revised five years later as the 1969 RVS Medical Codes. They were again revised five years later as the 1974 RVS Codes. When these were ruled as anticompetitive or collusion by the AMA (physicians) a study ensued. A large number of physicians and surgeons then met and designed a detailed description of each procedure to include the resources and time necessary to perform each procedure but with no numeric scale which was ruled as fee setting. This would allow a physician to base his or her fee more accurately on the basis of the amount of effort and resources required to perform each individual procedure but not all of his or her procedures.  This was then called the Resource Based Relative Value Scale or RBRVS of 1992. The subsequent evaluation and management guidelines placed an estimate of the amount of time the physician should be spending on each procedure without any relative value.

This in turn provided the data which federal attorneys could use to prosecute physicians. For example if a procedure required 60 minutes or one hour per the guidelines, and if a physicians billings indicated that he or she did 20 such procedures in an 8 hour day, Medicare would down code the procedure to a lesser value. If this represented the usual practice, the physician could be prosecuted for up coding, e.g. since there could not be 20 one hour procedures done in one day, the RBRVS code should have been a 20 or 30 minute procedure. The brightest physicians, who could diagnose and treat two or three times faster than the dumbest, were at the highest risk of being prosecuted.

The prosecution would review a certain number of charts and if they found an average of a 50% error, they would apply that to his or her entire income and then fine the physician 50% of his or her income for the period in question and frequently a jail term. There is one report of a family physician making an error in going from the prior procedure code to the current one and he spent 22 months in jail. An ophthalmologist spent 66 months in prison. Of course, this made both physicians felons, and neither could practice or vote again. In many cases it disrupted or broke up the family when they lost their homes as their income became negligible. Their parents, of course, lost the quarter million dollars or so that was invested in their education. This was a governmental retaliation against physicians which had nothing to do with quality of care. In fact, the best of physicians who could do excellent care in half the time of the slowest and most inefficient among us, were very ones being prosecuted, imprisoned, becoming felons, losing their voting and basic civil rights. One federal attorney was heard bragging that he had jailed three doctors that helped clean up the medical profession.

With new coding scheduled to be implemented in Oct 2015, our HMO is already warning us to have three months of income stowed away because of the confusion and payment delays or payment cancellations in October 2015. Hence a number of physicians are planning to close their practice that day, not only to avoid any such financial risks, but also the risk of losing their medical license, their most valuable asset.

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Medical Gluttony thrives in Government and Health Insurance Programs.

It could become devastating when the government changes the basis for payment in bureaucratese.

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