Guest Editorial: Creative Concepts, Codes, and Costs

    A 19th century patent commissioner may (or may not) have once said, “Everything that can be invented has been invented.”¹ Fortunately, he was wrong. Much has been invented since the 1800s and more is certain to come. This issue of Ostomy Wound Management takes a look at a mix of old and new technologies used in creative and novel ways. Reading articles like these reassures my “right” brain that we still have creative thinkers helping us improve the care we offer our patients.

    My “left” brain is likewise inspired, asking how long it takes to set up a wound for ultraviolet light C irradiation and how much will it cost to commercialize the clever disposable spacer designed by Thai et al² to allow for reproducible dosing. I wonder whether such innovation will require a Current Procedural Terminology (CPT) code and what that code will be. Or whether we can afford to introduce everyone with an ulcer to hyperbaric therapy. The answers to these questions are beyond the scope of my editorial role but not beyond our roles as a wound care experts and voters who can have a voice in determining the cost — ie, price and value — of products and services.

    When someone’s “light bulb moment” results in a new procedure or technique, a CPT code must be secured. The CPT code determination process is described on the American Medical Association’s (AMA) site.³ In brief: The AMA first developed and published CPT codes in 1966 to encourage the use of standard terms and descriptors to document procedures in the medical record. The codes play a number of roles in communicating accurate information on procedures and services to agencies concerned with insurance claims and actuarial and statistical studies.

    To initiate “coding,” an individual or society must prepare an application to convince the CPT Editorial Panel the service is new and not already described under a current code. Once the CPT code is approved, it goes through the AMA Specialty Resource-based Relative Value System Update Committee (RUC) process to define its relative value. The 29 members on the RUC include 23 fixed and six rotating seats (I represent organized dermatology, a fixed seat and original player in the process). The Centers for Medicare and Medicaid Services (CMS, formerly HCFA), the AMA, and the CPT committee sit at the table with representatives from the general “house of medicine” in attendance. Attendees “without seats” may participate in the code value creation process but have no vote. The CMS is not duty-bound to accept RUC recommendations but historically 90% have been accepted.

    The value of the service is expressed in relative value units (RVUs). The total RVU consists of physician work, practice expense, and liability RVUs, typically in a 55:42:3 ratio. Physician work RVUs are based on physician time, technical skill, physical effort, mental effort, judgment, and stress as related to potential risk to the patient. Practice expense RVUs consist of clinical (nurse, medical assistant, technician, but not MD or administrative staff) time, medical supplies, and a depreciable portion of durable equipment. Liability RVUs are based on controversial data the CMS amasses. For 2005, an RVU is worth $37.89.

    The new CPT code is surveyed using an instrument specific to the RUC process; details are available on the AMA website in the RUC information area.⁴ This survey instrument is distributed by specialties with an interest in the code to practitioners who perform the procedure undergoing valuation. The surveying groups then present their results at the RUC, while the practice expense components are reviewed by the Practice Expense Refinement Committee (PERC) that under the auspices of the RUC examines non-physician expenses in providing a service. The RUC makes its decisions based on a review of available data, functioning under a number of constraints. Interestingly, the RUC is expected to determine the value of a code in RVUs to within two decimal places, with a great amount of evidence needed to define a value for work. However, a commercial vendor can introduce a new disposable with no accountability for this pricing, which is free market on such devices. The only restriction: no discounts to providers as incentives to use them. The consumer is left to wonder why a little widget can cost hundreds of dollars. Public awareness of such situations can potentially stimulate elected officials to explore these policies openly and possibly allow patients and providers to share in some of the privilege reserved for manufacturers. Although the widget has associated research and development costs, recapturing these costs seems to occur much quicker than recapturing the reader’s educational costs.

    Astute readers may note that I am on my familiar soapbox, encouraging you to become educated and active. You can play a role in designing costs and participating in the survey processes related to codes relevant to your practice. The AMA sites, Federal Register, and the US government weekday record can help keep you informed and involved. Also read CMS 42 CFR Part 405, et al. Medicare Program: Revisions to Payment Policies Under the Physician Fee Schedule for Calendar Year 2006: Proposed Rule,⁵ released Monday, August 8, 2005 — the first salvo from the CMS for next year’s Medicare expenditure. The Final Rule should be available on November 1 but in some cases is delayed until as late as the new year. Proposed and Final Rules for previous years are also available on the Federal Register site. Interested parties should look for information regarding reimbursement levels, policies for services and supplies, and all the why’s behind reimbursement. Proposed and Final Rules welcome comments; individual citizens may comment but well-crafted arguments undersigned by large numbers of individuals or societies/organizations may have more impact.

    With ongoing escalating expenditures in Iraq and the recent New Orleans tragedy, moving more federal money into healthcare is unlikely in the near future. However, creativity, involvement, and engagement are critical to our way of life, both as Americans and healthcare professionals. The blessing/curse “May you live in interesting times”⁶ has never been more poignant.

1. http://www.ideafinder.com/guest/archives/wow-duell.htm. Accessed September 8, 2005.

2. Thai TP, Keast DH, Campbell KE, Woodbury G, Houghton PE. Effect of ultraviolet light C on bacterial colonization in chronic wounds. Ostomy Wound Manage. 2005;51(10):32-45.

3. http://www.ama-assn.org/ama/pub/category/3113.html. Accessed September 8, 2005.

4. http://www.ama-assn.org/ama/pub/category/2292.html. Accessed September 9, 2005.

5. http://a257.g.akamaitech.net/7/257/2422/01jan20051800 /edocket.access.gpo.gov/2005/pdf/05-15370.pdf. Accessed September 9, 2005.

6. http://www.noblenet.org/reference/inter.htm. Accessed September 10, 2005.