New Coronary Intervention Codes in 2013 Essay Example for Free

New Coronary Intervention Codes in 2013 Essay Coronary Intervention Codes and Reimbursement: Two Decades of Effective Advocacy Why have interventional cardiologists’ salaries ranked at or near the top compared to other specialties for the past decade (1)? Long hours under high stress using extreme skills to perform dangerous procedures? Yes, but there is more. Effective advocacy by the Society for Cardiac Angiography and Interventions (SCAI) and American College of Cardiology (ACC) has played a large role. This is the story. Medicare, enacted in 1965, based reimbursement for physician services on the actual charge on the current bill, the customary charge over the past year, or the local medical profession’s â€Å"prevailing† charge over the past year, whichever was lowest (2). This system was chaotic and confusing. In response, the Omnibus Budget Reconciliation Act of 1989 switched Medicare to the Resource Based Relative Value System (RBRVS). This used Hsaio et al’s estimates of physician time and effort to assign Relative Value Units (RVUs) to physician services (3). In 1991, the Center for Medicare and Medicaid Services (CMS) convened a series of Technical Expert Panels (TEP) to refine Hsaio’s initial estimates of work for selected procedures. One of these was percutaneous transluminal coronary angioplasty (PTCA). A representative of the SCAI/ACC convinced the TEP to increase reimbursement for PTCA from Hsaio’s estimate of 9.5 RVU’s to 10.5 RVU’s. The 20 million or so coronary angioplasty and stenting procedures performed in the US since 1992 have all been reimbursed at a rate reflecting that 1 RVU increase granted by the TEP in 1991. Thus, this one instance of effective advocacy by SCAI/ACC increased reimbursement for these 20 million coronary intervention procedures over two decades. Now jump to 1994 when STRESS (4) and BENESTENT (5) compared elective stenting to balloon angioplasty, and a randomized trial compared then state-of-the-art Palmaz-Schatz and Gianturco-Roubin II stents (6). Elective stenting was just starting; most stents were placed to bail out failed balloon angioplasty. In this milieu a code for coronary stenting was developed. The expert panel that advised CMS on reimbursement estimated that the average stenting procedure required 120 minutes of physician time from first injection of lidocaine to last catheter withdrawn (diagnostic catheterization not included), 45 minutes of preparation time before the procedure, and 60 minutes of physician work after the procedure, for a total physician work time of 225 minutes per coronary stenting case. Thus, interventionists have been paid for coronary stenting at a rate based on almost 4 hours per procedure for the past 17 years. New Coronary Intervention Codes and Values For the past several years, CMS has attempted to curb Medicare expenditures by identifying and reducing payment for over-priced services. In 2011 CMS identified coronary stenting as possibly over-priced and required that it be re-valued. The value of a service depends on the time required to perform it, and to a lesser extent the intensity of the work. SCAI and ACC knew that invasive cardiologists were reimbursed for 4 hours of work per stent case since 1994, and that procedural times might have shortened since then. A re-valuation could significantly decrease the RVUs paid for a coronary stenting procedure. Interventional cardiologists were also keenly aware of problems with the existing coronary intervention codes (Table 1). Reimbursement for an emergency middle-of-the-night ST elevation myocardial infarction (STEMI) stent procedure was the same as for elective stenting of a healthy patient at noon. Stenting of complex left anterior descending bifurcation lesions requiring 3 stents was valued the same as stenting of a type A lesion requiring 1 short stent. SCAI/ACC experts decided that if interventional procedures were to be re-valued, it was time to get codes that recognized and reimbursed for the extra work of performing complex coronary interventions. SCAI/ACC experts developed a new set of codes that describe interventional procedures with greater detail (Table 2) and won their approval by the AMA Current Procedural Terminology (CPT) Panel. Then they had to be valued. This required several steps. The first step was a survey of practicing interventionists to estimate physician work and time required for each new coronary intervention code. As expected, practicing cardiologists estimated the skin-to-skin time required for coronary stenting to be much less than original 2 hours – 45 minutes to be exact. Without the new codes, reimbursement for coronary stenting would likely have been reduced proportionately, by over 50%. Fortunately, SCAI/ACC experts convinced the American Medical Association Relative Value Update Committee to recommend to CMS that the new complex coronary intervention codes be reimbursed at higher rates (by up to 25%) than simple coronary stenting. Overall, reimbursement for the family of coronary intervention procedures will drop 18-20%, much less than the 50% that might have occurred without the new codes. New Coronary Intervention Codes Solve Old Problems The new codes solve several longstanding problems. .1. For a decade interventionists have complained that they are not reimbursed for the intensity of STEMI PCI. Now they are. RBRVS rates intensity using units of â€Å"RVU’s per minute of procedure time†. The intensity of seeing patients in clinic rates.03, coronary bypass surgery rates.10, and emergency tracheostomy rates.26. Coronary intervention codes were previously rated at.10, but the new code for STEMI PCI has an intensity rating of .18. Intensity of other new coronary intervention codes is raised to the .13 – 15 range. .2. The extra work and stress of PCI of grafts and chronic total occlusions is now recognized and reimbursed higher, by 10% and 25% respectively. .3. Stenting preceded by atherectomy is now reimbursed at a higher rate (by 12%) than stenting alone. Previously there was no differential. .4. The additional work of performing PCI on multiple branches of a single artery is now recognized with separate codes. CMS refuses to pay for these, and SCAI and ACC are lobbying CMS reverse this decision. The good news is that CMS’ decision does not limit reimbursement because CMS bundled the value of the â€Å"additional branch codes† into payment for the base codes. SCAI/ACC still recommends that the â€Å"additional branch codes† be used because some private payers may choose to reimburse them. Interventional Coding Examples to Illustrate Basic Principles .1. Problem: Coronary angiography is followed by ad hoc coronary stenting of the right and circumflex coronary arteries. Solution: 93454 (coronary angiography), 92928 (stenting single coronary), and 92928 again (stenting circumflex). Principles: As before, catheterization is coded using the separate cardiac cath codes, which are paid at 50% when performed with coronary intervention. Also, the base code for coronary stenting (92928) is used for both vessels, whereas previously the base code was used once, along with an â€Å"each additional vessel† code which was retired in 2013. .2. Problem: Stenting of the circumflex is performed followed by atherectomy and stenting of the ramus. Solution: 92928 (stenting single coronary), 92933 (atherectomy and stenting single coronary). Principles: Previously CMS recognized and reimbursed for procedures in only 3 arteries (the left anterior descending, the circumflex, and the right) and might have denied reimbursement for the ramus PCI. Starting in 2013, CMS recognizes two additional arteries (the left main and ramus arteries) and will reimburse for PCI in all of them. Also, use the new â€Å"atherectomy + stenting† code (92933) offers higher reimbursement than the stent code (92928). . 3. Problem: A patient with non-ST elevation myocardial infarction has a 99% lesion with slow flow stented. Solution: 92941: (stenting of subtotal/total occlusion causing acute MI). Principle: This code can be used for any acute MI patient (STEMI or non-STEMI) with a â€Å"total or subtotal† lesion. CPT does not provide a definition of â€Å"total or sub-total†, so if the code is used an accurate description of the lesion to support this code should be included in the procedural report. .4. Problem: Bifurcation stenting of the left anterior descending is performed, with PTCA of the sidebranch ostium and stenting of the parent vessel. Distally, a separate diagonal sidebranch is rotationally atherectomized. Solution: 92928 (stenting of the LAD), 92921 (angioplasty, additional branch for the LAD diagonal bi9furcation), 92925 (atherectomy, additional branch). Principles: PTCA of the diagonal as part of the bifurcation stenting is now recognized. When a separate branch is treated, use a second â€Å"additional branch† code. .5. Problem: Intravascular ultrasound (IVUS) shows a significant left main lesion extending into the proximal LAD which is stented. Fractional flow reserve across a distal lesion is measured and is not significant. Solution: 92928 (stenting of the left main/LAD), 92978 (intravascular ultrasound), 93571 (fractional flow reserve). Principle: As before, IVUS and FFR codes are used as â€Å"add-on† codes in addition to the base coronary intervention codes. When a single stent is used to treat a lesion in the left main extending into the LAD or circumflex, it is coded with only one code.

Peer Pressures of High School :: Peer Pressure Essays

Glaring down at the reddish glow coming from the tip of the cigarette, I found out that I was in a peer pressure situation. Peer Pressure can be a huge problem for some young adults. It can sometimes be positive, but most of the time it ¡Ã‚ ¯s negative and destructive. Smoking is just one of the peer pressures someone can go through. Alcohol and staying out late can also be huge peer pressures in high school. I know this because I have experienced them for myself. Drinking, smoking and staying out late were constant peer pressures throughout my high school career. Looking down at the cigarette and being encouraged by my friend to take a hit off of it, I knew that smoking was not something I wanted to do at that time in my life. Although smoking wasn ¡Ã‚ ¯t a huge peer pressure for me, it can be for others. Some of my friends did give into the pressure and are now addicted to cigarettes, and wish they hadn ¡Ã‚ ¯t give in to that peer pressure in high school. I would have say th at during high school, smoking was the most persistent peer pressure. It was at every party and gathering. Although it was there all the time sometimes alcohol would  ¡Ã‚ °rear its ugly head ¡Ã‚ ± at some of the parties. Drinking was probably the most dangerous peer pressure. It was extremely illegal for an underage adult to be caught drinking during this time. I never experienced this peer pressure during high school because I didn ¡Ã‚ ¯t hang around those types of people during that time. They were the types of people who didn ¡Ã‚ ¯t think it was a  ¡Ã‚ °party ¡Ã‚ ± unless there was alcohol involved. I have seen drinking totally deteriorate people, because it got the best of them. Some of my friends totally changed after they started drinking. At first it was just a social thing to do at parties, but then lead on to drinking during their  ¡Ã‚ °spare time ¡Ã‚ ±. It affected their grades and their overall behavior. I do think this was the most dangerous peer pressure in high school, but there was always the pressure to stay out late. Staying out late was a peer pressure I gave into on several occasions during high school. I know it affected my grades many times, and also made me late for school more than once. In high school you could always spot the students who stayed out late.

Dbq-Early Valley Civilizations Essay

DBQ-early valley civilizations essay Throughout history, civilizations have contributed to the cultural and intellectual life of humanity. These civilizations had developed about 5000 years ago. These civilizations had been defined as based on agriculture and urban settlements. At that period had been developed many cultural and intellectual achievements, but also stable government and a strong economy. The ancient River Valley civilizations of Egypt and Mesopotamia all made key contributions to future societies.For thousands of years, people all over the world have developed, progressed, and eventually formed civilizations. The area between the Tigris and Euphrates River was called Fertile Crescent because its rich soil and crescent shape (document 1). This region was where Mesopotamia one of the first civilization on earth grew. Sumer was an ancient civilization in Mesopotamia they created cuneiforms. Cuneiforms were the world’s first written language; Sumerians invented thi s writing system to keep track of business dealing (document 2).Mesopotamia developed between the Euphrates and Tigris River. Geographically, Mesopotamia occurred near major rivers since water was easily available and agriculture flourished. The most important invention that was created in the ancient times by Sumer in Mesopotamia was the wheel . it had a major impact in the world because it makes it easier for people to get to places faster and without the wheel the world would not have been the same. Egypt civilization was located in northeast Africa near on the border of the Nile River.Hieroglyphics was a system of writing that was based on pictures; it was created by the Egyptians to keep the records (document 6). pharaoh was the name of the king or god king of Egypt. Pharaoh built pyramids to serve as houses or tombs and specialized skill such as mathematics, geometry, engineering and architecture were need to built the pyramids (document 5). Life in ancient Egypt was centered largely on agriculture. The majority of the people were involved in farming. Wheat, fruits and vegetables were the principal crops.The Nile River helped irrigate the crops and made the soil fertile for good farming; people depended on the Nile for food and water (document 4). Egypt contributed many things in the world, such as their efforts in astronomy, medicine, writing, mathematics and architecture. In conclusion, the ancient River Valley civilizations Egypt and Mesopotamia did have many key contributions that helped expand future societies. Egypt and Mesopotamia were two civilizations that contributed to the expansion of trade, civilization, government, and political and social status.

Childhood Obesity Essay examples - 1472 Words

Forty years ago in America childhood obesity was rarely a topic of conversation. A survey done in the early 1970s showed that 6.1% of children between the ages 12 and 19 were overweight. Eight years later the same survey was done and 17.4% were considered overweight (Iannelli). â€Å"Childhood obesity epidemic in America is now a confirmed fact since the number of overweight or obese children has more than tripled during the last 30 years† (Childhood Obesity Epidemic). â€Å"Over the last 20 years, the prevalence of obesity in children aged 6 to 11 years has tripled from 6.5% to 19.6%† (Childhood Obesity Epidemic). As a nation statistics should be alarming. Why are American children today so obese? Before pointing fingers at any one reason, one†¦show more content†¦Find a different punishment or non-food reward. Step Three: Set an eating schedule for the family. Doing so will make it less likely for children to overeat and be hungry, if there’s a set time for eating. This is especially important for younger children for their metabolism and activity level. Step Four: Do not allow children to be entertained by television while eating. Television is an easy way to get carried away while eating. Step Five: Keep children busy, doing so can eliminate the urge to eat once they become bored. â€Å"Never offer food as a way to keep them busy while you are doing something else† (Childhood Obesity Epidemic). A parent should always supervise their children’s diet and should encourage them to be physical active because they have a key role when it comes to how their child eats. Another environmental cause of childhood obesity is the lack of physical activity. The problem is that physical activity has been replaced by video games, television, social networking and other technology. (Child Obesity Statistics) â€Å"It’s proven that children who watch the most hours of television have the highest incidence of obesity.† (Hosten) The American Heart Association they recommend â€Å"all children age 2 and older should participate in at least 60 minutes of enjoyable, moderate-intensity physical activities every day.† They also recommend â€Å"if your child or children dont have a full 60-minute activity break each day, try to provide atShow MoreRelatedChildhood Obesity : A Obesity1247 Words   |  5 PagesChildhood Obesity: A Review to Prevent the Risk Factors of Childhood Obesity in Our Community. The rates of childhood obesity Worldwide are alarmingly high! Obesity is a global nutritional concern and leads to horrible consequences on our children and becomes a worldwide pandemic. Worldwide estimates of obesity are as high as 43 million, and rates continue to increase each year. 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