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Fee Schedule Proposed Rule Comments

October 1, 2001

Thomas A. Scully
Centers for Medicare and Medicaid Services
Department of Health and Human Services
Room 443-G
Hubert H. Humphrey Building
200 Independence Avenue, SW
Washington, D.C. 20201

Re: Medicare Programs; Revision to Payment Policies Under the Physician Fee Schedule for Calendar Year 2002; Proposed Rule

Dear Administrator Scully:

The American Urological Association (AUA) which represents 10,000 urologists in the United States appreciates the opportunity to comment on the Centers for Medicare and Medicaid Services (CMS) Proposed Rule for Medicare Programs; Revisions to Payment Policies Under the Physician Fee Schedule for Calendar Year 2002, published in the August 2, 2001 Federal Register.

Payment Policy for CPT® Modifier 62 (Co-Surgery) and Modifier 80 (Assistants-at-Surgery)

CMS states that a revision to the payment policy for CPT® Modifier-62 and Modifier-80 is under consideration and requests information regarding the following issues:

1) Whether it would be possible to establish criteria for distinguishing the roles of a co-surgeon (when both surgeons are paid at 125 percent of the surgery amount) and assistant at surgery (when the total payment is 116 percent of the surgery amount);
2) Whether any such criteria should vary by type of procedure;
3) Which procedures require an co-surgeons and under what circumstances should documentation be required for payment; and
4) How to value the work performed by a co-surgeon.

The AUA appreciates that CMS clearly states that this provision contained in the proposed fee schedule is not considered as part of the rule and we would like to provide our comment on the issues raised in the discussion of co-surgery and assistants at surgery.

Very little information is given in the discussion on this issue as to problems that exist to warrant such major changes in the current payment and/or documenta-tion requirements for co-surgery or assistant at surgery services. The AUA has serious concerns about such a major undertaking where no documented problems exist. This may be an issue that is more appropriately addressed through better education of surgeons as to the correct definitions and necessary documentation needed in either instance.

Most procedures already have a designation as allowing either an assistant at surgery or co-surgeons but rarely can they be considered as both. Surgeons have little if any opportunity to "choose" whether they want to be paid at 16 percent or 62.5 percent of the fee schedule. According to the American College of Surgeons (ACS), there are only approximately 20 procedures that have a designation of assistant at surgery permitted with no documentation and that also have a designation of co-surgeon permitted with no documentation. In the vast majority of cases, documentation must be submitted with either type of claim. Since there are so relatively few cases that are allowed without documentation, a less burdensome adjustment would be to now include those few procedures in the documentation requirement.

Issue 1: There are already clear definitions for co-surgery and assistants-at-surgery that exist in both the AMA CPT® modifier language and in the Medicare Carriers' Manual (MCM) §4820-4828 and §15044-15046.
· An assistant at surgery serves as an additional pair of hands for the operating surgeon. He or she need not be a surgeon, or even a physician, and has no responsibilities other than the ones he assumes during the operation.
· Assistants at surgery do not carry primary responsibility for or "perform distinct parts" of the surgical procedure.
· Co-surgeons share responsibility for a surgical procedure, each serving as a primary surgeon during some portion of the surgery. Both must be surgeons, and are frequently of different specialties.
· Co-surgeons may also have pre-operative responsibility, are always responsible for dictating the operative report for the portion of the surgery that is their primary responsibility and always has the responsibility for some of the post-operative care.

The AUA strongly recommends that if revisions are considered to the co-surgeon and assistants-at-surgery modifiers, that both the American Medical Association Correct Procedural Terminology (CPT®) Editorial Panel and the Relative-Value System Update Committee (RUC) be involved in the early considerations of this issue.

Issue 2: The direction that the agency appears to be heading with the discussion on this question makes little sense in the realm of surgical procedures today. The AUA believes that it would be impossible to correlate the degree of invasiveness of a procedure to specific criteria that could help determine what the degree or work involved by a co-surgeon or assistant surgeon is in a given procedure. We strongly disagree that any workable criteria could be developed. For example, a radical prostatectomy done laparascopically is a highly complex procedure that requires two urologists coordinating assistance for the entire length of the case. On the other hand, a radical retropubic prostatectomy generally only requires an urologist assistant for specific portions of the central procedure (dissecting out the prostate and assisting in the anastamosis of the urethra to the bladder). There is no correlation between the level of assistance and the degree of invasiveness in these two cases.

Issue 3: Since 1991, the American College of Surgeons has provided a continuously updated list of procedures in its publication entitled: "Physicians as Assistants at Surgery." This publication has served as the primary resource to Medicare and other payers for determining appropriate assistant at surgery payment. AUA continuously works with the ACS to provide updates to this list based on new codes, revisions to existing codes, changes in technology or patient populations. In the Omnibus Budget Resolution Act of 1990 (OBRA '90), HCFA (now CMS) restricted payments for assistant at surgery services to those procedures that require an assistant at least five percent of the time. AUA originally disagreed with those restrictions as being arbitrary and not taking into account the numerous and varied circumstances that may necessitate the primary surgeon to request an assistant and we believe the same is true today. Circumstances and patient conditions can vary greatly in surgery and if a situation presents itself that a second pair of hands is needed for some portion of the procedure, the assistant should be able to bill for that work.

Issue 4: Again in OBRA '90, at the request of CMS, Congress reduced the payment for assistant at surgery services from 20 percent to 16 percent of the primary surgeon's fee. The AUA disagrees with that reduction and we believe that such an amount underpays in those cases when the assistance needed is more complex and requires another surgeon. Since more than ten years have passed from the 1990 reductions in assistant at surgery payments a separate review by AMA RUC as to the accuracy of such a value may be warranted. If changes are considered in valuation for co-surgery, AUA recommends that such a discussion begin with the AMA RUC and include those specialties that are involved with co-surgery procedures.

Payment Issues Specific to Urology in the Proposed Rule

There is one final issue regarding the payment of a new procedure for 2002 performed by urologists that the AUA would like to address in our comments on the Notice of Proposed Rulemaking for 2002.

The AUA wishes to emphasize our ongoing concerns with the AMA RUC recommendation for CPT® code 55857, cryosurgical ablation of the prostate. After three facilitation meetings during the last several RUC meetings, we still have major disagreement with the recommended value for this very complex procedure. During the first facilitation committee, (October 30, 2000) the RUC identified CPT® 55810, radical perineal prostatectomy (22.58 RVW), as a more appropriate reference procedure than the one submitted by the AUA (CPT® 55845), radical retropubic prostatectomy (28.55 RVW). The Committee also compared the ultrasound portion of the procedure to that of 76965, ultrasonic guidance for interstitial radioelement application (RUC approved value of 1.92 RVW). Both of these values were taken into consideration by the AUA in determining the final value for the total procedure.

However, as the original consideration strayed from standard RUC procedure and based the final value solely on an IWPUT/building block methodology (one which to date has still not received final RUC approval as the accepted standard), the code was referred to another facilitation committee. Despite further consideration at two additional meetings we are still concerned about the major discrepancy between the final facilitated relative work value (RVU) of 19.47 and our original surveyed value of 26.50.

AUA representatives pointed out a discrepancy in the reference service code cited in the final facilitation committee (55801) from the previously agreed upon code of 55810. During the second facilitation committee, CPT® 55801 (17.80 RVW) was cited as the appropriate reference code and was used as the sole gage in determining a value for cryoablation. A comparison to CPT® 55810 does make sense; however, a comparison to 55801, one that historically only refers to benign disease, does not. And second, there is no ultrasound component to CPT® 55801 (or to 55810, for that matter). While the AUA agrees that the work of cryosurgical ablation of the prostate can be compared to the work of CPT® 55810, consideration still must be given for the ultrasound component. A direct comparison between the work of the two codes is appropriate only as long as the ultrasound component is factored in. The final compromise to split the reference value between that of these two reference codes was extremely arbitrary and assigns a value that our membership believes is not appropriate for the work involved in this procedure.

We appreciate your consideration of these comments. If you have any specific questions regarding these comments, please contact Cherie L. McNett at the AUA at 410-689-3710 or via e-mail at


E. Darracott Vaughan Jr., MD
American Urological Association

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