Part B Insider (Multispecialty) Coding Alert

Published on Sat Apr 09, 2011 PDF

Question: Can you explain to me why some codes (such as 99172) do not have an associated relative value unit (RVU)? How can I find what the RVUs are for this code?

Answer: RVUs are based on the pricing established by the Medicare Physician Fee Schedule; if a CPT® procedure code does not have an RVU, it often is because Medicare does not cover the service. You can find out where Medicare stands on the payment status of any particular code by checking the Fee Schedule.

Key: When perusing the Fee Schedule, check the "Status Code" column (Column D). If a code with zero RVUs assigned to it has an "N" in it (as is the case with 99172, Visual function screening, automated or semi-automated bilateral quantitative determination of visual acuity, ocular alignment, color vision by pseudoisochromati plates, and field of vision [may include all or some screening of the determination{s} for contrast sensitivity,vision under glare]), you won't collect Part B payment from any Medicare contractors for that service, as it's a considered a "noncovered service."

 If, however, the code has a "C" in Column D, it will be listed with zero RVUs, but your MAC may still reimburse you for it. That's because "C" refers to a "carrier-price code." Individual Medicare contractors will establish the RVUs and payment amounts for these services,typically on a case-by-case basis after reviewing the documentation and/or operative report. You'll find that 93631 (Intra-operative epicardial and endocardial pacing and mapping to localize the site of tachycardia or zone of slow conduction for surgical correction) is considered a carrier-priced code.

Options: In cases where your MAC won't reimburse you for a particular service, it's sometimes possible that a secondary payer will. If the Part B patient has secondary insurance, check the other payer's fee schedule to determine whether it's payable. Some might allow separate payment, while some could consider procedures such as 99172 included in--and not separately payable from--preventive medicine, E/M, or other ophthalmology services.