A vascular surgery team at Audie L. Murphy VA Medical Center in San Antonio, Texas, uncovers “staggeringly low” numbers of correctly coded billing for three commonly performed vascular procedures, raising concerns over cases with more complex coding.
Not long after becoming chief of vascular surgery at Audie L. Murphy Memorial Veterans Hospital—one of the larger of the Veterans Affairs institutions in the U.S.—in the past year, Alissa Hart, MD, started to look at her team’s productivity, and identified a problem. Despite carrying out a brisk load of complex vascular cases for a VA setting like hers, there appeared to be a problem in terms of the level of relative work value units (RVUs) being captured by the center’s coding service. So she went “down the rabbit hole.” What she found astounded her.
“Only 42% were coded correctly, so the majority weren’t coded correctly,” Hart tells Vascular Specialist. “These are simple cases. The TCARs [transcarotid artery revascularizations] were actually coded pretty correctly, but the other two—EVARs [endovascular aneurysm repairs] and fenestrated EVARs (FEVARs)? This isn’t even a pedal access atherectomy with stent placement, or something along those lines.
“What I realized, when we looked at this in general, I went back and started trying to re-code my own cases, and there was a point where we did five EVARs in a month—which is pretty good for a VA—and only two of them were coded with a code that had RVUs attached to them.”
Based on her initial discovery, Hart and colleagues—including presenting author Luke Perry, DO, a first-year vascular surgery fellow at UT San Antonio—carried out a retrospective study of the total number of cases, those coded correctly, total number of RVUs, and the number of RVUs actually captured for TCARs, EVARs and FEVARs carried out at their center across a five-year period. The data are set to be presented at the 2024 Southern Association for Vascular Surgery (SAVS) annual meeting (Jan. 24–27) in Scottsdale, Arizona.
Total RVUs completed were 1,764.42 but only 1,196.82 were captured, SAVS 2024 will hear. “When I started looking at this, and looking at our productivity numbers, I thought, ‘How is this possible?’” Hart recalls. “We’re doing atherectomy cases, doing TCARs, EVARs and FEVARs, and all these things that a tertiary-level center would do at a VA. I was quite proud of our department. So having just come from private practice, where I had started to get more familiar with how outpatient-based labs code, and how many RVUs you can get out of a single procedure, I started looking at the way our coding was coming back from our centralized coders. That led me down a rabbit hole where I started to realize that, not just the VA but other organizations as well, are using coders that are primarily used as outpatient coders to code surgical packages.
“For vascular surgery, in addition to complex coding, you also have all these modifiers that really increase your RVUs. If a coder is not really sure how to do that properly, we’re doing all this work and we’re not getting the productivity value out of that, or the bonus value for our surgeons. We’re constantly being told you’re not productive enough and our system is trying to find ways for us to cut costs, when the reality is, if they would spend the time and put the energy into coding, then they could justify our existence as is—and probably provide us with more resources.”
With Hart being on the younger side— 34, she reveals—on becoming a chief all of sudden she realized she hadn’t really been prepared, either in her residency or during a stint in private practice, how to improve productivity or, for instance, justify the salaries of new hires.
There is also a vascular identity within hospital systems as well as resource allocation dimension to consider. “Vascular surgery should get the resources that it needs based on the services it provides,” Hart says. “Some of our cases, we are back-up for cardiology, or we are back-up for interventional radiology when they have access complications.
“To make sure vascular surgery gets the recognition and the resources that it deserves to provide both surgical back-up and radiological assistance to so many different departments is really important.”
The next step in this line of study will see Hart and colleagues delve deeper into their more complex endovascular cases in order to ascertain the extent of incorrect coding issues. “We’re trying to find out what that looks like now because one of the other issues that I’ve found in my department in my particular system is that we don’t get RVUs
associated with reading vascular labs,” she explains. “What I’ve learned in the complexity of the bureaucracy in the federal government, your [productivity] scores are only as good as the data put in.”
So now Hart’s team will look to incorporate that data with their operating room coding in
order to determine what is being missed—“not just with vascular lab readings, but also on the radiological interpretation, ultrasound guidance, all those things for those CPT [Current Procedural Terminology] code modifiers, and see how many RVUs we’re losing.”
SVS announces on-demand coding courses are now available
To expand coding educational resources, the Society for Vascular Surgery (SVS) and long-term partner KarenZupko and Associates Inc. (KZA), a consulting and education firm, plans to release a series of on-demand courses quarterly that will examine the intricacies of coding for vascular surgery. The first course launched in December 2023.
Each fall, the SVS hosts an in-person Coding and Reimbursement Workshop, but the need for additional resources was clear, stated SVS Advocacy Council Chair, Megan Tracci, MD. “Coding is a critical part of running a successful practice for all vascular surgeons and we’re in need of resources, but they’re scarce,” she explained. “The SVS is working to ensure our members have access to the information they need.”
The first course focuses on surgical modifiers in vascular surgery. Modifiers tell the payor what happened in surgery and, more importantly, how they impact on reimbursements. The course dives into the most common modifiers and how they are used accurately in vascular surgery scenarios. New courses will drop throughout 2024.
The courses will provide American Academy of Professional Coders continuing education credits. Vascular surgery professionals and their office staff can access the first on-demand course by visiting vascular.org/codinginquiries.
