Petition to AMA for better CPT code representation for complicated RP & abdominal tumors

Petition to AMA for better CPT code representation for complicated RP & abdominal tumors

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Jason Sicklick started this petition to United States Surgeons

Petition of Inadequate CPT Representation for:

· Complicated intra-abdominal tumor excisions involving diameter of greater than 15 cm, which require more time/effort than smaller tumors to remove due to size.

· Complicated intra-abdominal tumor excisions involving multiple tumors with cumulative diameter of greater than 10 cm diameter, which require more time/effort than excision of a single tumor.

·  Complicated intra-abdominal tumor excisions of any size tumors that:

o   encase one vascular structure (e.g., aorta, inferior vena cava, common iliac artery and/or vein, external iliac artery and/or vein, internal iliac artery and/or vein) and necessitate vascular excision.

o   encase greater than one vascular structure (e.g., aorta, inferior vena cava, common iliac artery and/or vein, external iliac artery and/or vein, internal iliac artery and/or vein) and necessitate vascular excision.

o   Abut one or more vascular structures or major nerves which require more time/effort to preserve adjacent vascular structures or major nerves.

o   Abut one or more adjacent organs (e.g., left/right colon, duodenum, liver, spleen, pancreas, stomach, kidney), which require more time/effort to preserve adjacent organs in lieu of resection.

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Dear Colleagues:

Please consider endorsing this petition to the RVS Update Committee (RUC) of the American Medical Association. This petition documents the extensive work (i.e., time and effort) involved in the open excision or destruction of single intra-abdominal tumors, cysts or endometriomas with: a diameter of greater than 15 cm; multiple intra-abdominal tumors with a combined diameter of greater than 10 cm (wherein the physician performs the surgery to remove all visible tumors similar to cytoreduction/HIPEC procedures without chemotherapy); intra-abdominal tumors encasing one or more vascular structures necessitating one or more vascular structure excisions; intra-abdominal tumors abutting one or more vascular or major nerve structures necessitating more time/effort to preserve adjacent vascular structures or major nerves; and intra-abdominal tumors abutting one or more organs (e.g., left/right colon, duodenum, liver, spleen, pancreas, stomach, kidney), which require more time/effort to preserve adjacent organs in lieu of resection. These very aggressive operative procedures can be very difficult with the average duration of 5-7 hours. CPT codes 49203-49205 (Figure 1) do not adequately represent the work, intensity, technical difficulty, physical and mental effort, distorted anatomy due to larger tumors, potential for increased blood loss with larger tumors and especially tumors involving major intra-abdominal vascular structures, and presence of excessively large specimens involved in these challenging operative procedures.

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Complicated intra-abdominal tumor excisions involving diameter of greater than 15 cm diameter which require more time and effort than smaller tumors to remove due to size.

The size of a tumor is often compared to the size of spherical fruits (Figure 2A). With increasing diameter of a sphere, there is an exponential increase in the surface area around the sphere. Appropriate oncological excision of a tumor requires circumferential dissection in 3-dimenstions, thus necessity dissection around the entire surface area of the tumor (Figure 2B). Complete, circumferential resection of a tumor (assumed to be a sphere for simplicity) of increasing size requires more time, effort, and skill than excising a smaller diameter tumor. Because surface area increases exponentially with tumor diameter, current CPT codes 49203-49205 inadequately reflect the work to remove larger tumors (Figure 2B). Because CPT codes 49203-49205 represent diameters of 5 cm increments up to 10 cm and beyond, the need for additional CPT codes to represent 15.1-20 cm, 20.1-25 cm, 25.1-30.0 cm, 30.1-35.0 cm, and 35.1 cm or greater is apparent (Figure 2C).

Based upon the disparity CPT codes and amount of work required, we are proposing an update to the current CPT codes to accurately represent the complexity of these complicated operative procedures, such as:

· 49203: Excision or destruction, open, intra-abdominal tumors, cysts or endometriomas, 1 or more peritoneal, mesenteric, or retroperitoneal primary or secondary tumors; total diameter of tumors 5 cm or less.

· 49204: Excision or destruction, open, intra-abdominal tumors, cysts or endometriomas, 1 or more peritoneal, mesenteric, or retroperitoneal primary or secondary tumors; total diameter of tumors 5.1-10.0 cm.

· 49205: Excision or destruction, open, intra-abdominal tumors, cysts or endometriomas, 1 or more peritoneal, mesenteric, or retroperitoneal primary or secondary tumors; total diameter of tumors 10.1-15.0 cm.

Proposing additional CPT codes to accurately represent the complexity of these complicated operative procedures, such as:

· 49206: Excision or destruction, open, intra-abdominal tumors, cysts or endometriomas, 1 or more peritoneal, mesenteric, or retroperitoneal primary or secondary tumors; total diameter of tumors 15.1-20.0 cm.

· 49207: Excision or destruction, open, intra-abdominal tumors, cysts or endometriomas, 1 or more peritoneal, mesenteric, or retroperitoneal primary or secondary tumors; total diameter of tumors 20.1-25.0 cm.

· 49208: Excision or destruction, open, intra-abdominal tumors, cysts or endometriomas, 1 or more peritoneal, mesenteric, or retroperitoneal primary or secondary tumors; total diameter of tumors 25.1-30.0 cm.

· 49209: Excision or destruction, open, intra-abdominal tumors, cysts or endometriomas, 1 or more peritoneal, mesenteric, or retroperitoneal primary or secondary tumors; total diameter of tumors 30.1-35 cm.

·  49210: Excision or destruction, open, intra-abdominal tumors, cysts or endometriomas, 1 or more peritoneal, mesenteric, or retroperitoneal primary or secondary tumors; total diameter of tumors 35.1 cm or greater.

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Complicated intra-abdominal tumor excisions involving multiple tumors with cumulative diameter of greater than 10 cm diameter which require more time and effort than excision of a single tumor.

At present, CPT coding accounts for the largest tumor resected. Excising multiple tumors and only coding the largest tumor does not adequately reflect the work involved. In the era of improving systemic chemotherapeutic agents, surgical resection of peritoneal and retroperitoneal metastases within the abdomen is becoming increasingly common in the treatment of cancers. Thus, we aggressively attempt to cytoreduce all visible disease with the goal of improving overall survival. These very aggressive operative procedures can be quite difficult, tedious and time consuming with the average duration of 5-7 hours. At present, if a physician performs the surgery to remove all visible tumors (i.e., 2 to 100+) similar to a cytoreduction/HIPEC procedures without intraperitoneal chemotherapy, the CPT codes 49203-49205 (Figure 1) inadequately represent the work, intensity, technical difficulty, physical and mental effort, as well as potential for increased blood loss with multiple tumors involved in these challenging operative procedures. We propose that the cumulative maximum diameters of lesions follow the proposed CPT codes (Figure 2C).

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Complicated intra-abdominal tumor excisions of any size tumors that encase vascular structures that require more time and effort, as well as are associated with significantly increased risk.

At present, CPT coding accounts for the largest tumor resected, but size alone does not account for the complexity of a given operation. An intra-abdominal tumor that encases a major vascular structure is inherently more dangerous to resect than the exact same-sized tumor that does not encase a major vascular structure (e.g., aorta, inferior vena cava, common iliac artery and/or vein, external iliac artery and/or vein, internal iliac artery and/or vein). In order to safely remove such tumors often requires multidisciplinary care (e.g., surgical oncologist and vascular surgeon) for safe tumor excision en bloc with the vascular excision.

Even more inherently complex to resect is a tumor than encases greater than one vascular structure (e.g., aorta, inferior vena cava, common iliac artery and/or vein, external iliac artery and/or vein, internal iliac artery and/or vein) and necessitates vascular excision en bloc with the tumor.

Excising intra-abdominal tumors encasing major vascular structures poses a greater risk to the patient and greater skill. Many of the patients at UC San Diego Health have been deemed inoperable by other tertiary health organizations and the operative procedures are successfully performed at UC San Diego Health. The CPT codes 49203-49205 (Figure 1) inadequately represent the work, intensity, technical difficulty, physical and mental effort, potential for increased blood loss, and potential for increased mortality with tumor excisions involved in these challenging operative procedures.

These cases (especially those involving venous structures) are very high risk for exsanguination and death. The example given above does not demonstrate the proper use of modifier -22 as this is not a one off increased procedural service. Furthermore, these complex cases require a team of surgeons (i.e., vascular or transplant surgeons, in addition to surgical oncologists). Thus, the entire procedure clearly is difficult beyond the norm and significantly greater than 49203-49205, even with a -22 modifier.

Proposing two additional CPT codes to accurately represent the complexity of these complicated operative procedures, such as:

· 492XX: Excision, open, intra-abdominal tumors, cysts or endometriomas, encasing 1 major vascular structure, which necessitates removal of the tumor and the blood vessel.

· 492XX: Excision, open, intra-abdominal tumors, cysts or endometriomas, encasing 2 or greater major vascular structure, which necessitates removal of the tumor and the blood vessels.

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Complicated intra-abdominal tumor excisions of any size tumors that require extra effort and time to preserve abutted vascular structures, major nerves, and adjacent organs.

At present, CPT coding accounts for the largest tumor resected, but size alone does not account for the complexity of a given operation. An intra-abdominal tumor that abuts a major vascular structure, major nerves, and/or adjacent organs is inherently more difficult to resect than the exact same sized tumor that does not abut or involve these structures. Perhaps ironically, a tumor that abuts one or more vascular structures or major nerves may require more time/effort to preserve adjacent vascular structures or major nerves than resecting them. These dissections can be technically challenging and tedious, but this effort is not captured by current CPT codes.

Also, it is more inherently complex to resect a tumor that abuts one or more adjacent organs (e.g., left/right colon, duodenum, liver, spleen, pancreas, stomach, kidney), which require more time and effort to preserve adjacent organs in lieu of resection. This may require medial visceral rotation of the colon, splenic flexure, liver, spleen, pancreas, stomach and/or kidney. Each of these steps is added time, effort, and mental/physical challenges. These dissections can be technically challenging and tedious, but not captured by current CPT codes. In fact, in both the former (neurovascular) and latter (organ) scenarios of abutment, it may in fact be easier to resect adjacent vascular structures, nerves, and organs than to take the extra effort and time to preserve them. Ultimately, organ preservation may be in the best interest of the patient if appropriate according to oncologic principles.

Taken together, it can be quite time consuming to tediously preserve adjacent organs without compensation. Thus, it is to the surgeon’s benefit to remove more major structures or organs than to spend the time to preserve them. On average, preserving adjacent organs can add 1-3 hours to a resection. Thus, the current system rewards perhaps a less patient-centered approach. This is not to say that it is inappropriate to resect adjacent organs. But the coding should reflect the extra effort of preserving adjacent, but not invaded, organs.

The CPT codes 49203-49205 (Figure 1) inadequately represent the work, intensity, technical difficulty, physical and mental effort, distorted anatomy due to larger tumors, potential for increased blood loss with larger tumors and especially tumors abutting major intra-abdominal vascular structures, and presence of excessively large specimens involved in these challenging operative procedures.

Proposing three additional CPT codes to accurately represent the complexity of these complicated operative procedures, such as:

· 492XX: Dissection of retroperitoneal tumor free of 1-3 adjacent organs/major structures.

· 492XX: Dissection of retroperitoneal tumor free of 3-5 adjacent organs/major structures.

· 492XX: Dissection of retroperitoneal tumor free of greater than 5 adjacent organs/major structures.

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I greatly appreciate your endorsement and support of this very important issue for practicing surgeons in the United States.

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