Coding Quandaries and Conundrums: Why the Need for the HCEC?

February 2008

Robert C. Fifer, PhD, CCC-A

The need for a committee like the Health Care Economics Committee (HCEC) was unheard of 20 years ago. Most audiologists at that time did not know what Current Procedure Terminology (CPT) codes were and were billing audiological procedures in the same manner as during the previous 20 years. However, almost exactly 20 years ago from the present, tremendous changes were taking place in the realm of health care. Health maintenance organizations (HMOs) had achieved greater standing among individual subscribers and companies, Congress was trying to get a grip on the rapidly increasing costs of health care, and Medicare and Medicaid were beginning to exert tremendous influence on health care policy. A Harvard survey on procedures and the cost of health care was nearing its completion, and Congress mandated that Medicare begin using CPT and International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) coding systems to standardize the language of procedures and diagnoses.

The American Medical Association (AMA) coding committees took on new importance in both the development and the recommended valuation of CPT codes. With the recognition that some procedures are performed predominantly by non-physician health care providers, the AMA CPT Editorial Panel and the AMA Resource-Based Relative Value Scale (RBRVS) Update Committee (RUC) established Health Care Professions Advisory Committees (HCPACs) with representation from national associations representing qualified health care professions. Early in this process, ASHA was invited in 1992 to represent speech-language pathologists and audiologists. The invitation was based, in part, on the AMA's identification of ASHA as the organization to represent the professions of audiology and speech-language pathology in a manner comparable to other organizations already involved with the RUC.

In its earliest days, what is now known as the ASHA HCEC was not a committee. It was simply a formal working group focused on coding endeavors. The first foray into this coding arena was in 1993 when otoacoustic emissions codes were presented for both diagnostic and screening purposes. The second foray was in 1995 in a joint effort with the American Academy of Audiology to obtain code recognition for auditory rehabilitation assessment and treatment, central auditory processing, cochlear implant programming and rehabilitation, visual reinforcement audiometry, and editorial revisions on CPT codes 92585 (auditory evoked potentials), 92557 (comprehensive audiometry), 92555 (speech audiometry threshold), and 92556 (speech audiometry threshold with speech recognition). At that time, CPT Editorial Panel members feared that the CPT Manual was growing much too fast, meaning that they were granting as few new code designators as possible. A compromise was reached whereby the AMA would recognize several of the new procedures without granting new code designators. As new procedures were approved, they were combined into the descriptors of currently existing codes on the basis of some similarity. As a result of the AMA compromise, the auditory rehabilitation procedures and central auditory processing were rolled into the descriptors for CPT codes 92506 (speech, language, voice, communication...evaluation), 92507 (speech, language, voice, communication...treatment; individual), and 92508 (speech, language, voice, communication...treatment; group). The rationale presented by the AMA is that the valuation would most likely be sufficiently similar that these codes could easily be multidisciplinary, multi-access procedure codes. Indeed, this worked very well for the first 2 years until Medicare entered into the picture.

The year 1997 brought great philosophical changes to the reimbursement arena as it related to audiology's scope of practice in the eyes of Medicare. Under the guise of controlling the cost of health care, Medicare classified all non-physician specialties as either diagnostic or rehabilitative. Generally the dichotomy was based on either legislative language or the predominance of code billing. Speech-language pathology was named alongside physical therapy and occupational therapy as being in the rehabilitation specialty area. Conversely, audiology's forte by this time was diagnostics, especially since Medicare was forbidden to cover hearing aids by federal law. Audiological rehabilitation had become completely overshadowed by audiology's emphasis on diagnostic evaluation and site of lesion testing. CMS's categorization of audiology meant that the procedures rolled into CPT codes 92506, 92507, and 92508 were no longer accessible and billable by audiologists. It also meant that the cochlear implant programming with rehabilitation code (CPT code 92510) would soon be nonreimbursable to audiologists because the code focused on rehabilitation in addition to programming. This provided the motivation for the first set of new codes starting with the 2002 presentation to the CPT Editorial Panel.

The Non-Physician Work Pool

Something happened in the late 1990s that would have a profound effect on audiology in 2006. The Balanced Budget Act of 1997 directed CMS to adopt fully all aspects of RBRVS for reimbursement. However, CMS realized in its analysis of reimbursement levels relative to the cost of service delivery that certain procedures would be extremely undervalued. The undervaluation meant that the level of reimbursement would not cover the cost of service delivery. The procedures most affected were those that did not involve physician work as a key component of the reimbursement formula. For the most part, these procedures involved services by technicians, paraprofessionals, and some non-physician licensed health care professionals. Examples included radiology, oncology, pathology, cardiology laboratory procedures, psychology, social work, nutrition, some speech-language pathology procedures, and the majority of audiology procedures.

To explain the impact of this cost analysis, one must digress for a moment to explain how the reimbursement formula operates. The formula has three components: physician work (also known as the professional component), practice expense (also known as the technical component), and malpractice expense. The physician work focuses on the elements of skill level in the execution of the procedure, intensity of mental effort, risk to the patient, and duration of the procedure. Practice expense includes ancillary support personnel who provide direct assistance to the physician in the care of the patient, disposable supplies, and depreciation of investment equipment. The malpractice expense is a scaled relative value that is established both by risk to the patient and by comparison with other procedures of comparable risk. The primary factor in determining the practice expense value is the number of minutes required for the assistance of ancillary personnel. Typically, this is based on the U.S. Bureau of Labor Statistics median salaries broken down to a per minute value. Audiologists, for example, are valued at $.52 per minute.

The value of our procedures based on the standard practice expense formula would grossly undervalue the services, falling short of the cost of service delivery. As a temporary measure until CMS could determine a better method of reimbursement, a special reimbursement pool was created called the Non-Physician Work Pool. Instead of using the $.52 per minute value for audiologists, the all-physician average of approximately $.93 cents per minute formed the basis of reimbursement. This was in addition to disposable supplies and depreciation of investment equipment. Also added in were indirect costs. Indirect costs include expenses not directly related to the cost of service delivery and typically include such items as rent, utilities, support personnel, office equipment, and so on. It is calculated by taking a percentage of the physician work plus practice expense and adding that value to the standard reimbursement formula such that the formula now looks like (Work + Practice Expense + Malpractice Expense) + (Indirect Cost Percentage * [Work + Practice Expense]). In many cases, addition of the indirect cost percentage increases the original RVU value by approximately 40%. The catch, however, is that both work and practice expense must be present to qualify for indirect costs. The addition of the indirect costs as part of the Non-Physician Work Pool payments was an element of artificial inflation to assist in the reimbursement values of these otherwise undervalued procedures. The Non-Physician Work Pool was never intended to be a permanent fix. It was a short-term, temporary measure that would last only until CMS could determine a more equitable formula for reimbursement.

The changes in the late 1990s highlighted the need for an ongoing ASHA committee, in contrast to a working group, that would specialize in advocating, developing, valuing, and assuming a greater role in representing the discipline than had been envisioned early in the decade. All aspects of health care were now revolving around the ability to define what we do in terms of CPT codes. That meant we must assume the responsibility to educate members regarding these changes in health care structure and that we must achieve a trusting relationship with other "movers and shakers" within the coding community as well as CMS.

The Health Care Economics Committee (HCEC)

The year 2000 not only ushered in a new millennium, it saw the establishment of the HCEC as a full-fledged, standing committee. ASHA now recognized the need and importance of developing expertise in the area of coding and reimbursement—and of providing a formal budget commitment to support the efforts of the committee. A primary charge to the committee has been to work with the Government Relations and Public Policy Board regarding policies and regulations that could affect both service availability and reimbursement, represent the professions of audiology and speech-language pathology to the AMA coding panels (CPT Editorial Committee and the CPT/RUC HCPACs). The initial makeup of the committee was four audiologists and four speech-language pathologists. The chair and vice chair of the committee would alternate professions. That is, if the chair is an audiologist, the vice chair must be a speech-language pathologist, and vice versa.

By this time ASHA had already changed its governance to formally recognize both audiology and speech-language pathology as distinct professions with distinct needs. Hence, the makeup of the committee was evenly divided with the idea that audiologists would deal with audiology issues and speech-language pathologists would deal with speech, language, and swallowing issues. Documents are shared between professions but only for the sake of having fresh, unbiased eyes look at what has been written to catch unclear statements, red flags, or potential problems before the documents are shared with other profession-related organizations and especially before presenting the documents to the AMA. It is important for audiologists to know and understand that only audiologists on this committee influence the actions and outcomes of the audiology codes and proposals. The sharing of documents with the speech-language pathology colleagues is on the following basis: The AMA and Medicare system for developing and valuing codes and advocating their coverage by Medicare requires expertise that doesn't just walk in off the street. By virtue of our working together and knowing each other, there is a tremendous trust that everyone on the committee wants what is most beneficial for everyone concerned. Because speech-language pathologists are not experts in audiological procedures, they make excellent first reviewers of our proposals because the AMA panel to whom we present the codes will know little about audiological procedures. It is our job to educate panel members in 3 minutes or less on exactly what it is that audiologists do on a procedure-by-procedure basis. This is accomplished through the written proposal and by verbally answering questions at the table during the presentation at the AMA CPT Editorial Panel or RUC meeting. But the point is that we must do everything possible to present the cleanest, clearest proposal possible to expedite the process and help ensure success. The judgment of colleagues who don't know our procedures but know the coding process has been of tremendous value in this effort.

One of the key goals of this committee was to convince the ASHA Executive Board that this committee should not be managed like every other committee with members rotated every 2–3 years. The learning curve for the basic principles and nuances typically requires a minimum of 2 years. The representatives from other disciplines who sit at the AMA coding tables typically have been there for years and years. Some have been members of the panel since the CPT and RUC process began around 1990. They know each other well and have developed a trust for one another that allows progress to be made more quickly.

ASHA's Executive Board approved these changes in 2002 that allow our representatives the longevity needed in the AMA coding processes and politics, paired with their particular expertise, to represent the professions well. Over the past 5 years, this longevity has served us well in allowing the professions to obtain 28 new CPT codes and defend values of existing codes before the respective panels. That doesn't mean it has been easy—there are still questions and challenges that arise. For example, our presentation for the cochlear implant codes (92601–92604) before the RUC HCPAC had us answering questions for almost 3 hours. But it means that we have had the opportunity to develop working relationships with key members of each panel to facilitate the passage and valuation of the respective codes.

In that same time frame, it was decided that the work of the HCEC was such that 2 additional members were needed, one for audiology and one for speech-language pathology. The committee now has a total of five audiology members, including Tom Rees, Ken Bouchard, Bob Woods, Stu Trembath, and myself, as well as our ex-officio member, Steve White. Past audiology HCEC members have included Walt Smoski and Kyle Dennis. Our collective efforts, first and foremost, have been to improve audiology and the welfare of the profession.

The HCEC also has a consultant, Bernie Patashnik, who worked in key positions in payment policy at CMS for many years. He is extremely familiar with the inner workings of CMS, the CPT and RUC process, and many nuances of the entire reimbursement system. Mr. Patashnik brings to the table a perspective that is very distinct from our respective viewpoints and that has been extremely beneficial in guiding us to be more proficient in what we do.

AMA Coding Processes

One of the requirements of the representative who sits at the table for the AMA panels is that all elements of the profession are represented through that person. What that means is this: We introduce ourselves and state the sponsoring organization that provides the representative, but when the gavel comes down, each member is required to no longer represent a single organization. All panel participants are required to represent their profession and/or health care in general. Consequently, when the meeting officially starts, I do not represent the professional organizations to which I belong—I represent audiology. The same holds true for psychology, social work, podiatry, physical therapy, occupational therapy, nutrition, chiropractics, and any other field represented on the panel. We come together to be arbiters of code valuations in a manner as unbiased as possible in order to abide by the tenants of the RBRVS system. There are sufficient checks and balances built into the system to prevent one profession's representative from "gaming" the system to obtain disproportionate reimbursement to the detriment of others around the table. All proposed values must be justified based on comparisons to other codes (procedures) with similar time, complexity, and value. And if something slips through with a disproportionately high recommendation, Medicare has reserved the right to reject the HCPAC's recommendation and set their own value.

Another important point for the readers to understand is that Wayne Holland, who is a speech-language pathologist and representative to the CPT Editorial Panel, and I are "interchangeable." That means if an audiology code comes forward, I, or another audiologist well versed in the procedure, move over to the CPT side of the house to present that code. I then follow it to the valuation side to present and defend the survey data for the RUC side of the house. If a speech-language code comes forward, Wayne is responsible for presenting it to the editorial panel, and then either Nancy Swigert, the RUC CPT Alternate Advisor, or Wayne follows the code to the valuation side to sit beside me and defend the survey data. Consequently, an audiology code is always presented by an audiologist, and a speech-language code is always presented by a speech-language pathologist.

The productivity of the committee, with input from other groups, thus far has been new codes for cochlear implants, auditory processing evaluation, auditory rehabilitation assessment, tinnitus assessment, an auditory rehabilitation code for prelingual patients, an auditory rehabilitation code for postlingual patients, a new code for programming the auditory brainstem implant, an editorial change on the acoustic reflex codes to highlight the distinct nature of reflex threshold versus reflex decay, and, most recently, recognition for "work," or the professional component of the reimbursement formula, to begin converting our codes from practice expense only to include physician work.

Outreach and Collaboration

In the spirit of representing all facets of the profession, the HCEC extends invitations to participate in portions of our meetings to other profession-related organizations such as AAA, ADA, Military Audiology Society, VA audiologists, ASHA Special Interest Divisions, and other interested groups. I would be remiss if I did not recognize two members of AAA in particular who have been close allies in all that has happened: Kadyn Williams and Deb Abel. We have developed a good, effective working relationship that has been beneficial, not just for the AMA activities but also for some of the "economic" activities highlighted above. More recently, Alan Desmond has become part of this relationship and has been of tremendous assistance in developing a parallel family of balance evaluation codes using goggle recordings.

Another key charge to the HCEC focuses on economic factors apart from coding that affect service availability, service delivery, and reimbursement. Examples of this include advocacy directly to Medicare, advocacy to Medicare carriers, advocacy to various insurers, and monitoring Medicare policy. For instance, a Medicare carrier was placing undue restrictions and excessive risk on audiologists in a manner that was beyond their control. ASHA helped to convene audiologists representing multiple audiology organizations, along with Mark Kander, ASHA's staff Medicare analyst, for a long telephone conference call to influence the situation in a positive manner and outcome. And when Medicare announced that the Non-Physician Work Pool would be abolished 2½ years ago, ASHA and AAA representatives jointly met with Medicare officials to discuss the impact on the profession and to request a 1-year moratorium. The moratorium was granted for 1 year to allow more time to develop an equitable solution to the anticipated drop in value when the Non-Physician Work Pool disappears. These functions are in addition to what happens with the AMA and focus primarily on the economics part of the Health Care "Economics" Committee. But the contributions in the economics arena originate from the knowledge gained from the AMA work on coding, reimbursement, and overall Medicare policy.

I have also developed tremendous appreciation for Steve White as ex officio and for the expertise he has developed through the years on coding, Medicare, and insurance issues. And Nancy Swigert and Wayne Holland have been extremely supportive in their respective roles of committee chair/RUC HCPAC alternate advisor and CPT HCPAC representative. We have gotten to know each other very well over the past 6 years. We are together between 21 and 30 calendar days each year, depending on the number of new codes coming through the system, and that is in addition to our conference calls each month and our face-to-face gatherings three times a year. It is extremely important that we get along and are supportive of one another because any time that money is involved (such as new codes and the Medicare fee schedule), things are not always friendly on either the CPT or RUC sides of the house.

ICD-9-CM Coding

I have given you some insight into how the committee works and who some of the key characters are in the audiology coding realm. There is another function, another type of coding, that is necessary to make the picture complete—diagnosis coding. The ICD-9-CM system of codes has been roundly criticized in recent years, and with good reason—it's terrible! It doesn't truly describe what we find, many details are left out, the descriptors can be quite out of date, and some diagnosis codes are in sections of the book that make no sense (e.g., developmental auditory processing disorder in the Mental Disorders chapter of the manual). Until last year, the codes in the book had not been updated since 1972. Last year was the committee's first foray into the proposing new, revised, and updated diagnosis codes. The two individuals primarily responsible for this are Kyle Dennis, a former member of the HCEC, for the audiology codes and Dee Nikjeh for the speech/language/swallowing codes. The process is completely different, including the application submission, the presentation, and the deliberation. But you will notice that a number of new audiology ICD-9-CM codes have appeared in the October 2006 and especially in the October 2007 editions of the ICD-9-CM manual.

Challenges and Opportunities

In 2002, twenty-three codes were presented for practice expense revaluation as part of the 5-year review required by Congress. As I described what an audiologist did for each procedure, members of the panel continually scratched their heads and replied that what was being described was work, not practice expense. It was a matter of convincing key entities such as both CMS and the AMA that we should be recognized for work. We were finally successful in that endeavor, although the valuation of the converted codes is not as we had hoped.

You need to know that not everyone appreciates what we have tried to accomplish, especially in the area of being recognized for the professional component of the reimbursement formula. The American Academy of Otolaryngology - Head and Neck Surgery (AAO-HNS) is opposed to our efforts based, in part, on their perception of the AuD degree and belief that the AuD is simply a way for audiologists to call themselves "Doctor" and promote themselves as being equivalent to MDs. They are also very opposed to audiology independence. Along this line of thought, AAO-HNS leadership has commented in person and in written publication that they believe recognition of audiologists for professional work, along with the AuD, are two major steps toward that slippery slope of audiology independence.

Our motivation for seeking recognition for "work" RVUs are primarily twofold. The first (and foremost) has been to stabilize our reimbursement to the extent possible. The second reason is to recognize our professional status in the realm of health care. Of all the professions that are potentially eligible for work RVUs, only audiology and speech-language pathology had not been successful until now in moving from the practice expense category to "work." Because of the elimination of the Non-Physician Work Pool, we were forecast to receive a decrease in reimbursement of approximately 25% to 40%. And that decrease is independent of what Congress may do to drop the Medicare reimbursement across the board. Our attempts to stabilize reimbursement were only partly successful by virtue of the final survey data that was presented to the RUC. The outcome will result in work RVUs that will give an increase in reimbursement for 2008 but will decrease the values considerably in 2009 and 2010. How much of a decrease will depend on congressional action over the next 2 years.

One last comment on the difference in perspectives between audiology and otolaryngology: It is very important that audiologists understand that otolaryngologists view what we do as "tests," not services or evaluations or assessments, simply tests. This is also reinforced in the CPT manual introduction to our code family. The preamble to the "Special Otorhinolaryngologic Services" reads as follows: "Diagnostic or treatment procedures usually included in a comprehensive otorhinolaryngologic evaluation or office visit are reported as an integrated medical service using appropriate descriptors from the 99201 series. Special otorhynolaryngologic services are those diagnostic and treatment services not usually included in a comprehensive otorhinolaryngologic evaluation or office visit. These services are reported separately using codes 92502–92700. Technical procedures (which may or may not be performed by the physician personally) are often part of the service, but should not be mistaken to constitute the service itself." (AMA CPT Manual, 2008, p. 395). And with the perspective that our procedures are simply tests, AAO-HNS leadership does not believe that there is any clinical decision making associated with the performance of tests. It is a profound difference in perspective and viewpoint, but it is a difference that we as audiologists must understand to comprehend fully the origins of these disagreements.

Pay for Performance

Quality of health care provision is a very important topic for Medicare and for Congress. Both entities have tried various methods to reduce the cost of health care or at least slow its rapid rise over the past 30 years. Various attempts have included clinical outcomes measures (which is a concept that is still alive and well), standards of practice, price limiting, not paying for "mistakes," and a host of other measures. One of the latest is Pay for Performance (P4P). Under this program, a percentage of reimbursement will be withheld and placed in a special monetary pool. If the professional (physician or non-physician) completes certain quality measures, then a portion of what is withheld will be paid as a type of bonus for practicing good quality of care. One example of quality of care measurement is the administration of an aspirin to a patient presenting with myocardial infarction symptoms (chest pain, shortness of breath, radiated pain, etc.). At the present time, audiologists are excluded from participating in P4P. Speech-language pathologists are named as potential participants in the authorizing legislation, but to date no standards have been adopted at the Medicare level as a quality performance indicator.

It will admittedly be difficult to include a specialty like audiology in a P4P program by virtue of the nature of what we do. Someone might say that we should be judged on the accuracy of our testing, but what is the quality performance standard by which accuracy could be compared? Another could be patient satisfaction, but that is subjective and could be based on relationships as much as quality of care. Again, what would be the objective standard to which comparison could be made? The stated desire is to move everyone to objective quality indicators in order to achieve the P4P "bonus" payment. In reality, the objective is to provide consistent, clinically demonstrated quality care to do what the consensus literature says should be done in the first place.

Direct Access

Many audiologists are clamoring for direct access to Medicare beneficiaries, thinking it will cure all that ails us. From our perspective, direct access is a good thing because it levels the playing field with Medicare for what is enjoyed by enrollees of many commercial health plans. But, at the same time, it adds tremendous responsibility to each audiologist. Specifically, the onus of "medical necessity" is currently on the referring physician to justify why the test is necessary. Even under the current system, we must verify that medical necessity does indeed exist. But for the most part, the patients are prescreened in that regard. Direct access would mean that the entire responsibility of medical necessity is on our shoulders. One asks, "Why is this important?" The answer lies in the federal regulations. Both Medicare and Medicaid operate entirely on the premise of medical necessity. The ICD-9-CM diagnostic coding system is built on the idea of medical necessity. And most private payers have adopted the concept of medical necessity to justify payments for services. This means, in part, that a legitimate presenting complaint, sign, or symptom must be determined to justify the services we render. It also means that we are not free to perform whatever we want. We will be required to use clinical judgment to determine which services are truly necessary—and it also means that we must give careful thought and consideration to the application of the "standard battery" that we learned in our university training programs. We must critically evaluate the need and justification of everything that we do. We must police ourselves.

The documentation requirements will also exceed what many of us are accustomed to. In a document separate from the audiogram, we must document the presenting complaints, a description of what we did, what we found, what it means, and what we recommend. Anything less will be unacceptable. In fact, if the billing goes out in the audiologist's name and provider number, these documentation requirements currently apply.

Direct access will not be a panacea for the troubles of audiology. It will not offer unfettered freedom to do whatever we desire. It will bestow on us tremendous responsibility to THINK about many things—why is the patient there, what is the clinical question, what is necessary to answer that question, and what do we do with the information once we have it?

New Technology

A new realm that is just now being explored is the greater use of technology for diagnostic purposes. To make a distinction, we have used technology for automated data gathering for the past 35 years. Examples include tympanometry, acoustic reflex measurements, and auditory evoked potentials. The issues of automated data gathering do not refer to these types of instruments. Rather, the issues focus on computer-administered testing and interpretation. This is a very new area of health care in general and one that is still in its infancy.

The entire reimbursement system is based and valued on the personal, professional delivery of health care services. For the standard reimbursement formula of "work + practice expense + malpractice expense," approximately 54% of the overall reimbursement is found in the "work" component of the formula. For procedures where the practice expense is a piece of equipment and the malpractice risk is low, a much higher percentage of that code's reimbursement is contained in "work." The equipment, regardless of type, is depreciated for the minutes used in testing the "typical" patient.

Psychology offered the first meaningful peek into how computer-administered tests would be valued when they obtained the new CPT code 96103 (Psychological testing (includes psychodiagnostic assessment of emotionality, intellectual abilities, personality and psychopathology, e.g., MMPI), administered by a computer, with qualified health care professional interpretation and report). The valuation for this code includes 8 minutes of professional preservice time, 8 minutes of intraservice time, and 14 minutes of postservice time compared to 60 minutes of computer administration of the psychological tests. The valuation of the procedure included 0.51 work RVUs, 0.49 practice expense RVUs, and 0.02 malpractice RVUs. Total reimbursement is $36.76. This value is compared to another psychology code, 96118 (Neuropsychological testing (e.g., Halstead-Reitan Neuropsychological Battery, Wechsler Memory Scales, and Wisconsin Card Sorting Test), per hour of the psychologist's or physician's time, both face-to-face time with the patient and time interpreting test results and preparing the report). Code 96118 is a per hour code reimbursed at $117.48 for each hour of test administration.

A major part of the difference in reimbursement for the automated versus professional services focuses on the assumptions of how "work" is valued. The skill, mental effort, physical effort, risk to the patient, risk to the provider, time, and complexity of medical decision making are all key factors that determine the work RVUs. Under this thought process, a "machine" that operates by protocol, even a decision-matrix protocol, does not exert the level of effort, awareness of risk, or complexity of medical decision making that is encountered by a living, breathing professional. A machine is still a machine. It may be vital to the execution of the procedure, but it is still a machine and not a degreed professional. Even with computer administration of diagnostic procedures, it is the professional who will be accountable. The issue is what did the professional need to do to obtain and interpret those results. There is no movement within the realm of health care to change this reimbursement formula and system. In fact, there is considerable resistance to changing the valuation process. The personal, professional delivery of services will be held preeminent for the foreseeable future.

Concluding Thoughts

Health care reimbursement occupies much attention these days because of the national costs, safety issues, new treatments, new technology, and impact on the economy. The RBRVS system (without dollar valuation attached to each RVU) has been designed to be as fair a system as is humanly possible. Its intent is to establish relative value units for each procedure based on the time and complexity of that procedure compared to other procedures already established for time and complexity (hence, the relative value aspect of RBRVS). The process to establish, value, and update each procedure has evolved into a very complex system of rules, guidelines, policies, and, in the case of Medicare, politics. I have been very fortunate to have been allowed to find a niche where I feel useful and helpful and to have been given the opportunity to learn many aspects of this system.

Moreover, I am indebted to the current and past audiology HCEC members, and a host of other audiologists who have participated in meetings, surveys, ideas, and review comments. I have been very fortunate to have been in good company during these years. The conclusion of the matter is that what has been accomplished over the past 6 years has truly been a team effort, with the input of many outstanding audiologists and support staff and through effective working relationships with AMA staff and other members of the AMA coding committees.

About the Author

Dr. Fifer is director of audiology and speech-language pathology in the pediatrics department at the University of Miami School of Medicine. His clinical and research interests focus on the areas of auditory evoked potentials, central auditory processing, early detection of hearing loss in children, and auditory anatomy and physiology. He is a past president of the Florida Association of Speech-Language Pathologists and Audiologists, a member of ASHA's Health Care Economics Committee, and the ASHA representative to the American Medical Association's Health Care Professions Advisory Committee for the Relative Value Utilization Committee, in addition to being ASHA's representative to the AMA's Practice Expense Advisory Committee. Contact Dr. Fifer at

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