William D Donovan

The RUC: a primer for neurointerventionalists.

The Relative Value Scale Update Committee (RUC) plays a critical role in determining physician payment. When the Centers for Medicare and Medicaid Services (CMS) transitioned to paying physicians based on the Resource-Based Relative Value Scale, the American Medical Association developed this unique multispecialty committee. Physicians at the RUC determine the resources required to provide physician services and recommend appropriate payment for those services. The RUC then submits its recommendations to CMS. Physicians have thus been important in determining relative value and hence payment for the services they provide.

Current procedural terminology; a primer.

In 1966, The American Medical Association (AMA) working with multiple major medical specialty societies developed an iterative coding system for describing medical procedures and services using uniform language, the Current Procedural Terminology (CPT) system. The current code set, CPT IV, forms the basis of reporting most of the services performed by healthcare providers, physicians and non-physicians as well as facilities allowing effective, reliable communication among physician and other providers, third parties and patients. This coding system and its maintenance has evolved significantly since its inception, and now goes well beyond its readily perceived role in reimbursement. Additional roles include administrative management, tracking new and investigational procedures, and evolving aspects of ‘pay for performance’. The system also allows for local, regional and national utilization comparisons for medical education and research. Neurointerventional specialists use CPT category I codes regularly—for example, 36 215 for first-order cerebrovascular angiography, 36 216 for second-order vessels, and 37 184 for acute stroke treatment by mechanical means. Additionally, physicians add relevant modifiers to the CPT codes, such as ‘−26’ to indicate ‘professional charge only,’ or ‘−59’ to indicate a distinct procedural service performed on the same day.

Component coding and the neurointerventionalist: a tale with an end

Component coding is the method NeuroInterventionalists have used for the past 20 years to bill procedural care. The term refers to separate billing for each discrete aspect of a surgical or interventional procedure, and has typically allowed billing the procedural activity, such as catheterization of vessels, separately from the diagnostic evaluation of radiographic images. This work is captured by supervision and interpretation codes. Benefits of component coding will be reviewed in this article. The American Medical Association/Specialty Society Relative Value Scale Update Committee has been filtering for codes that are frequently reported together. NeuroInterventional procedures are going to be caught in this filter as our codes are often reported simultaneously as for example routinely occurs when procedural codes are coupled to those for supervision and interpretation. Unfortunately, history has shown that when bundled codes have been reviewed at the RUC, there has been a trend to lower overall RVU value for the combined service compared with the sum of the values of the separate services.

Sustainable Growth Rate Repealed, MACRA Revealed: Historical Context and Analysis of Recent Changes in Medicare Physician Payment Methodologies

APM : Alternative Payment Models CHIP : Childrens Health Insurance Program CMS : Centers for Medicare and Medicaid Services MACRA : Medicare Access and CHIP Reauthorization Act of 2015 MIPS : Merit-Based Incentive Payment System SGR : Sustainable Growth Rate Intended to provide long-

Professional Component Payment Reductions for Diagnostic Imaging Examinations When More Than One Service Is Rendered by the Same Provider in the Same Session: An Analysis of Relevant Payment Policy

PURPOSE The aim of this study was to assess potential physician work efficiencies when more than one diagnostic imaging study is interpreted by the same provider during the same session. METHODS Medicare Physician Fee Schedule data from the American Medical Association Resource-Based Relative Value Scale Data Manager for 2011 were analyzed to quantify relative contributions of preservice, intraservice, and postservice physician work to the total work of rendering diagnostic imaging services. An expert panel review identified potential duplications in preservice and postservice work when multiple examinations are performed on the same patient during the same session. Maximum potential percentage work duplication for various diagnostic imaging modalities was calculated and compared to US Government Accountability Office estimates. RESULTS The relative contributions of preservice and postservice work to total work varied by modality, ranging from 20% [computed tomography (CT)] to 33% (ultrasound). The maximum percentage of potentially duplicated preservice and postservice activity ranged from 19% (nuclear medicine) to 24% (ultrasound). Maximum mean potentially duplicated work relative value units ranged from 0.0212 for radiography to 0.0953 for magnetic resonance imaging (MRI). Maximum percentage work reduction ranged from 4.32% for CT to 8.15% for ultrasound. This corresponds to maximum professional Physician Fee Schedule reductions of only 2.96% (CT) to 5.45% (ultrasound), approximating an order of magnitude less than the Government Accountability Offices recommendations. CONCLUSION Although potential efficiencies in physician work occur when multiple services are provided to the same patient during the same session, these are highly variable and considerably less than previously estimated.

Diagnostic carotid and cerebral angiography: A historical summary of the evolving changes in coding and reimbursement in a complex procedure family

Carotid and cerebral angiography have been a mainstay of neurointerventional and neuroradiologic practice for years. Centers for Medicare and Medicaid Services (CMS) and Relative Value Scale Update Committee (RUC) initiatives have compelled the professional societies to bundle component codes under threat of unilateral CMS revision and revaluation. Code bundling usually results in a decrease in the professional Relative Value Unit (RVU) valuation, and thus the MD reimbursement. The year 2013 saw a dramatic revision to the Current Procedural Terminology (CPT) code set that defines carotid and cerebral procedures. This paper reviews the process that led to that code set being revised and estimates the impact on professional reimbursement. We show the current and previous carotid angiography CPT codes and use clinical examples to assess professional RVU valuation before and after code revision.

Professional Efficiencies for Diagnostic Imaging Services Rendered by Different Physicians: Analysis of Recent Medicare Multiple Procedure Payment Reduction Policy

PURPOSE The aim of this study was to quantify potential physician work efficiencies and appropriate multiple procedure payment reductions for different same-session diagnostic imaging studies interpreted by different physicians in the same group practice. METHODS Medicare Resource-Based Relative Value Scale data were analyzed to determine the relative contributions of various preservice, intraservice, and postservice physician diagnostic imaging work activities. An expert panel quantified potential duplications in professional work activities when separate examinations were performed during the same session by different physicians within the same group practice. Maximum potential work duplications for various imaging modalities were calculated and compared with those used as the basis of CMS payment policy. RESULTS No potential intraservice work duplication was identified when different examination interpretations were rendered by different physicians in the same group practice. When multiple interpretations within the same modality were rendered by different physicians, maximum potential duplicated preservice and postservice activities ranged from 5% (radiography, fluoroscopy, and nuclear medicine) to 13.6% (CT). Maximum mean potential duplicated work relative value units ranged from 0.0049 (radiography and fluoroscopy) to 0.0413 (CT). This equates to overall potential total work reductions ranging from 1.39% (nuclear medicine) to 2.73% (CT). Across all modalities, this corresponds to maximum Medicare professional component physician fee reductions of 1.23 ± 0.38% (range, 0.95%-1.87%) for services within the same modality, much less than an order of magnitude smaller than those implemented by CMS. For services from different modalities, potential duplications were too small to quantify. CONCLUSIONS Although potential efficiencies exist in physician preservice and postservice work when same-session, same-modality imaging services are rendered by different physicians in the same group practice, these are relatively minuscule and have been grossly overestimated by current CMS payment policy. Greater transparency and methodologic rigor in government payment policy development are warranted.

Emergency Department CT of the Abdomen and Pelvis: Preferential Utilization in Higher Complexity Patient Encounters

PURPOSE The aim of this study was to assess the association of patient encounter complexity and the utilization of CT of the abdomen and pelvis (CTAP) in the emergency department (ED) setting. METHODS Using 5% research identifiable files for 2007, ED visits for Medicare fee-for-service beneficiaries were identified. Contemporaneous ED physician evaluation and management codes were used as the basis for patient complexity categorization. Encounters in which CTAP was performed on the same date of service were identified, and variables affecting the utilization of CTAP were analyzed. RESULTS Of 1,081,000 ED encounters, 306,401 (28.3%) were of lower complexity and 774,599 (71.7%) were of higher complexity. CT of the abdomen and pelvis was performed in 65,273 of all encounters (6.0%), corresponding to 4,069 (1.3%) of lower complexity and 61,204 (7.9%) of higher complexity encounters (odds ratio, 5.95; 95% confidence interval, 5.76-6.14). Of the 65,273 ED encounters associated with CTAP, 61,204 (93.8%) were of higher complexity. CONCLUSIONS Of patients undergoing CTAP in the ED setting, a very large majority (93.8%) are clinically complex. CT of the abdomen and pelvis is 5.95 times more likely to be utilized in higher than lower complexity ED patient encounters.

Current Procedural Terminology: History, Structure, and Relationship to Valuation for the Neuroradiologist

SUMMARY: The year 1965 was critical for US health care policy. In that year, Medicare was created as part of the Social Security Act under President Lyndon B. Johnson after several earlier attempts by Presidents Franklin Roosevelt and Harry Truman. In 1966, the American Medical Association first published a set of standard terms and descriptors to document medical procedures, known as Current Procedural Terminology, or CPT. Fifty years later, though providers have certainly heard the term “CPT code,” most would benefit from an enhanced understanding of the historical basis, current structure, and relationship to valuation of Current Procedural Terminology. This article will highlight this evolution, particularly as it relates to neuroradiology.

The Resource-Based Relative Value Scale and Neuroradiology: ASNR’s History at the RUC

The Resource-Based Relative Value Scale (RBRVS) has been the defining algorithm for professional reimbursement of medical services since its introduction in 1992. This article reviews the history of the RBRVS, with an emphasis on the integral involvement of the radiology and neuroradiology communities. Appropriate reimbursement of radiology procedures has been chaperoned by physician volunteers and society staff attending Current Procedural Terminology Panel meetings and American Medical Association/Specialty Society RVS Update Committee (RUC) meetings. In recent years, governmental and RUC initiatives have created an unfavorable environment for neuroradiologists to maintain reimbursement levels seen previously.