ACR Letter to Blue Cross Blue Shield of Massachusetts re: Instituting Multiple Surgical Reductions for Contiguous Body Scans
May 30, 2003
James E. Fanale, M.D.
Senior Vice President & Chief Medical Officer
Blue Cross Blue Shield of Massachusetts
Landmark Center
401 Park Drive
Boston, MA 02215-3326
Dear Dr. Fanale:
The American College of Radiology (ACR) has learned Blue Cross Blue Shield of Massachusetts (BCBSMA) intends to implement, July 15, 2003, a medical policy which will result in a fifty percent reduction in the professional component (PC) allowable when two or more ultrasound, Computed Tomography (CT), Magnetic Resonance Imaging (MRI), Magnetic Resonance Angiography (MRA), Positron Emission Tomography (PET) or Single Photon Emission Computed Tomography (SPECT) examinations are performed on the same date for contiguous body areas.
Based on established valuation of Current Procedural Terminology (CPT®) codes, it is ACR’s position that interpretation of radiological imaging procedures are separately identifiable full services, each of which has been assigned a relative value unit (RVU) through the American Medical Association (AMA) relative value update committee (RUC) process. This relative value is determined by a multispeciatly panel using evidence based data to rigorously define the pre-service, intra-service and post-service components of physician work for each procedure. As such, there are no significant savings in physician work when multiple imaging procedures are interpreted and it is therefore the position of both ACR and Centers for Medicare and Medicaid Services (CMS) that these interpretations are not subject to the multiple surgical rules.
The multiple surgical rules, as outlined by Medicare, apply to procedural codes for which, as a result of duplicated pre-, intra- or post-service work, there is less physician work done for the second, third, fourth, and fifth procedures.
- For example, a surgeon doing a lapraotomy involving multiple intra-abdominal procedures, does one pre-operative physical exam, one operative consent (both part of “pre-service work”), one laparotomy incision and closure (“intra-service work”), and one set of follow-up office visits (“post-service work”) regardless of how many intra-abdominal procedures were performed. It is these areas of significant physician time and effort that would be “double payed” if no reduction was applied.
- Using a radiology example, when multiple selective catheter positions are performed for arteriograms of the left and right carotids and vertebral arteries during the same angiographic session, physician work for the initial catheterization most commonly includes introduction of the catheter into the femoral artery and advancing it to the highest order branch selected. Additional catheterizations of different vascular families would be paid at 50% because a significant portion of the work including patient interview, obtaining informed consent, skin preparation and local anesthesia, arterial puncture, vascular sheath placement, initial catheter placement, catheter withdrawal, hemostasis, post procedural monitoring and care, patient discharge and instructions is only performed once. Clearly this represents a substantial portion of the physician work and time of the procedure and thus justifies the 50% reduction for the second and additional procedures.
These selective catheterization procedures and injections are accompanied by “radiologic supervision and interpretation” of the resulting arteriograms of the respective vessels. Each arteriographic study requires separate and individual evaluation and interpretation and is therefore a separately identifiable service with no savings of physician time or work relative to interpreting similar studies on different patients. In fact, findings on one set of arteriographic images would have to be correlated with the images from the other vascular distributions, which adds work to the interpretation compared with a single vessel study. As a result, each of these is coded and should be paid at the full rate.
This example is to demonstrate the difference between procedural codes, for which there are economies as a result of multiple simultaneous procedures, versus imaging interpretation codes (like CT and MRI) for which no significant economy exists. The concept of the multiple surgical rule with its economies of physician work does not apply to interpretations of multiple CT or MRI studies. The only “economy” in interpreting consecutive studies with either of these modalities is dictating the patient’s name and unit number once. Certainly this does not represent a significant savings of time or physician work. It more appropriately parallels the imaging portion of angiograms where separate identifiable services are provided for each area.
ACR’s guidelines for CT and MRI studies require documented procedures and technical factors to be prepared by each anatomic site. According to the guidelines, the physician has the responsibility for all aspects of these studies including but not limited to: reviewing all indications for the examination, specifying the pulse sequences to be performed, specifying the use and dosage of contrast agents, interpreting images, generating written reports, and assuring the quality of both the images and interpretations.
The ACR strongly recommends that the integrity of the resource based relative value scale (RBRVS) be preserved in all medical coverage policies and finds no basis in fact to justify this proposed BCBSMA medical policy.
Please do not hesitate to contact me with any questions. You may reach me through the ACR at (800) 227-5463 ext. 4774. Please ask for Rachel Kramer.
Sincerely,
William T. Thorwarth, Jr., M.D.
Chairman, Commission on Economics
WTT/eg
cc: Allen J. Hinkle, M.D., Vice President, Health Care Quality & Innovation
Donald M. Bachman, M.D., President, Massachusetts Radiological Society (MRS)
John A. Patti, M.D., Chair, MRS Managed Care Committee
Rachel Kramer, Assistant Director, ACR Economics & Health Policy Department
