Coding and Payment Policy: ACR Successes


The year 2004 is off to a productive start for the ACR Economics and Health Policy Department. By maintaining positive relationships with the Centers for Medicare and Medicaid Services, the American Medical Association CPT® Editorial Panel and private payers, the ACR has positively impacted the way radiologists, radiation oncologists and medical physicists are reimbursed. Successes of the past year are highlighted here.

CCI Edits and Appropriate Reimbursement

The College continuously reviews and comments on numerous proposed Correct Coding Initiative code pair edits related to radiology and radiation oncology. The ACR devotes considerable time and resources to commenting on inappropriate edits, since these edits directly affect physician Medicare reimbursement. Over the last year, the ACR has reviewed and commented on five versions of CCI edits, totaling over 27,000 code edits. As a result, numerous edits were deleted or now allow for the use of an appropriate modifier. ACR successes in regard to CCI edits include:

The ACR influenced CMS' decision to delete CCI code pair edits that bundled transvaginal and transabdominal ultrasound services. The ACR provided clinical indications that supported the need for these two procedures to be performed on the same patient on the same date of service. These particular edits required the use of an appropriate modifier in order to receive reimbursement. If the appropriate modifier was not appended to the transvaginal study, a nonhospital facility would lose an average of $96.33 in reimbursement per procedure.

Through letters, conference calls and a meeting with CMS, the ACR was successful in influencing CMS' decision not to implement a CCI edit that bundled central venous access guidance, 75998 (fluoroscopic guidance for central venous access device placement . . .), with ultrasound guidance, 76937 (ultrasound guidance for vascular access . . .). If this edit had been implemented and these studies reported without the appropriate modifier, a nonhospital facility would have lost an average of $34.35 in reimbursement per procedure. The deletion of the above code pair edit allows radiologists to be reimbursed by Medicare for these services when performed by the same physician on the same date of service.

The ACR, in conjunction with the American Society for Therapeutic Radiology and Oncology, was successful in working with CMS to delete a CCI code pair edit that bundled IMRT planning services (77301) with dosimetry calculation service (77300). Since this edit did not allow for a modifier to be used when billing these two procedures on the same day, a nonhospital facility performing IMRT services for Medicare beneficiaries would lose an average of $85.13 in reimbursement per procedure.

Ensuring Appropriate Coverage for Medicare Beneficiaries

In addition to working to ensure that radiologists, radiation oncologists and medical physicists are appropriately reimbursed, the ACR actively works with Medicare to ensure that beneficiaries receive appropriate coverage for radiological services. Through letters and conference calls, the ACR was successful in 2003 in securing expanded national coverage for Medicare beneficiaries for breast biopsies, magnetic resonance angiography and positron emission tomography.

Breast Biopsy: The ACR was successful in getting national coverage expanded for percutaneous image-guided breast biopsy for palpable lesions. The ACR recommended national coverage for image-guided breast biopsy for both palpable and nonpalpable lesions to avoid unnecessary open breast biopsies for histological diagnosis and to maximize the yield of percutaneous biopsies. As a result of our efforts, national coverage became effective on Jan. 1, 2003, and includes palpable lesions that are difficult to biopsy using palpation alone.

MRA: The extensive efforts of the ACR were instrumental in obtaining expanded coverage of MRA procedures. As of July 1, 2003, coverage includes evaluation of renal arteries in patients without a damaged aorta, pelvic arteries in patients without a damaged aorta, and catheter angiography.

PET: The ACR was successful in securing expanded coverage for PET for the restaging of recurrent or residual thyroid cancers, perfusion of the heart for potential cardiac diseases, and specified coverage for ammonia N-13 with PET. The effective date for expanded coverage of these additional indications was Oct. 1, 2003.

Also on the national coverage front, the ACR is currently spearheading efforts to encourage CMS to consider coverage for magnetic resonance spectroscopy and expanded coverage for low osmolar contrast media.

ACR Managed Care Committee Responds to Private Payer Pressures

The College is actively involved in working with private payers to ensure appropriate reimbursement for radiological services and quality patient care. The ACR Managed Care Committee was established to respond to the economic pressures of private health care insurance companies, since these pressures often affect ACR members and compromise patient care. This committee, with the support of the

ACR Managed Care Network and the ACR Economics and Health Policy Department, assists members in dealing effectively with issues related to non-Medicare payers.

In 2003, the ACR successes on the private payer front included:

The ACR Managed Care Committee was successful in getting a Blue Cross/Blue Shield payer to:

  1. reimburse for MRS when used to: 1) differentiate residual brain tumors from post-therapy changes; and 2) differentiate brain tumors from abscesses or other infectious or inflammatory processes.
  2. reimburse for PET for breast cancer staging, restaging and monitoring response to therapy.
  3. expand coverage to include Indium–111 capromab pendetide (ProstaScint®) for monoclonal antibody imaging, when the information will impact management for the following indications: 1) staging newly diagnosed prostate cancers in patients with high suspicion of metastasis or locally advanced disease by PSA or Gleason Score; and 2) evaluating post-prostatectomy patients with rising PSA levels who have an otherwise negative workup for metastasis.

In response to comments from the ACR Managed Care Committee, a Blue Cross/Blue Shield payer in Massachusetts rescinded its policy on professional component reimbursement for same day imaging scans. The payer had been incorrectly applying the multiple surgical reduction rule to radiology services.

The ACR looks forward to additional success in 2004 as it works to maximize reimbursement for members and make the best possible care available to patients.