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Good News for Radiology and Radiation Oncology with the Release of the 2005 Medicare Physician Fee Schedule Final Rule

Low-Osmolar Contrast Media

It's official, the Centers for Medicare and Medicaid Services (CMS) accepted the ACR's request for expanded Medicare coverage of low-osmolar contrast media (LOCM). Effective April 1, 2005, CMS will begin to reimburse physicians for LOCM provided to all Medicare patients requiring enhanced images, not just those falling into one of the previously required 5 categories of coverage. Practices should continue to report LOCM using HCPCS codes A4644, A4645, and A4646, and CMS will establish reimbursement rates based on the average sales price of LOCM (as per data submitted by manufacturers) plus 6%. In addition, CMS will not apply an 8% reduction to LOCM reimbursement as originally proposed (it was proposed to account for the costs CMS currently captures for use of high-osmolar contrast media in these procedures).

Conversion Factor

The good news does not end with expanded coverage of LOCM as CMS published the 2005 conversion factor (CF) of $37.8975, which is 1.5% higher than the 2004 rate ($37.3374). This seemingly small update is of course a great improvement over the previously projected 3.3% cut which would have occurred without passage of the Medicare Prescription Drug Improvement and Modernization Act (MMA).

Radiation Oncology

Another benefit for radiation therapy physicians and providers, CMS also accepted ACR's request to reinstate HCPCS code Q3001 (radioelements for brachytherapy, any type, each) so physician offices and freestanding clinics may report brachytherapy sources with this code in 2005. Practices previously reported brachytherapy sources with CPT® code 79900 (provision of therapeutic radiopharmaceutical(s)); however as of January 1, this code was deleted from CPT® and no longer available for use.

CMS also agreed to maintain the current global period of "XXX" for radiation treatment management code 77427 as requested by the ACR and other specialties and thus maintain established Medicare policy regarding the number of follow-up visits a radiation oncologist may bill in association with radiation treatment management. In August,

CMS proposed to change the global period assigned to code 77427 from an XXX global period to a 90-day global period to reflect the longstanding policy that follow-up visits 90 days after the course of therapy are included and should not be reported separately. However, since a course of radiation therapy consists of many weeks of treatments, with 77427 claims being submitted in series, a 90-day global period would not allow for the 5 fraction codes to be used as they are intended during a course of therapy. Accordingly, the ACR and others commented emphatically that this change in policy should not occur. As a result, CMS will retain the XXX global period of 77427 and no changes in coding or payment policy will occur.

Beginning in 2005, solid compensator-based beam modulation delivery must be reported using Category III tracking code 0073T (compensator-based beam modulation treatment delivery of inverse planned treatment using 3 or more high resolution (milled or cast) compensatory convergent beam modulated fields, per treatment session) and practices will no longer be permitted to report this type of delivery using radiation therapy CPT® code 77418 (intensity modulated treatment delivery). Typically, such a tracking code would be priced by individual Medicare contractors; however CMS announced its decision to assign interim relative value units (RVUs) to this tracking code. To do so, CMS will crosswalk the practice expense and malpractice RVUs assigned to CPT® code 77418 to the Category III tracking code 0073T (note that this code is a technical-only code).

Positron Emission Tomography

CMS will continue to use established HCPCS codes for positron emission tomography (PET) services and will also continue to rely on local level Medicare contractors to establish reimbursement rates for these services at this time. However, CMS announced its intent to examine the overall issue of Medicare coding, payment, and coverage of PET services in the near future. Accordingly, the ACR and CMS will meet to discuss the new PET and PET/CT codes, relative values, and their timeline for acceptance in the Medicare Physician Fee Schedule.

Other Coding Issues

These and other important coverage and coding policy announcements were issued with CMS' release of the Medicare Physician Fee Schedule (MPFS) 2005 Final Rule on November 15, 2004.

Reimbursement Increase for Naso or Gastric Tube Placement service, 43752

As a result of ACR's comments and discussions with CMS, the RVUs assigned to CPT® code 43752 (naso or gastric tube placement, requiring physician's skill and fluoroscopic guidance) will increase from a .68 RVU to a .81 RVU for calendar year 2005.

Bone Marrow Aspiration

CMS created a new add-on G-code, G0364, to report for bone marrow aspiration performed with bone marrow biopsy through the same incision on the same date of service. This code should be used in conjunction with the CPT® code for bone marrow biopsy (38221), with G0364 reported for the second procedure (bone marrow aspiration). When the two procedures, aspiration and biopsy, are performed at different sites (for example, contralateral iliac crests, sternum/iliac crest or two separate incisions on the same iliac crest), CMS indicates that the –59 modifier, which denotes a distinct procedural service, is appropriate to use and Medicare's multiple procedure rule will apply.

Venous Mapping for Hemodialysis

A new G-code, G0365 (vessel mapping of vessels for hemodialysis access, services for preoperative vessel mapping prior to creation of hemodialysis access using an autogenous hemodialysis conduit, including arterial inflow and venous outflow), was created for use when patients have not had a prior hemodialysis access prosthetic graft or autogenous fistula. Reporting of this code is limited to two times per year and CMS will not permit separate payment for CPT® code 93971 when this G-code is billed, unless CPT® code 93971 is being performed for a separately identifiable indication in a different anatomic region. In addition, other imaging studies may not be billed for the same site on the same date of service unless an appropriate "KO" modifier, indicating the reason or need for the second imaging study, is provided on the claim form.

5-Year Review

Every 5 years, CMS reviews the RVUs assigned to each CPT® code in the Medicare Physician Fee Schedule to determine if any services are over-or undervalued; 2005 marks the third 5-year review since the developmentof the MPFS and CMS is once again reviewing and evaluating physician work RVUs. Accordingly, CMS has requested public comment regarding those services which are potentially under- or overvalued and will also specifically review high-volume services that were previously performed in the inpatient setting but are now predominantly performed on an outpatient basis. In addition, CMS will review any services which were not previously valued by the Relative Value Update Committee process. The ACR is currently analyzing radiology and radiation oncology CPT® codes to determine if any may require consideration during this 5-year review process.

Impact of RVU Changes and the CF Update on Total Medicare Allowed Charges by Specialty

With the release of the MPFS 2005 Final Rule, CMS announced a conversion factor increase of 1.5%. In addition, CMS outlined adjustments that will be made to practice expense RVUs as a result of the code refinement process (which was designed to achieve resource-based RVUs), recently completed by the Practice Expense Advisory Committee, of which the ACR was a part. CMS also updated the methodology used to develop malpractice RVUs to incorporate a resource-based algorithm. The impacts of these changes, coupled with the 1.5% conversion factor update, are outlined below for a few select specialties.

Codes Pertaining to Radiology for 2005

The table below outlines those codes relevant to radiology and radiation oncology that are new for 2005 and the associated relative value units assigned to each of those services as published in the 2005 MPFS Final Rule.

Questions or Additional Information

A copy of the final rule may be obtained from the CMS Web site at http://www.cms.hhs.gov/physicians/ or by contacting the ACR Economics and Health Policy Department. A full summary of the Final Rule as well as year-to-year RVU comparisons are also available by contacting the ACR Economics and Health Policy Department. The ACR submitted comments on the Final Rule.