April 30, 2011

ACR Radiology Coding Source™ for March-April 2011

Bundling of CPT® Codes to Continue in 2012

All of medicine continues to feel the effects of the Centers for Medicare and Medicaid Services’ (CMS) initiative to bundle codes (combine multiple codes into a single code) and, thereby, reduce Medicare payments for those procedures performed together greater than 75 percent of the time.  For radiology, this was realized in 2010 with the creation of:  

       ·    Combined myocardial perfusion imaging, wall motion and ejection
         fraction study codes (78451-78454)
·    Combined arteriovenous shunt dialysis catheter procedures and
         radiological supervision and interpretation (RS&I) codes (36147, 
       ·     Facet joint injection procedure codes to include imaging guidance

In 2011, bundling continued with the creation of:  
·     Combined CT abdomen and pelvis codes (74176, 74177, 74178)
·      Lower extremity revascularization codes to include the work of
         accessing and selectively catheterizing the vessel traversing the lesion, 
         radiologic supervision and interpretation directly related to the
         intervention(s) performed, embolic protection if used, closure of the
         arteriotomy by any method, imaging performed to document completion
         of the intervention in addition to the intervention(s) performed, and
         moderate conscious sedation (37220-37235)
·     Atherectomy codes above the inguinal ligaments to include RS&I

This process of bundling will continue in 2012 and, likely, into the near future until alternate payment models are designed and implemented by CMS. 

In anticipation of additional bundling and most likely payment reductions, the following is provided to inform radiology practices of what is being considered for bundling in 2012 so that radiologists can be prepared to negotiate adequate reimbursement for private payer contracts and develop appropriate capital expenditure budgets for the upcoming fiscal year.

While the ACR is not permitted to provide detailed information on the codes and descriptors developed for 2012 at this time,* we can inform our members of codes being considered for bundling.  Additional code pairs identified as being performed together greater than 75 percent of the time and considered for bundling in 2012 include:
·    Computed tomographic angiography (CTA) of the abdomen and CTA of
        the pelvis (74175, 72191) 
·    Renal angiography and RS&I (36245-36248, and 75722, 75724) 
·    Inferior vena cava filter and RS&I (37620, 75940)
·    Abdominal paracentesis and imaging guidance (49080, 49081 and
        76942, 77012)
·    Sacroiliac joint injections and RS&I (27096, 73542)   

Additional codes caught in the 75 percent screen and being considered for future revision include: carotid angiography, embolization, thrombolysis and foreign body retrieval procedure codes.

In addition to bundling, radiology practices also should look for revision and re-valuation of the nuclear medicine lung ventilation/perfusion and hepatobiliary code families.  These codes were identified to be re-surveyed by the Five-Year Review Identification Workgroup (now known as the Relativity Assessment Workgroup).Given the amount of questions the ACR and Society of Nuclear Medicine receive regarding the proper use of the current codes, the societies recommended that these codes be sent to the CPT Editorial Panel to provide clarification with a focus on simplification of the descriptors prior to going back to the AMA Relative Value Scale Update Committee (RUC) for survey and possible revaluation.  

CMS continues to search for misvalued codes and to develop new screens to identify additional services to be re-valued by the RUC.  Additional screens used by CMS include codes with low relative value units but high utilization, codes that have the largest growth in utilization in the Medicare database, site of service anomalies, different performing specialty from the specialty surveyed, and Harvard-valued codes with utilization over 100,000. 

Bibb Allen, Jr., M.D., chair of the ACR Commission on Economics, summarized in a January 10 EBlast to the ACR membership, why the CT abdomen and CT pelvis codes were selected for bundling, how the codes were developed and valued, and why payment rates could not be preserved.  Allen notes that the ACR has and continues to actively participate in the CPT and RUC processes to ensure appropriate values for radiology services.  We will continue to vigorously advocate on behalf of radiology and radiation oncology at CPT, the RUC, at CMS and with Congress to maintain the relativity of our services and practice expense payments.1 

Ezequiel (Zeke) Silva, III, M.D., ACR alternate RUC Advisor, has been keeping ACR members up to date on the challenges radiologists face in his monthly Radiology Rounds articles published in the Journal of the American College of Radiology (JACR).  See the May JACR Reimbursement Rounds piece titled CT Abdomen and Pelvis: A Case Study in Devaluation.  This article also discusses why such severe cuts in payment were applied to the combined CT abdomen and pelvis studies. 

The ACR Bulletin is running a series of articles, beginning in April, which discusses how bundling is being handled through the CPT and RUC processes.


It is important that radiology practices keep up to date with what is happening at CPT and the RUC, as CMS continues its search to look for ways to decrease Medicare payments.  The ACR BulletinJACR, and ACR Radiology Coding Sourcewill continue to keep members and other interested parties informed. 

*Recognizing the need to notify providers and suppliers of new codes earlier than October, the AMA has scheduled an August 31 release date of a downloadable version of the CPT 2012 code book  from the AMA Bookstore. The CMS-approved values for codes, however, will not be known until the Medicare Physician Fee Schedule Final Rule is published in the Federal Register by the Department of Health & Human Services in early November. 


1Bibb Allen, Jr., M.D., EBlast to ACR membership, January 10, 2011.


New Codes From a New Source: The Rolling Five-Year Review, JACR, pp. 10-12
The Significance of 2011’s New Codes, JACR, pp. 10-11
Bundling Realities, ACR Bulletin, April 2011, pp. 20-21.
The ACR Radiology Coding Source, Sept/Oct 2010. 
ACR comments to CMS regarding the 2011 Medicare Physician Fee Schedule  Final Rule.
ACR comments to CMS regarding the 2011 Hospital Out-patient Prospective Payment System Final Rule.