The chair of the Commission of Economics discusses cardiac computed tomography angiography revenue code, with Juan Carlos Batlle, MD, MBA, FACR, FSCCT.
From the Chair of the Commission on Economics
Gregory N. Nicola, MD, FACR
Juan Carlos Batlle, MD, MBA, FACR, FSCCT, is an attending radiologist and clinical assistant professor at the University of Pennsylvania in the cardiothoracic division. In addition to serving as a member of ACR and on the Council Steering Committee, he also serves on the Society of Cardiovascular Computed Tomography (SCCT) board of directors. Batlle recently spoke with the Bulletin about the cardiac computed tomography angiography (CCTA) revenue code.
CCTA is the preferred evaluation for symptomatic coronary artery disease patients (the leading cause of death in the United States) based on strong clinical evidence and international guidelines, cost-effectiveness and improved patient outcomes.
When CCTA emerged as a new way of deploying CT technology, several factors led to the linking of CCTA reimbursement to that of generic CT. First, many assumed the facility cost of performing a CCTA would be very similar to a generic CT, when in fact activity-based costing studies have shown that, even in highly experienced CCTA centers, CCTA requires at least three to four times the expense. This derives mainly from the additional complexity of the study and extra cardiac-trained nursing and technologist time.
Second, when imaging facilities report the cost of producing a CCTA in their accounting systems, they often lump in CCTA with all the other CT exams in the department. Since CCTA is usually a very small percentage of the overall CT examination count, even if a facility is appropriately reporting a higher cost for the CCTA within the CT suite numbers, that cost is diluted over the entire department’s CT output.
Third, the cost of running the CT department is typically accounted for using a “square-foot method” that allocates the cost of each modality according to the physical amount of space used rather than the actual direct costs specific to a modality. In the case of CT in general and CCTA specifically, this undermeasures the cost of acquiring and maintaining the CT machine and therefore the cost to produce each individual examination. These factors combine to reduce the expense inputs CMS uses to calculate outpatient hospital payment rates.
It would be more accurate to call it an expense code, as in, what kind of expense does a facility incur in producing a particular examination?
Under the same HIPAA statute that provides for protected health information, revenue codes are billed on hospital claim forms to indicate the type of service or department in which a service takes place. They are essential in determining accurate reimbursement. In short, when a facility issues a claim to a payer, that claim includes not only the procedure performed (e.g., the CPT® code) but also a revenue code (a four-digit number governed by the National Uniform Billing Committee). “Revenue code” is a misnomer because it actually reflects the cost to a facility to produce an examination: the cost of the CT machine, the space within the facility that the CT suite occupies, utilities and disposables, technologist labor, maintenance, etc. It would be more accurate to call it an expense code, as in, what kind of expense does a facility incur in producing a particular examination?
There is a taxonomy of revenue codes that can be chosen by facilities for every kind of examination they perform, and providers should utilize the revenue code best associated with their cost to perform CCTA tests. Different costs related to these tests, such as depreciation of the CT equipment and cardiology/radiology nurse time, contribute to the unique, higher operating costs of CCTA. Or, to use another modality as an example, a facility need not granularly itemize what one specific patient’s mammogram costs the facility (e.g., one mammogram patient might spend a longer amount of time in an exam room than another or might use twice as many linens). Instead, the facility can simplify its cost reporting by applying the screening mammography revenue code (0403), which averages expense among all screening mammography patients.
Hospitals are required to map the CPT codes for services they perform to the most appropriate revenue codes in their chargemasters, cost reports and billed claims. Accurate pairing of the codes is essential for claim submission and reimbursement. As an example, CPT code 75574 is defined as CT angiography with contrast and 3D image. Using the cardiology revenue code 0480 provides key information about the resources used for the test, such as the cardiology nurse to administer medication.
Accurate coding best reflects the resource utilization and clinical value of CCTA for improving cardiac care. Historically, Medicare Administrative Contractors had an inappropriate edit requiring the CT revenue code 035X on CPT codes 75572, 75573 and 75574. A claim edit in this case essentially meant “error message” because the edit improperly lowered CMS calculation of the costs to perform CCTA. CMS mandated the edit’s removal, recognizing the CT revenue code did not reflect the full expense of CCTA. When it removed the harmful edit, CMS affirmed hospitals’ ability to utilize revenue codes that best reflect higher operating costs and better align with higher cost-to-charge ratios when appropriate.
In addition to 048X (cardiology), other revenue codes with higher and more appropriate cost-to-charge ratios are 0409 (other imaging) and 032X (radiology — diagnostic). To properly change the revenue code, confirm or update your hospital’s cost center mapping in the cost report.
CMS recently approved a temporary reclassification of CCTA into a higher Ambulatory Payment Classification (APC) payment grouping (alongside other cardiac exams). This assignment better reflects the resource utilization and clinical value of CCTA in improving cardiac care and aligns reimbursement more closely with the true costs of delivering this service. It also addressed CMS’ removal of the improper claim edit that prevented utilization of cardiology revenue codes for CCTA.
However, for this reclassification to become permanent, hospitals are expected to change the revenue codes billed on claims for CCTA tests. Facilities now need to back this up by actually reporting their expenses in line with what the new APC expects. If facilities continue to report that CCTA expenses are similar to generic CT expenses (by continuing to utilize the same CT revenue code for both), the APC change may be reversed.
This claim edit has complicated wider utilization of these codes and may still exist for some codes and payers. ACR, SCCT and the American College of Cardiology, among others, are working to educate the healthcare community on the importance of correcting CCTA revenue codes while also encouraging CMS to expand its communications.
CMS has clarified that facilities are free to change the revenue code for CCTA in their chargemasters and on their billed claims and make corresponding updates to their cost reports, if necessary. Hospital coding and billing are complex and supported by many professionals from different disciplines. As a result, it has taken time to reach and educate the appropriate people about the importance of making the revenue code changes. Many of the accounting systems used internally by facilities retain the old edit and may dissuade the revenue cycle team from applying different revenue codes. So, though CMS may accept the new codes, your own internal software may be incorrectly stopping you.
To make the higher APC payment permanent, CMS has said the majority of CCTA claims must utilize cardiology or other non-CT revenue codes (e.g., 480, 489 or 409x) within the next three years or reimbursement could be reduced by half. Although this APC change most directly affects reimbursement to facilities under the Outpatient Prospective Payment System (OPPS), the 2005 Deficit Reduction Act imposes an OPPS-anchored cap on technical component reimbursement to non-OPPS facilities that utilize the Medicare Physician Fee Schedule. The APC reassignment therefore also indirectly raises the technical component caps on these codes even for non-OPPS locations (e.g., an independent diagnostic testing facility or physician’s office).
Cardiologists, radiologists, technologists or researchers may require help to reach those who can make revenue code changes. Begin by identifying your health system’s revenue cycle administrators and other key staff such as revenue integrity and chargemaster coordinators. In larger organizations, this process typically starts with your division or department administrator or practice manager, who can guide you.
Validate the revenue code currently used on claims, and if it is the CT revenue code (035X), emphasize the need to utilize a cardiology revenue code (0480) or other radiology (0409) revenue code and the reasons why.
Hospitals are free to make revenue code changes in their chargemasters and on claims and to update their cost reports if needed to be consistent with CMS guidance. At the same time, hospitals have a mandate that requires that charges be related consistently to the cost of the item or service and uniformly applied to all patients, whether inpatient or outpatient and no matter the payer, so focus on explaining or examining how costs are applied. For example, some clearinghouses and other payers may still have inappropriate edits preventing utilize of cardiology or other revenue codes with CCTA. However, this is not appropriate per CMS guidance or under the HIPAA requirements.
There may be apprehension regarding revenue coding compliance given that the term “CT” is included in the CPT code description, making some hesitant to deviate from the CT revenue code. However, CMS has resolved this perceived concern and validated its long-standing guidance enabling hospitals to choose for themselves the most appropriate revenue code.
Revenue codes categorize services based on their type and location, are billed on claims governed by HIPAA requirements and are mapped in cost reports. Often, there are cardiology operating costs involved in CCTA tests, such as a cardiology nurse to administer or monitor medication. Using the cardiology revenue code reports that it is a cardiology test rather than a generic CT test. Even if cardiac CT is done in the radiology department, hospitals should utilize the revenue code best associated with the operating cost to perform CCTA tests. As explained earlier, the generic CT revenue code has long-standing problems with under-reporting the costs of even a generic CT, much less the more complex CCTA, and CMS has acknowledged this.
Bear in mind that, if necessary, facilities can update their cost reports to reallocate some CCTA resources to the cardiology cost center in the cost report, allowing them to appropriately utilize a cardiology revenue code on claims. This does not affect the facility’s payment budget or “ownership” of CCTA services. As utilization of CCTA continues to grow because of its extraordinary clinical importance, it makes sense for facilities to ensure the true costs of the test are adequately reimbursed — which means continued placement within APC 5572.
Dr. Batlle would like to acknowledge his collaborators at SCCT: Joanne Olson, MBA (executive director), Matthew Fenwick, MBA (director, health policy and practice) and Ahmad Slim, MD, FSCCT (health policy and practice committee chair).
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