The term “bundling” is often viewed negatively in radiology and medicine. Recently, it has gained renewed attention due to the announcement that CT angiography head and CTA neck procedures will be bundled. Radiologists are particularly sensitive to this because bundling typically results in reduced reimbursement. A notable example was the 2011 bundling of CT abdomen and pelvis, which led to a 27% drop in professional component relative value units when compared to billing separately. Importantly, radiologists themselves do not initiate these changes — they are directed by the Relative Assessment Workgroup (RAW).
RAW is a subcommittee within the AMA’s Relative Value Scale Update Committee (RUC) responsible for identifying potentially misvalued physician services. One of RAW’s main criteria is flagging services that are billed together more than 75% of the time, based on CMS claims data. The logic is that if procedures are routinely performed together, there may be efficiencies — reduced time or effort — that should be reflected in reimbursement. While radiologists may argue that interpretation time remains the same regardless of bundling, other efficiencies exist, such as reviewing history only once, creating a single report and contacting referring physicians only once.
These reductions are not arbitrary; they go through a rigorous process applicable to all CPT® codes. Once RAW determined that CTA head and CTA neck should be bundled, the matter went to the CPT Editorial Panel, which defines what each code entails and determines how to capture distinct work types. Fortunately, radiologists from ACR and other societies play a crucial role in this process, ensuring accurate code definitions.
Fortunately, radiologists from ACR and other societies play a crucial role in this process, ensuring accurate code definitions.
Jacob Ormsby, MD, MBA
American Society of Neuroradiology RUC Advisor
In this case, the goal was twofold: define a new bundled code for CTA head and neck and preserve separate codes for each when performed independently. While this may sound simple, the CPT language must be very precise — developing it took multiple panel meetings. The definitive source for this language is the annually updated AMA CPT manual.
Once the CPT Editorial Panel approved the new and revised codes, they returned to the RUC for valuation. Contrary to what might seem logical, RVUs from the previous separate procedures are not simply added together. Instead, surveys are conducted among society members to gather data on time and intensity for the bundled procedure. This step is required for all codes submitted to the RUC.
After survey data is collected, RUC advisors must present it to justify both the time and complexity of the service. Radiology is fortunate to have informed representatives who advocate effectively for the value these procedures offer. However, convincing other specialties — who are also competing for limited reimbursement dollars — is an ongoing challenge.
As we await the proposed rule from CMS, based on RUC recommendations, we recognize the frustration many feel with this system. However, it’s crucial to work within the current structure and continue advocating for radiology. Bundling will not end here, but efforts will persist to minimize its impact. One of the best ways to support this advocacy is by maintaining membership in the AMA and actively engaging with ACR on reimbursement issues.
