In the first of this two-part series that published in the May issue, I discussed how a decision to bring forth new codes must be carefully considered in terms of current coding and reimbursement. In this month’s column, I’ll outline the subsequent steps in the lifecycle of a new code.
Category I codes created through the Current Procedural Terminology (CPT®) process go to a committee called the Relative Value Scale Update Committee (RUC) that assigns relative value unit (RVU) values for physician work and practice expense. The work of the RUC is a zero-sum game, so for any new codes given value, other codes must go down proportionally. The RUC determines what is in the “family” of a new code being valued and requires revaluation of the codes in that family.
Unfortunately, “revaluation” usually means “lower valuation” in terms of decreased RVU values from what we previously had for these services. Consequently, when we make new codes, we try hard to consider the effect on other codes in what may be considered the same family. For example, if we created specific liver or breast elastography codes, then the abdominal US or breast US codes would have been revalued. Instead, we created generic elastography codes that work with a large variety of existing US codes so as not to pose a valuation threat to specific existing codes.
Consequently, we must carefully consider any downstream effects and unintended consequences before we create any new code. We don’t want to create codes where you get paid more for something you do 10% of the time but consequently get paid less for the things you do the other 90% of the time. We have to be very strategic. Sometimes, for example, we are forced to revalue existing codes because they have been identified by the RUC or CMS as “potentially misvalued” or “overvalued.” In those circumstances, if we are forced to revalue existing codes, that is a good time to introduce changes. As an example, when we were forced to revalue breast MRI, we took the opportunity to divide existing codes into breast MR without contrast and breast MR with and without contrast. In this way, we were able to bundle breast computer-aided detection (CAD) into the later set. By purposefully doing this, we were able to capture increased value for the more complex services performed with and without contrast and capture CAD when performed.
So, what should folks do if they have questions about CPT codes? The answer is to ask the ACR. There may be a different coding mechanism to achieve the desired outcome. For example, let’s look at abbreviated breast or liver MRI. Advocates want to improve access to screening with lower cost exams, and “full” exams can be quite costly — understanding that there is a huge variation in cost for these exams, depending on where they are performed (a topic for another day). In this particular example, a discussion of modifiers is helpful. Modifier –52 is a “reduced services” modifier. You can use it, at your discretion, whenever you feel that you did less than a full exam, and you have the ability to set a different price for that reduced services exam. There is a similar modifier –22 for increased professional services that you can use when you go above and beyond for that 27-sequence abdominal MRI but none of the payers or CMS pay for its use. If you have a shorter protocol, with fewer sequences than your standard protocol, you are not required in any way to use a –52 modifier since MRI codes do not specify how many sequences you must perform — but you have the “option” to use that modifier if you desire to charge less. This has been a source of confusion to members because they have gotten advice from the AMA and the ACR that the modifier is not necessary. That advice is correct. The modifier is not necessary but is an “option” to use if you desire to set a lower charge for an exam that is less than your standard.
In summary, there is a very coordinated interplay between your ACR CPT and RUC teams, and strategy always revolves around both patient care and reimbursement. We make new codes each year, but each code application is thought through as carefully as possible to ensure we are providing an accurate coding system while doing the right thing for our members and to avoid unintended consequences. Your ACR CPT and RUC teams have dedicated physician volunteers and incredibly knowledgeable and dedicated staff — with decades of combined experience — who work tirelessly to ensure you can code and bill appropriately for what you do.