JACR: Hunt for misvalued services targets imaging

As the Centers for Medicare & Medicaid Services comb through reimbursement codes to identify potentially misvalued codes, radiology is disproportionately targeted, primarily because of the specialty’s historic accuracy in coding, according to an article in the January issue of Journal of American College of Radiology.

The article pinpointed three sources of bias against radiology services. The primary current reimbursement emphasis in radiology is characterized by revisions to existing code families or unchanged codes subject to revisions rather than the development of new codes. Efforts by CMS, the CPT editorial panel and the Relative Value Scale Update Committee (RUC) appear to target imaging. “Radiology has had more codes brought forth for revaluation in this process than any other specialty,” wrote Ezequiel Silva III, MD, of South Texas Radiology Group in San Antonio.

According to Silva, the disproportionate impact on radiology stems from inherent qualities in its coding and payment structure, which make it stand out among other physician services. 

CMS and RUC use “screens” to locate potentially misvalued codes. These screens are designed to capture services reported together and combinations of high utilization and high expenditures. The radiology coding structure includes numerous combinations of services reported together, which are then captured in this screen.

Another bias arises on the utilization front. Because CMS and RUC cannot review all identified codes, the organizations focus on high utilization codes and set thresholds of 100,000 and 30,000 to determine which codes to review. Silva pointed out that radiology has 75 codes for the abdomen and pelvis. In contrast, surgery has 777 abdomen and pelvis codes, so utilization appears disproportionately higher in radiology. This issue is compounded by higher practice expenses and higher technical component payments in imaging as CMS and RUC use total payment as a basis for prioritizing codes in screens.

Finally, although the American College of Radiology had historically provided CMS with practice expense data to determine technical component payments, these data were replaced by data gathered by the American Medical Association in 2010. “The data are under-representative of radiology … It has subsequently become apparent that the practice expense methodology itself is incapable of accurately representing the expenses innate to a capital intensive specialty such as radiology unless supplemental survey data are considered,” wrote Silva.

Despite the challenges, Silva remained positive, and concluded, “Hopefully, these shortcomings will be recognized and reversed so that once again, radiology can enjoy its share of success without worry that our successes will make us victims in the future.”