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New Codes for Coronary Interventions Allow Reimbursement for Complex Procedures
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For the last 20 years, interventional cardiologists have coded and billed for their interventional services using codes constructed 18 to 20 years ago. Medicare has paid for these services using values that were assigned when the codes were created — also about 2 decades ago. During this period, everything about the practice of interventional cardiology has changed, except for the codes and their values. Cardiologists have not lobbied for changes because they perceived reimbursement as generally appropriate.
Background for Change
For the past several years, CMS has employed various strategies to decrease reimbursement for procedures it suspected of being over-reimbursed and developed screens to identify such potentially overpriced services. Coronary stenting was caught by one of those screens, and CMS notified the Society for Cardiovascular Angiography and Interventions and the American College of Cardiology that coronary stenting would be re-valued. In the current health care environment, where Medicare may be headed for bankruptcy, re-valuing usually leads to devaluing. Although devaluing a procedure is entirely appropriate if that procedure can be performed faster and requires less work than when it was originally valued, many experts feel this process routinely and unfairly devalues procedures in which work and time have not changed.
James C.
Blankenship
Clifford Kavinsky
To reassess the physician work of a procedure, practicing physicians are surveyed about the time and work required to perform the procedure. The results of the survey are evaluated by a committee sponsored by the American Medical Association. That committee, known as the AMA Relative Value Update Committee (RUC), makes a recommendation to CMS regarding the physician work required for the procedure. CMS may accept that recommendation, or reject it and substitute CMS’s estimate of the work involved (although CMS does not have any other reliable method for estimating physician work).
Physician work is measured in relative value units (RVUs). CMS changes the value of an RVU yearly; for 2012 it was $34.04.
Faced with the prospect of CMS devaluing the procedure on which the entire specialty of interventional cardiology is based, representatives from SCAI and ACC considered their options. As practicing interventional cardiologists, they were aware of inconsistencies with the current codes that had been tolerated by cardiologists for more than a decade (Table 2). For example, reimbursement for an emergency middle-of-the-night STEMI stent procedure was the same as for an elective stent procedure done on a healthy outpatient at 9 a.m. Another example is that treating a complex left anterior descending bifurcation lesion and two diagonal lesions with 100 mm of stents was reimbursed the same as stenting one discrete left anterior descending lesion with a single 12-mm stent. It seemed logical that if interventional procedures were to be re-valued, then it was time to also get codes that more appropriately describe the procedures performed by interventionalists.
Establishment of New Codes
The representatives of SCAI and ACC developed a new set of codes that describe interventional procedures with greater detail (Table 3). These new codes support different reimbursement for different amounts of physician work. They solve the problems of no reimbursement for the extra work/stress involved with bypass grafts, chronic total occlusions and ST-elevation PCI by including new codes for each situation. The new codes solve the problem of no reimbursement for the extra work of atherectomy when performed with stenting by creating a code that includes both. They also solve the problem of no reimbursement for PCI of branches by adding specific codes for this indication.
In their surveys, interventionalists estimated the time required for angioplasty, atherectomy and stenting to be significantly less than the times assumed to be accurate for the past 18 years. As a result, reimbursement for the new angioplasty, atherectomy and stenting codes was expected to decrease. The new coding structure — supporting higher reimbursement for more complex procedures — would also mitigate the overall drop in reimbursement by providing appropriately higher reimbursement for more complex procedures.
These codes were approved by the AMA Current Procedural Terminology (CPT) Editorial Panel, surveyed by SCAI/ACC members to estimate physician work and time, reviewed by the AMA RUC committee and forwarded to CMS with recommended values for each code. In its final rule in the Federal Register in November 2012, CMS published its plans for payment for the new coronary intervention codes.
First, CMS agreed with the AMA RUC and surveyed cardiologists that the work of coronary interventions in general has decreased compared with 1994 and deserves fewer RVUs. CMS agreed with AMA RUC that the new codes describing more complex procedures should be valued higher than simple PCI codes. CMS generally agreed with the valuations recommended by the AMA RUC. However, CMS took the unusual position of bundling payment for PCI of branches (eg, diagonal, obtuse marginal) into payment for the base major vessel codes. CMS plans to increase the RVUs for major vessel interventions above values recommended by the RUC, but not pay for the branch PCI codes (92921, 92925, 92929, 92934, 92938 and 92944). At press time, the overall effect of these values was still being assessed by SCAI and ACC, but the societies’ predictions that payment for PCI would decrease overall are proving correct.
Important New Feature
A key feature of the new codes is not apparent in the wording of the codes themselves. In the current coding structure, “each additional vessel” codes are used to describe PCI of an additional major artery that follows PCI of an initial major artery (major arteries are defined in 2013 by CMS as left anterior descending, circumflex, ramus, left main and right coronary arteries). In the new coding structure, each major artery is coded with the base code. In other words, stenting of the right coronary artery would be described with 92928 (stenting, single coronary artery or branch). If the circumflex is also stented, instead of using an “each additional vessel” code as is currently done, the appropriate approach will be to use 92928 (the base code) again.
One might think that this would lead to overpayment. However, CMS uses the “multiple procedure rule” for reimbursement. This provides for full reimbursement for the first code and 50% reimbursement for the second code. The multiple procedure rule will continue to be used for reimbursement of diagnostic catheterization procedures when done at the same session as PCI. This means that when ad hoc PCI is performed, the diagnostic catheterization done in the same session is reimbursed at 50% of the usual value.
These changes do not affect diagnostic catheterization procedures (which went through this same re-valuation process from 2009 to 2011), IVUS or fractional flow reserve procedures, or structural heart disease procedures. These changes affect coronary angioplasty, atherectomy and stenting procedures. All of the codes used for these procedures through Dec. 31, 2012, (listed in Table 1) will be replaced on Jan. 1, 2013, with the new codes (Table 3).
Conclusion
With the number of PCI codes more than doubling, the complexity of coding interventional procedures will increase. Already, coding personnel are seeking guidance from SCAI and ACC on how to code various complex coronary interventions. Additional information is available in the AMA’s CPT manual (see reference). Information is available from both SCAI and ACC. As is always the case, adequate documentation will be important, particularly when claims are rejected and must be appealed.
In summary, with CMS requiring revaluation of coronary intervention codes, SCAI and ACC developed a new and improved set of PCI codes that will allow better reimbursement for more complex codes, mitigating the inevitable decrease in reimbursement for the simplest PCI codes. Interventionalists and coding personnel must become familiar not only with the new codes themselves but also with the complex coding policies listed in the CPT manual that governs the appropriate use of these new codes.
Disclosure: Blankenship and Kavinsky report no relevant financial disclosures.