What has the ACR been doing to obtain new CPT codes for contrast-enhanced ultrasound?
The College is working strategically to ensure fair reimbursement.
As chair of the ACR Economics Committee on Coding and Nomenclature, I hear from members almost daily since the FDA-approved IV contrast use in liver ultrasound last year.
This innovation can benefit our patients in many ways, and we know the ultrasound community is anxious to bring the latest technology to the bedside. Chair of the ACR Board of Chancellors James A. Brink, MD, FACR, has kindly allowed me to take over his regular column to update our members on the progress toward obtaining current procedural terminology (CPT)TM codes.
You can be sure that a lot of work has been going on regarding contrast-enhanced ultrasound since FDA approval. We have a workgroup of CPT advisors from the ACR, American Roentgen Ray Society (ARRS), RSNA, Association of University Radiologists (AUR), and American Institute of Ultrasound in Medicine (AIUM) working on this effort with input from the Society of Radiologists in Ultrasound (SRU), Society of Pediatric Radiologists (SPR), and International Contrast Ultrasound Society (ICUS).
To assign a Category I CPT code, the CPT Editorial Panel requires procedures to meet specific criteria. The threshold is well above that of FDA approval. The specific criteria can be found at the beginning of the CPT code book in the introduction (see page xiv of the CPT 2017 Professional Edition). We have no doubt that contrast-enhanced ultrasound meets the newer, more stringent literature requirements to obtain Category I CPT codes. What we are working on now is the “frequently performed” requirement, which states, “The procedure or service is performed with frequency consistent with the intended clinical use (i.e., a service for a common condition should have high volume, whereas a service commonly performed for a rare condition may have low volume).”
Over the past few years the CPT Editorial Panel has been very cognizant of the “frequently performed” requirement and has been stringent in its assessment when CPT advisors seek creation of a Category I CPT code. The panel expects a procedure or service to be widely performed in clinical practice (as opposed to research-directed utilization) at many facilities across the U.S. in order to receive approval for a Category I code.
We all understand that this situation is a bit of a Catch-22. Utilization doesn’t typically increase without a CPT code, yet the CPT Editorial Panel won’t approve new codes until clinical utilization increases. The problem is that once we submit a proposal for a code, it is out of our hands. The CPT Editorial Panel will determine if it meets the Category I criteria. If the panel determines it doesn’t, the proposal will be rejected altogether or assigned a Category III CPT code. Category III CPT codes are reserved for new or emerging technologies and are used to track utilization until services are performed with sufficient frequency (or the literature matures, which is not an issue here) to warrant Category I CPT codes. Because Category III codes are not valued by the Relative Value Scale Update Committee (which advises CMS on the relative value of services under the Medicare physician fee schedule), payment for the service is at the discretion of the individual payers. The rub here is that most Medicare contractors and private payers don’t pay for Category III codes, so we work hard for Category I code status whenever possible.
We all understand that this situation is a bit of a Catch-22. Utilization doesn’t typically increase without a CPT code, yet the CPT Editorial Panel won’t approve new codes until clinical utilization increases.
The ACR, ARRS, RSNA, and AUR CPT advisors have been actively working with the ACR Commission on Ultrasound since FDA approval. In the fall and winter, we brought in the AIUM, SRU, ICUS, and SPR. (SPR is employing ultrasound contrast for some really exciting non-vascular uses, such as ultrasound cystourethrograms.) Our workgroup spent many hours working on a survey that we recently sent to as wide an audience as possible so that we can gauge the number of cases currently performed in clinical practice across the country. Furthermore, the survey includes questions pertinent to the current procedures in which ultrasound contrast is used and the clinical workflow around these cases. Hopefully you took the time to fill out the survey if you received it. If you have it and have not completed it, please do so as soon as possible. We hope to get a very robust response. Obviously, solid data showing that indeed these exams are widely performed across the country at multiple institutions will be very persuasive when we argue to the CPT Editorial Panel that these exams deserve Category I codes.
Ensuring fair reimbursement for the high-value services that radiologists perform for our patients is the value proposition of the ACR.
In 2017, CPT Editorial Panel meetings take place in February, June, and September. Any codes accepted at any one of these meetings will go into effect in 2019 (based upon normal cycle time for code implementation). From our perspective, the September meeting gives us the best chance of success because we suspect that utilization of these procedures is rising quickly. The longer we can wait to submit for the 2019 cycle, the greater chance of sufficient utilization for Category I success. The deadline to submit for the September meeting is in June, so we need the data from our survey in May so that we have enough time to craft the code proposal. We believe the results of the survey will demonstrate sufficient utilization of these procedures across the country so that we can move forward in a successful manner for our members.
When you or your partners ask, “What has the ACR done for me lately?” consider the following: A process like this has already taken hundreds of staff and volunteer hours, and it will consume many more before we reach the finish line. While this is truly a multi-society effort, the ACR has coordinated all of the calls, emails, and work to date based on our scope and unique experience with the CPT process. The College also has a team of dedicated staff to assist. Further, once codes are approved by the CPT Editorial Panel, the next step is to present those new codes at the RBRVS Relative Value Update Committee so that relative value units can be assigned. Again, this is a forum in which ACR has unique strengths and experience, including expert physician volunteers (led by Kurt A. Schoppe, MD), to ensure that the value assigned to these codes is appropriate for the effort and intensity associated with performing them. Ensuring fair reimbursement for the high-value services that radiologists perform for our patients is the value proposition of the ACR. It’s yet another reason every radiologist in the country should belong to this organization. If you have a colleague who has not chosen to be a member, please share this column.
By Mark D. Alson, MD, FACR, RCC, Chair of the ACR Economics Committee on Coding and Nomenclature and ACR CPT advisor