Radiology's Unlucky Number
Understanding the story behind CPT® Code 73721 and what it means for the future medical reimbursement.
CPT® code 73721, non-contrast lower extremity MRI, is the poster child for what has happened on the technical side to radiology reimbursement in the past seven years.
Leaving aside the egregious imposition of a multiple procedure reduction on the professional component for a moment, I want to focus on how the technical component (TC) reimbursement for outpatient practice has been devastated by a series of cuts.
In 2006, the technical component of this code was reimbursed at a rate of approximately $440 by Medicare to outpatient imaging centers. This year, that figure will be less than half — about $215. Outpatient hospital facilities are now reimbursed at a higher rate with the Hospital Outpatient Prospective Payment System (HOPPS) TC reimbursement for this code set at about $338.
As a result of these drastic cuts, the College has been inundated with members calling in disbelief. "How could the ACR let this happen?" they ask. "Does the ACR even care about the technical component? How can outpatient imaging centers stay in business at these reimbursement levels?"
The butchering of the TC has been multifactorial. It started with the 2006 Deficit Reduction Act, with equating outpatient reimbursement with HOPPS fees in 2007, and with the imposition of a TC multiple procedure reduction in 2006.
The next hit was from the disastrous Physician Practice Information Survey, which was conducted by the AMA in 2007 and 2008, ostensibly to gain a better understanding of the resources involved in providing surveys. The radiology responses were a poor representation of outpatient practices and, despite multiple efforts from the ACR to dismiss these results, a 14-percent decrease in TC reimbursement for radiology occurred. This decrease took place over four years, and now, in 2013, it's in full effect.
Another blow to the TC came with the adjustment of the interest-rate assumption that feeds into the reimbursement formula. Citing low market rates, in January 2013, CMS reduced this from the traditional 11 percent to rates that vary based on a variety of factors, effective immediately. Requests from ACR to transition this over several years fell on deaf ears.
But 73721 was even unluckier than some other services. It was also caught on a CMS screen as potentially misvalued because it had not been evaluated by the Relative Value Update Committee since 2001. During that review process, CMS fundamentally changed the rules based on assumptions about how the resources necessary for the provision of this service are paid for. Traditionally the MRI room was assumed to be dedicated to one patient at a time. CMS now says that it will only pay for the time that the patient is actually being imaged — it will not pay for the time that the technologist is going through essential safety precaution questions with the patient or the time that the technologist is using to reconstruct sequences and images, in spite of the fact that it is not possible to use the room for anything else during these activities. This resulted in a reduction of almost 50 percent in the room-time assumption for 73721.
This is the point we were at when the final rule was issued for the 2013 Medicare Physician Fee Schedule in November 2012. As you know from my column in February, the slashing was not finished. In late-night negotiations, Congress decided and eventually voted to increase the utilization rate assumptions for advanced imaging equipment from 75 percent to 90 percent. This is predicted to add another 10 percent cut to the TC for 2014.
If that has left you scratching your head, you're not the only one. CMS is now telling us that we use our equipment 90 percent of the time, yet it won't pay for anything except the actual imaging time. Seems like a double whammy to me.
Lest this seem like one long whine from the ACR commission specifically tasked with preventing these types of cuts, I will admit that it is frustrating for our dedicated staff and physician volunteers to fight so hard and see such negative impacts on our specialty despite their efforts. Could it be worse? Believe it or not, it could, and we continue to push back on further cuts such as the possible extension of the multiple procedure payment reduction (MPPR) to all imaging and its extension into the private-payer arena. Our team includes physicians from all types of radiology practice, and we recognize the inherent value of practice diversity in providing choice and the highest quality care for all our patients. We fight on all fronts to maintain reimbursement for radiology services wherever they are provided.
That said, we recognize that the conversation among policymakers and payers, both federal and commercial, is not about fee-for-service these days, and our expectations are realistic about what we can achieve with this type of approach. CMS does not believe there has been any meaningful decline in access to imaging services for beneficiaries, and in fact, there are now efforts to potentially target the HOPPS reimbursement levels and bring them down to those in the outpatient arena. We continue to dedicate significant ACR staff and volunteer resources to maintaining fee-for-service reimbursement while recognizing that this model will likely service as the basis for reimbursement in many integrated payment models. However, we have, of necessity, diversified our efforts to include legislative approaches such as decision support using the ACR's Appropriateness Criteria® and ACR Select™ products in value-based payment models as well as to force greater transparency and adherence to credible evidence from CMS.
Another important fact to recognize is that we are not the only constituency in health care that is under attack. Our cardiology and ophthalmology colleagues are just starting down the MPPR path with a TC MPPR imposed for 2013. Hospitals were dismayed to see that much of the savings used to fund the Sustainable Growth Rate extension were coming from hospital reimbursements. Right now, primary care physicians seem to be enjoying a honeymoon from reimbursement cuts. But unless the financial benefits of integrated care start to become apparent soon, our primary care colleagues may also be under scrutiny. The lesson to take from this is that we must find ways to to link arms with our fellow physicians and find similar goals that outweigh our differences if we are to ensure that those in charge of the health-care payment system recognize the value of all physician services.
By Geraldine B. McGinty, MD, MBA, Chair