The Path of CT Colonography Reimbursement

CHICAGO - CT colonography’s tale from development to reimbursement tells of a complicated, long and often grueling process. It’s also a reminder of the need for individual radiologists to get involved in political advocacy.

“Government action is defining radiology’s future in a variety of ways,” said Christopher G Ullrich, MD, FACR, who serves on the American College of Radiology’s economics commission and spoke on a panel Tuesday at RSNA 2012 that explored the complex path of CT colonography reimbursement.

Public policy is a political process, Ullrich said, and economic advocacy requires political advocacy.

Take for example Connecticut’s approach to coverage of CT colonography. After many negotiations, a bill passed that adopted the American Cancer Society’s guidelines for insurance coverage, which includes CT colonography and is a flexible standard (meaning it doesn’t limit coverage to a certain exam or procedure for colon screening), Ullrich explained.

CT colonography’s path has been a bit unusual, panelists explained. It started almost a decade ago when it was FDA approved. The procedure was initially assigned a category III CPT code, usually designated for emerging technologies.  The American College of Radiology continued to press for category I codes, which have higher thresholds and are recognized as distinct reimbursable services.

The radiology community went head-to-head with the gastroenterology community, which argued against the code for competitive reasons. Finally, the ACR prevailed in 2010 with a category I code.

However, that doesn’t guarantee reimbursement. CMS made a non-coverage decision for CTC screening in 2009, but recent studies could bolster the argument for reversing that. Meanwhile, several private payers are now reimbursing for CT colonography, albeit to varying degrees.

That arduous path for CT colonography demonstrates that making sure radiologists are appropriately reimbursed isn’t an easy task. Another glaring example is the multiple procedure payment reduction (MPPR), a 25 percent cut to the professional component for CT, MRI, and ultrasound imaging performed by one or more providers in the same practice on the same patient, during the same session on the same day. The MPPR, proposed in the 2013 Medicare fee schedule, is before lawmakers in the lame duck session of Congress.

“That permanently devalues radiology relative to other physician services,” said Ullrich.

There are also two bills that would postpone or reverse this cut, Ullrich explained. Reimbursement issues like this are where radiologists need to get involved to ensure the industry is properly represented, he argued. Get to know your local representative, he said,.

“It needs local physician activist involvement,” he said. “It’s part of the cost of doing business in our current economic world.”

Here’s how, according to Ullrich:

• Get to know your local representative. That local politician will one day be your senator or governor.

• Get involved with state medical societies, hospital government relations teams, and medical specialty societies.

• Try to get radiologists appointed to state government committees.

• Consider doing a payroll deduction for political action committee contributions. For example, $42 per member per month can add up to a sizeable amount each year. “Over time, this makes us politically visible,” he said.

• Designate people in your practice to go to events and know your local politician

• Pay certain organizational dues as business expenses. An individual in your group can opt out, but they can’t take that money; remember, it’s a business expense.

• Engage your group leadership and business manager in response plans so you are ready to respond when legislators reach out.

“If you’re not at the table,” Ullrich said, “you’re on the menu.”