Re-valuation: Examining the Economic Impact of New CPT Codes

Developing a new CPT code is hard. And as the number of minimally-invasive therapeutic options available to interventional radiologists continues to multiply, despite clear proof of improved efficacy (in the setting of improved technical capabilities of physicians), the challenges for crafting codes that accurately capture the degree of physician work, and practice expense associated with these procedures is becoming increasingly complex.

But why is it hard? Can’t you just apply for a new code once a new technology is developed and start getting paid? 

Not really. 

Understanding the code development process- and using percutaneous ablation procedures as a case example- might help to elucidate some of the challenges.

There are a few basic requirements to understand up front: 1) A certain amount of literature is required to get a Category I (Cat1) CPT code. Without it, no code. No code = no payment. 2) The procedure must be performed by many physicians across the United States. 3) The procedure must be performed at a reasonable frequency within the patient population for which it was intended.

If a procedure does not meet the criteria for a Cat1 code, it may be eligible for a category III code, which can be helpful for tracking the frequency with which the procedure is being performed, despite not being reimbursed.

Currently, some of the existing Cat1 percutaneous ablation codes include RF and cryoablation in the liver, kidney, and bone. There is a Cat1 percutaneous RF ablation code for pulmonary tumors, as well. What is conspicuously missing is percutaneous pulmonary cryoablation, which is being performed across the United States. And despite coding guidance clarifying that microwave ablation is part of the RF spectrum and should be reported with radiofrequency ablation codes, some payers are not paying for microwave ablation as there are no microwave-specific ablation codes. Lastly – irreversible electroporation is a novel ablation technique with a growing of body of literature supporting its use in certain scenarios. The bottom line is that there are a number of established and budding ablative technologies that are not being (or going to be) reimbursed in the current coding milieu.[[{"type":"media","view_mode":"media_crop","fid":"42421","attributes":{"alt":"","class":"media-image media-image-right","id":"media_crop_9450852386728","media_crop_h":"0","media_crop_image_style":"-1","media_crop_instance":"4588","media_crop_rotate":"0","media_crop_scale_h":"0","media_crop_scale_w":"0","media_crop_w":"0","media_crop_x":"0","media_crop_y":"0","style":"border-width: 0px; border-style: solid; margin: 1px; float: right;","title":"C. Matthew Hawkins, MD","typeof":"foaf:Image"}}]]

So, should our specialty societies just apply for new Cat1 codes for all of these ablation techniques in the organs in which they are being used? Should we get a liver microwave ablation code, a pulmonary cryoablation code, and a pulmonary microwave ablation code? Sounds great, right? Then everyone that is performing these procedures might get reimbursed appropriately for the work being done and the equipment being used. Physicians would be happy, hospitals would be happy, and vendors can begin to reap their return on investment.

But, chew on this possibility for a minute. Let’s say we craft and propose a Cat1 CPT code for pulmonary cryoablation – which, for all intents and purposes seems appropriate based on the frequency of use and supporting literature. And let’s assume that the code is approved by the AMA’s CPT Editorial Panel.

Once approved, a new code must then be surveyed by the specialty societies in order to assess the amount of work involved in performing a procedure, as compared to existing CPT codes. The results of these surveys inform the RUC, which then submits recommendations to CMS about what the valuation of the code should be. But, precedent exists from the RUC (who determines relative value for all CPT codes) to ask that when a new code is introduced, that the entire family of codes be resurveyed and revalued. And let’s not forget that by “revalue” – the RUC and CMS actually mean “devalue”.   

So in the instance of pulmonary cryoablation, what is considered the family? Should only pulmonary RF ablation be resurveyed? That seems most sensible. Or should all percutaneous ablation codes be resurveyed? Remember, this is not the choice of our specialty societies. If all percutaneous ablation codes are resurveyed – it is exceedingly unlikely that current reimbursement will be preserved. And if imaging guidance is currently not bundled into the CPT code – you can bet the ranch that after resurveying and revaluing, it will be bundled. While it is likely that a Cat1 CPT code for pulmonary cryoablation can be attained – is it worth the risk of potentially decreasing valuation for existing CPT codes? Furthermore – will re-valuation appropriately account for the variation in practice expense associated with the different ablation technologies? Will what be lost be gained with new codes? Is the data that currently exists accurate enough to answer these questions?

The challenge is real, but not insurmountable. All is not lost. This scenario simply accentuates the necessity for accurate coding (so that coding data can be mined) and population of data registries (so that clinical outcomes can be tracked). Accurate claims and outcomes data allow our specialty societies the ability to study how often procedures for which an existing Cat1 code exists are performed, how often they are performed in hospitals versus outpatient facilities, and what the economic impact of “re-valuation” might be for the family – should a new Cat1 code be introduced.

If you haven’t audited the accuracy of your practices’ coding efforts – audit it. Make sure it is accurate. If you haven’t yet planned to enroll in the ACR’s IR registry – please register. Report your outcomes and resource utilization. Our specialty needs accurate data in order to make informed decisions about these complex scenarios.

These types of practice management issues – that impact the collective diagnostic and interventional radiology communities – will continue to be of heightened importance as we move into the era of mixed alternative payment models and incentive payments systems.