Regional Reimbursement for Virtual Colonoscopy Varies

If you’re a radiologist in Chicago, you may actually be reimbursed for diagnostic virtual colonoscopies. In Seattle? Maybe not.

As nationwide utilization of computed tomographic colonography (CTC) has increased, regional payment denial rates vary widely, according to a new study in the April issue of the Journal of the American College of Radiology. This is the second study in recent weeks to examine the rise of CTC.

The regional payment disparities, however, can be good news, said lead author Richard Duszak Jr., MD. It’s an opportunity for physicians to advocate with their local Medicare carriers for reimbursement coverage.

“For physicians in these pockets [of the country] that are more restrictive, the hope is that they can continue their dialogue with their carrier medical director,” he said in an interview. “They can point out what their peers in other areas are doing, and hopefully level the playing field.”

Duszak referred to their study as a “glass half-full approach” to the expansion of CTC. To those less optimistic physicians, Duszak says times are changing, and though they might have struggled for payment a few years ago, it’s worth exploring again.

Here’s a look at some of the regional denial rates between 2005 and 2008. In Chicago, denial rates declined from 89.9 percent to 33.6 percent. Philadelphia’s denial rate dropped from 84.6 percent to 28.7 percent. Denial rates rose slightly in New York to 50 percent. Dallas had the highest overall denial rates at 68.5 percent, when aggregated over four years. The lowest four-year aggregate denial rates were found in Boston at 35 percent, researchers found.

Coverage decisions for CTC as a diagnostic tool - that is when it’s performed in the setting of signs or symptoms that night indicate disease -are made at the local carrier level. Screening services, however, are determined at a national level, and CTC as a screening tool is still not covered.

But Duszak said he is hopeful that the regional shifts “will create an environment that Medicare at a national level will be receptive of CT colonography for screening.”

Meanwhile, nationwide utilization has tripled. Between 2005 and 2008, annual claims for diagnostic CTC increased by 195 percent, from 3,660 to 10,802, researchers found. National denial rates also declined from 70 percent to 43 percent (which is still high if you compare that with abdominal CT, whose denial rate remained stable around 4 percent).

Still, all of these are positive signs, Duszak said. “Although regional variation exists,” the authors wrote, “coverage for diagnostic CTC, as reflected in reduced payment denials, continues to expand across the country. Physician awareness of their own regional coverage policies should facilitate that expansion.”