Radiology Coding Alert

Find out which CPT^® codes could see a value increase on January 1.

The Centers for Medicare and Medicaid Services (CMS) released the calendar year (CY) 2023 Physician Fee Schedule (PFS) proposed rule on July 7, 2022, and at a whopping 2,066 pages, the document is a wealth of proposed additions, deletions, and revisions.

Learn how the proposed CY 2023 PFS could affect radiology practices’ bottom line and which codes may see adjusted values if the rule is finalized.

Will Radiology Specialties Feel the Burden of a Decreased Conversion Factor?

When compared to the CY 2022 conversion factor (CF) of $34.6062, the estimated CY 2023 CF of $33.0775 is a $1.5287 decrease. CMS calculated the decrease by removing the one-year 3 percent increase provided by the CY 2022 Protecting Medicare and American Farmers from Sequester Cuts Act followed by implementing a negative 1.55 percent budget neutrality adjustment.

If the proposed provisions are finalized, radiology specialties could experience an estimated overall impact of:

• Radiology: 3 percent decrease
• Interventional radiology: 4 percent decrease
• Nuclear medicine: 3 percent decrease
• Radiation oncology: 1 percent decrease
• Radiation therapy centers: 1 percent decrease

A portion of the decreases is due to the second year of the transition to clinical labor pricing updates as well as adjustments in relative value units (RVUs).

“The proposed decrease would negatively impact the reimbursement for radiology practices. As reimbursement decreases, the cost of doing business increases and could lead to practices being more selective on the exams they perform and the patients they accept,” says Kristen Taylor, CPC, CHC, CHIAP, associate partner of Pinnacle Enterprise Risk Consulting Services.

Understand How Specific Services Are Valued

As an integral part of the PFS, establishing values for new or revised CPT^® codes is crucial to ensuring proper reimbursement for services.

Background: RVUs are used to establish the value of a procedure or service compared to all services and procedures. RVUs help determine compensation for the provider when the CF is applied to (multiplied by) the total RVUs.

Work RVUs are one type of RVU that represent the provider’s work when performing a procedure. Work RVU variables include amount of time required to perform the procedure, physical effort, mental effort, and technical skills. Each year, the AMA’s Specialty Society Relative Value Scale Update Committee (RUC) makes recommendations to CMS regarding RVUs for new, revised, and possibly misvalued codes.

CMS examines these recommendations and then accepts, revalues, or disagrees with the RVUs, publishing results in the PFS. In the CY 2023 PFS, CMS acknowledged 10 CPT^® codes pertaining to radiology.

Gear Up for Adjusted Guidance RVUs

CMS is proposing to accept the values for codes that pertain to contrast X-rays of the knee joint, 3D rendering and interpretation, fluoroscopic guidance, and ultrasound guidance.

For 73580 (Radiologic examination, knee, arthrography, radiological supervision and interpretation), CMS is proposing to accept the RUC-recommended work RVU of 0.59, which would be an increase from the current RVU of 0.54. Code 73580 was first identified in 2008 via the high-volume growth screen, and, in 2021, the Relativity Assessment Workgroup (RAW) recommended the code be surveyed since it never was previously. CMS is proposing the increased RVU “to make up for the lack of growth screen since 2008,” says Amy C. Pritchett, AAPC Fellow, BSHA, CCS, CPC, CPC-I, CANPC, CPMA, CASCC, CDEO, CRC, CPMP, CMPM, CMRS, CEDC, C-AHI, Approved ICD-10-CM/PCS Trainer, senior consultant of Pinnacle Healthcare Consulting.

In the CY 2020 PFS final rule, CMS nominated 76377 (3D rendering with interpretation and reporting of computed tomography, magnetic resonance imaging, ultrasound, or other tomographic modality with image postprocessing under concurrent supervision; requiring image postprocessing on an independent workstation) “as potentially misvalued,” and is proposing the RUC-recommended work RVU of 0.79.

For 76942 (Ultrasonic guidance for needle placement (eg, biopsy, aspiration, injection, localization device), imaging supervision and interpretation), CMS is proposing the RUC-recommended work RVU of 0.67. For add-on codes +77002 (Fluoroscopic guidance for needle placement (eg, biopsy, aspiration, injection, localization device) (List separately in addition to code for primary procedure)) and +77003 (Fluoroscopic guidance and localization of needle or catheter tip for spine or paraspinous diagnostic or therapeutic injection procedures (epidural or subarachnoid) (List separately in addition to code for primary procedure)), CMS is proposing the RUC-recommended work RVUs of 0.54 and 0.60, respectively.

Neuromuscular Ultrasound RVUs Need Further Revisions

While CMS proposed the acceptance of values of the codes listed above, the agency proposed further adjustments for other codes, which include neuromuscular ultrasound CPT^® codes.

CMS disagrees with the work RVUs recommended by the RUC for the following CPT^® codes:

• 76881 (Ultrasound, complete joint (ie, joint space and peri-articular soft-tissue structures), real-time with image documentation)
• 76882 (Ultrasound, limited, joint or other nonvascular extremity structure(s) (eg, joint space, peri-articular tendon[s], muscle[s], nerve[s], other soft-tissue structure[s], or soft-tissue mass[es]), real-time with image documentation)
• +76XX0 (Ultrasound, nerve(s) and accompanying structures throughout their entire anatomic course in one extremity, comprehensive, including real-time cine imaging with image documentation, per extremity)

The RUC recommended work RVUs of 0.90 for 76881, 0.69 for 76882, and 1.21 for +76XX0, but CMS indicates that the values “do not account for the surveyed time changes or the appropriate comparisons for the new add-on code.” (Note: +76XX0 uses placeholder Xs, and you should check the final code set for the official code numbers when they become available.)

According to the CY 2023 PFS proposed rule, the RUC discussed and noted that 76881 is an imaging-specific CPT^® code, so the physician work detailed in the descriptor wouldn’t overlap with an evaluation and management (E/M) service. In the proposed rule, CMS states that 99214 (Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and moderate level of medical decision making. When using time for code selection, 30-39 minutes of total time is spent on the date of the encounter.) is the most common E/M code reported with 76881, and includes “Review interval correspondence, referral notes, medical records, and diagnostic data generated since that last visit.”

CMS also identifies how the post-service work for 76881 is similar to what is included with 99214’s post-service work:

• 76881: “Discuss significant findings with the referring physician, review and final report. Review and sign final report.”
• 99214: “Arrange diagnostic testing and referral if necessary, document the encounter in the medical record, spending time to further refine the differential diagnosis, workup, or treatment plan as necessary; coordinate care by discussing the case with other physicians of the health care team and write letters of referral if necessary (review and analyze interval testing results and refine the differ­ential diagnosis, workup, and treatment plan based on these results and communicate results and plan modifi­cations with patient and/or family.”

After examining the descriptions and what’s included for the two codes, “CMS disagreed with the RUC recommendations, as the descriptions of the pre- and post-service work directly overlap. Therefore, CMS is proposing 0 minutes for the pre-service and post-service time, as opposed to the RUC recommendations of 5 minutes for pre-service and post-service time,” Pritchett says.

As a result, CMS is proposing the work RVUs for 76881, 76882, and +76XX0 as 0.54, 0.59, and 0.99, respectively.

In October 2021, the CPT^® Editorial Panel approved the addition of +76XX0, which permits you to report the “real-time, complete neuromuscular ultrasound of nerves and accompanying structures throughout their anatomic course, per extremity.” The Editorial Panel also added “focal evaluation” to 76882’s descriptor during the same meeting.

Comment period open: CMS will accept comments on the proposed rule until 5 p.m. on Sept. 6, 2022.

Note: Review the full CMS Proposed Rule at www.federalregister.gov/documents/2022/07/29/2022-14562/ medicare-and-medicaid-programs-cy-2023-payment-policies-under-the-physician-fee-schedule-and-other.