Radiology Coding Alert

You've got to take the good with the bad in CMS's latest round of releases. The proposed physician fee schedule is sure to make you tighten your belt, but proposed changes to MRI coverage may give you added reimbursement to look forward to. Add to that the final ICD-9 2010 rule and you've got plenty of items on your "must watch" list. Here's a quick look at these recent releases.

CMS is projecting a record 21.5 percent rate cut with a proposed conversion factor decrease from 2009's $36.0666 to $28.3208, states the proposed 2010 Medicare Physician Fee Schedule (MPFS), in the July 13 Federal Register (http://edocket.access.gpo.gov/2009/E9-15835.htm).

And so begins the annual wait to see if Congress will step in to soften the blow.

But the conversion factor isn't the only item you need to keep an eye on. Remember that Medicare calculates payment by multiplying a code's assigned relative value units (RVUs) by the conversion factor and adjusting the total for your geographic location. The proposed rule (Table 39) indicates that radiologists can expect practice expense and malpractice RVU changes to drop reimbursement 11 percent (10 percent for interventional).

Table 40 reveals deeper cuts for several services: 32 percent for global 71010 (Radiologic examination, chest ...) and 29 percent for global 77057 (Screening mammography, bilateral ...), for example.

Red alert: Diagnostic testing facilities can expect a 24 percent overall decrease because of a proposed expensive equipment utilization rate change. The gist is that if CMS assumes centers use their equipment more often, then CMS will decrease the equipment costs it allocates to these services. In other words, CMS will reduce practice expense RVUs for CT, MRI, and other services associated with equipment that costs $1 million or more.

Another MPFS bombshell: For 2010, CMS also plans to end payment for consult codes. Instead of reporting consult codes, you'd report new or established patient office visit or hospital care (E/M) codes for these services, and CMS would increase payments for the existing E/M codes.

To determine the impact of this change, you'd have to compare the reimbursement from the new fee schedule office visit fees vs. the current office consult fees, as well as the new hospital visit E/M charges vs. the current hospital consult fees, says Quinten A. Buechner, MS, MDiv, CPC, ACS-FP/GI/PEDS, PCS, CCP, CMSCS, president of ProActive Consultants in Cumberland, Wis. A rough calculation shows that planned additional E/M payments may not cover the loss of consult money.

By September's end, CMS should declare whether CMS will allow coverage of your MRI for blood flow claims. Currently, Section 220.2 of the National Coverage Determination (NCD) manual lists blood flow measurement in the nationally non-covered indications. As a result, Medicare hasn't covered the following codes:

• 75558 -- Cardiac magnetic resonance imaging for morphology and function without contrast material; with flow/velocity quantification

• 75560 -- ... with flow/velocity quantification and stress

• 75562 -- Cardiac magnetic resonance imaging for morphology and function without contrast material(s), followed by contrast material(s) and further sequences; with flow/velocity quantification

• 75564 -- ... with flow/velocity quantification and stress.

CMS invited public comment on the coverage analysis, and many comments echoed those of Erik Schelbert, MD, cardiovascular magnetic resonance director for the University of Pittsburgh: "As the Letter from the various Colleges and Societies clearly attests, CMR measurements of flow are absolutely necessary for assessment of patients with valvular heart disease and congenital heart disease."

Watch your contractor's policy: The proposed decision memo acknowledges that evidence does not support blanket noncoverage. If CMS removes "blood flow measurement" from the nationally noncovered list, your individual contractors will be responsible for deciding coverage. MRI coverage for patients with pacemakers isn't looking as good, though. In the same proposed decision memo, CMS states that after considering a request from Medtronic for a change, CMS plans to maintain its policy that MRI "is not covered for patients with cardiac pacemakers or with metallic clips on vascular aneurysms."

Resource: Links to open coverage analyses are available here: www.cms.hhs.gov/mcd/index_list.asp.

3. Add 1 More Change to Embolism ICD-9 Update

Radiology Coding Alert, Vol. 11, No. 9, covered the proposed ICD-9 code changes for 2010. Now the final list is out, so be sure you note the differences that matter most for your practice:

• Proposed: 209.75 -- Merkel cell carcinoma, unknown primary site

• Final: 209.75 -- Secondary Merkel cell carcinoma.

• Proposed: V10.90 -- Personal history of unspecified type of malignant neoplasm

• Final: V10.90 -- Personal history of unspecified malignant neoplasm.

The final rule also added a revision:

• 2009: 453.2 -- Other venous embolism and thrombosis; of vena cava

• 2010: 453.2 -- Other venous embolism and thrombosis; of inferior vena cava.

This change clarifies that 453.2 is not appropriate for the superior vena cava, the large vein which returns blood to the heart from the head, neck and both upper limbs. The inferior vena cava instead returns blood to the heart from the lower body.

Resources: You can find the final list of codes at www.cms.hhs.gov/ICD9ProviderDiagnosticCodes/07_summarytables.asp.

And the addendum is available at www.cdc.gov/nchs/datawh/ftpserv/ftpicd9/ftpicd9.htm.