HR 5238 Introduced to Repeal DRA Imaging Reimbursement Cuts
PRODUCT SPOTLIGHT: IR Coding Application Is Web-Enabled
Biggest Payor at Risk, Estimates Show
Nursing Service Fees Reinstated; Moderate Sedation Codes Change
LEGAL AFFAIRS: CAD and the Law
CMS Web Site Creates Easier Access
The Bill Box

HR 5238 Introduced to Repeal DRA Imaging Reimbursement Cuts

Lobbying efforts are starting to pay off for organized radiology. At the end of April, Rep Carolyn McCarthy (D-NY) introduced HR 5238, a bill that would repeal the cuts to imaging reimbursement set forth by the Deficit Reduction Act of 2005 (DRA).

The DRA, set to go into effect January 1, 2007, calls for the technical component reimbursed under the Medicare Physician Fee Schedule (MPFS) to be paid at either the Hospital Outpatient Prospective Payment System or the MPFS, whichever is lower. According to the American College of Radiology (ACR), Reston, Va, the imaging services most likely to feel the brunt of cuts include MRI, MR angiography, CT, CT angiography, nuclear medicine, and ultrasound. On top of the DRA, CMS has reduced its reimbursement for imaging contiguous body parts: 25% this year, and another 25% in 2007.

“We support anything that either repeals or delays the implementation of the imaging provisions,” said Cindy Moran, assistant executive director for government relations and economic policy at the ACR. “[HR 5238] is a very straightforward bill, because it just strictly repeals the two provisions that were in the DRA regarding imaging reimbursement.”

Currently, HR 5238 does not have any sponsors, and Moran said that she is not aware of anyone in the industry working with McCarthy on the bill, including the ACR. “The College is a member of a broad-based coalition with other medical specialties and industry representatives,” she said. “It’s a coalition that is really very active and very adamant about trying to reverse those policies, or at least delay them in the DRA.”

Moran added that other actions have been at work as well to bring attention to the DRA, including a “Dear Colleague” letter from House Republicans that was sent to House Speaker Dennis Hastert (R-Ill) in May; 38 House Republicans have signed the letter asking House leadership to revisit the DRA’s imaging provisions this year, including members of the two health committees in the House: the Ways and Means Committee, and the Energy and Commerce Committee. Moran said that the ACR will probably develop a “Dear Colleague” letter to House Democrats later this year.

“Members of Congress are hearing from radiologists, other physicians, and employees of the industry in their districts, and I think that this is really becoming a very visible issue and an issue of real concern,” she said. “Representatives from all geographic regions of the country, urban as well as rural, [have heard] that the imaging provisions in the DRA are not well-thought-out policy and that it needs to be revisited.”

—M. Saffari

PRODUCT SPOTLIGHT

IR Coding Application Is Web-Enabled

CodeRyte’s Web-enabled interventional radiology coding application features new enhancements.

CodeRyte of Bethesda, Md, has made significant improvements to its Web-enabled interventional radiology (IR) application so that users can further facilitate, manage, and appropriately maximize the IR coding process. The application uses natural language processing (NLP) technology to process a physician’s free text to ensure better and more efficient coding. Improvements to the application include detailed, anatomically accurate diagrams of the male and female circulatory systems so users can visualize catheterization from beginning to end. The diagram, which also serves as a coder’s reference tool, is now integrated directly into the coding form. Other new features include allowing coders to support code assignments with text evidence identified directly from the medical reports; providing coders with a list of terms from which to choose (once they type in letters to identify the appropriate term); and enabling coders to print the highlighted vascular diagram to retain for documentation of the bill, to communicate with the physician, or to use for educational purposes. CodeRyte also made improvements to the ergonomics and layout of the graphical user interface. For information, call (301) 951-5300 or visit www.coderyte.com.


Source: A Summary of the 2006 Annual Social Security and Medicare Trust Fund Reports. Available at: http://www.ssa.gov/OACT/TRSUM/tr06summary.pdf. Accessed May 17, 2006. (Click the images for a larger version.)

Biggest Payor at Risk, Estimates Show

According to the estimates detailed in “A Summary of the 2006 Annual Social Security and Medicare Trust Fund Reports,” the Hospital Insurance (HI) trust funds are failing the trustees’ test of short-range (2006–2015) financial adequacy. The estimates show that the HI funds will drop below the level of 2007 expenditures by 2012. On the other hand, both the Old-Age and Survivors Insurance (OASI) and the Disability Insurance (DI) trust funds are considered financially adequate throughout the short range, though long-range prospects are less rosy.

Nursing Service Fees Reinstated; Moderate Sedation Codes Change

The American Healthcare Radiology Administrators (AHRA), Sudbury, Mass, recently presented an audio Web conference updating members on radiology coding and its impact on reimbursement. John Marshall, CRA, RCC, RT(R), a radiology consultant with Coding Strategies Inc, Powder Springs, Ga, gave a detailed account of new billable procedures, the good news/bad news in reimbursement, and how 2007 looks to be uncertain because of reimbursement cuts from the Deficit Reduction Act of 2005 (DRA) and CMS’s reduction in reimbursement for the technical component in imaging contiguous body parts. Look for periodic coverage of this conference in upcoming issues of Axis Imaging News, starting with nursing service fees and moderate sedation codes.

First, CMS has reinstated some nursing service fees that are now billable procedures. However, Marshall stressed, “These services must not be routine procedure protocol. It requires a specific patient clinical indication.” In other words, for those specialized patients who need to be hydrated several hours before a procedure, the infusion for hydration can be billed per hour. The first hour is billed to Medicare as C8950 and pays $120.77. The fluids given are billed separately. For private insurers, those patients should be billed under 90760, and payment varies. Each additional hour is billed as C8951 under Medicare and is paid $0; 90761 is used for private insurers.

The second item in radiology nursing services is billing for more than one IV push for reasons not directly related to the procedure. The billable code for the first IV push for Medicare is C8951 and pays $47.82; the code for private insurers is 90774. For each additional IV push, it is C8952-59 for Medicare (paying $47.82) and 90775 for private insurers.

Marshall said that two new codes have been established for those patients requiring a Foley catheter for a clinical condition. The first is a simple catheter insertion, where a Foley catheter is inserted in the traditional manner—obtaining a catheter kit, inserting the catheter, hooking it up to the bag, etc. This procedure is billed as 51702, and Medicare pays $36.52. The second method is a complex catheter insertion, where—because of the patient’s anatomy or a clinical condition—the insertion requires a physician’s expertise. This procedure is billed as 51703, and Medicare pays $69.03.

Next, Marshall discussed moderate sedation. The old codes—99141 and 99142—no longer exist. With moderate sedation, it is now a “status in,” meaning it is packaged and not paid on the hospital side. There is > no technical reimbursement on the imaging center side. If it is billed separately, it is billed on the physician side. Some payors under Part B are not reimbursing physicians for it. Marshall said the key is that it is a status C, which means carrier priced on the physician side, and that it must be checked with a physician’s carrier to see if it pays separately for this procedure.

If moderate sedation is going to be billed, three factors need to be examined: Is the person over or under the age of 5? Who provides the service? What is the duration of the service? Service duration starts when the sedative or medication is administered; it ends when the patient is physiologically stable, and the face-to-face time with the physician is no longer required, Marshall explained. Service duration does not include recovery time. The three billing codes are: 99143, moderate sedation for the first 30 minutes for a patient under the age of 5; 99144, moderate sedation for the first 30 minutes for a patient over the age of 5; and 99145, moderate sedation for each additional 15 minutes.

If a second physician is performing the moderate sedation, he or she is billed under different codes: 99148, moderate sedation for the first 30 minutes for a patient under the age of 5; 99149, moderate sedation for the first 30 minutes for a patient over the age of 5; and 99150, moderate sedation for each additional 15 minutes.

—M. Saffari



LEGAL AFFAIRS: CAD and the Law

By Dana Hinesly

To keep or not to keep—in today’s world of inexhaustible digital images, that is the question. The increasing use of computer-aided detection (CAD) for review of medical images creates a myriad of interesting legal issues, not only in what images should be kept but also in the weight they hold in future lawsuits.

“CAD itself cannot offer testimony; it is allowed into evidence to support expert testimony and as part of the basis for the testimony,” said R. James Brenner, MD, JD, chief of breast imaging and professor of radiology, University of California, San Francisco. Brenner cites the Supreme Court decision in Daubert v Merrill Dow Pharmaceuticals, which found that if the judge admits scientific evidence for a jury to consider, the protection against its potential prejudicial value is a rigorous cross-examination. “The issue is whether CAD’s probative value is sufficient to override its potential prejudicial value,” Brenner said.

Because it is impossible to cross-examine a CAD system, the relevance of CAD as scientific evidence is only in support of expert testimony, and it does not extend beyond that, he added.

This issue was addressed by the 2004 appellate decision on Gray v Fairview General Hospital, in which negative CAD results were introduced by the defense to help validate the radiologist’s decision for not recalling the patient.

An article coauthored by Brenner and published in the January issue of the American Journal of Roentgenology stated the case determined that “CAD was not advocated as a standard of care but rather as a technology sufficient to support the reliability and probative value of a defense expert’s testimony that referred to its results.”1

Precedent was set not only by CAD’s role in the proceedings, but because the technology was presented by the defense. “CAD had more impact in terms of supporting the defense witness’s testimony that the [questionable] calcifications were sufficiently subtle that they didn’t necessarily, in the standard of care, require recall,” Brenner said. “As a prior study that I was involved in a couple of years ago pointed out, the fact that CAD marks [something] is not tantamount to prompting a recall.”

The case also bolsters Brenner’s position that physicians are best served by maintaining an archive of all images, including those produced by CAD systems. While Brenner acknowledged the concerns that some clinicians have about the prejudicial value of a CAD mark in an area that was not recalled and later became malignant, he noted that CAD algorithms are intentionally designed so the majority of marks will be discarded.

“Studies often report a CAD find, even if CAD sees or marks something in only one view, which is insufficient for diagnostic purposes,” Brenner said. Conversely, he added that CAD is intended for use only as a detection aid to help a radiologist. “Ultimately, if something needs to be recalled, then it needs to be recalled—whether or not CAD marks it.”

Because of this reality, the bottom line for radiologists is that discarding CAD images does not eliminate legal liability and could actually work to the clinician’s detriment.

“The more direct issue is whether or not the physician is concerned about potential downstream liability,” Brenner said. “The discarding of that information could be seen as a spoliation of evidence—and a jury is, in general, very offended by the concept of evidence spoliation—so the better thinking is to keep the CAD overlay.”

Hanging on to CAD images also could prove beneficial as the technology continues to improve. In 5 years, a CAD program might be capable of detecting different abnormalities than today’s systems; however, in court, physicians are held only to the current standard of care.

Reference

1. Brenner JR, Ulissey MJ, Wilt RM. Computer-aided detection as evidence in the courtroom: potential implications of an appellate court’s ruling. AJR Am J Roentgenol. 2006;186:48–51.


CMS Web Site Creates Easier Access

The Centers for Medicare and Medicaid Services (CMS) has redesigned its Web site, www.cms.hhs.gov, creating eight main locations to obtain information: Medicare; Medicaid; State Children’s Health Insurance Program; About CMS; Regulations and Guidance; Research, Statistics, Data, and Systems; Outreach and Education; and Resources and Tools.

Find information regarding the Health Insurance Portability and Accountability Act of 1996 (HIPAA) by clicking on the Regulations and Guidance category and then find the HIPAA Administrative Simplification section.



The Bill Box

California Challenges Per-Click

The California Radiological Society (CRS), Sacramento, Calif, is supporting Assembly Bill (AB) 2805, introduced on February 24, and targeted at ending sham lease arrangements between physicians and imaging facilities—better known as “per-click” arrangements that allow physicians to refer patients to imaging facilities where they or their physician groups lease time on diagnostic imaging equipment.

The society maintains that the fees function more like a discounted rate for using the equipment, and the physicians then can pocket the difference between this rate and the higher technical component reimbursement they receive from payors.

If passed, AB 2805 would prohibit physicians from using the in-office exception to the state’s version of the federal Stark laws when they lease time on equipment that they do not own. CRS Executive Director Bob Achermann reported that the bill has had a hearing in the Assembly Business and Professions Committee and the Assembly Health Committee and is currently being reviewed by the Assembly Appropriations Committee to assess impact on the California budget.

As a “1-year” bill under California law, AB 2805 is fast approaching its deadline to come out of committee, and at press time, Achermann predicted “a slow and painful death” for the bill.

“Obviously, there is strong opposition by the orthopedists and the cardiologists,” Achermann said. “It was passed by both committees with the proviso that the author would hone in on their objections.”

According to Achermann, the other specialty societies want to preserve the lease arrangement safe harbors outlined by the Office of Inspector General. Although Achermann is not optimistic about a legislative solution, he said that the bill has raised the profile of the issue with payors in California.

“As this bill has meandered through the legislature, we are receiving more support from the health plans that are seeing the increase in utilization and seeing the proliferation of these arrangements …. If a legislative solution is not fashioned, I think you will see payors devise a solution, and that may be more effective than any legislation.”

Time Running Out for Massachusetts Self-Referral Fix

The Massachusetts legislature is considering a bill that would ban physicians from referring patients to non-hospital-based providers of positron emission tomography (PET), MRI, and radiation treatment if the physician or group has an ownership or investment stake in the facility. Introduced by State Rep Paul Kujawski (D-Webster, Mass) in early 2005, House Bill 2711 exempts radiologists and physicians employed by a hospital or hospital affiliate, as well as facilities that were providing these services prior to June 15, 2004. If passed, violation of the law could result in fines of $25,000 to $100,000. The bill received a hearing in November and is under review by the Committee on Public Health. In order to become law, it must be referred out of committee and voted on before July 31, 2006.

RA Bill on Governor’s Desk

If the governor signs the Radiological Personnel Certification Act, Florida will join the three other states that regulate the physician extender for radiologists. The bill specifies educational requirements and fees, and it includes a requirement for clinical preceptorship with a radiologist. Because the radiologist assistant (RA) will be required to have at least a bachelor’s degree, compensation for this position could exceed that of a radiologic technologist.

In 2005, six universities offered radiologist assistant educational programs. Graduates of these programs are allowed to sit for the RA certification examination administered by the American Registry of Radiologic Technologists (ARRT).

Under the new legislation, the scope of practice for an RA must be adopted by rule and be consistent with the national scope of practice—adopted by the American College of Radiology, the American Society of Radiologic Technologists, and the ARRT—which restricts RAs from interpreting images, making a diagnosis, or prescribing medications or therapies. RAs assist radiologists in performing arthrograms, upper and lower gastrointestinal tract examinations, and placements of feeding tubes and central venous catheters.

C. Proval