Local, State, Federal

The Bill Box
Medicare Proposes to Expand Coverage of Percutaneous Transluminal Angioplasty
Current Reimbursement for Radiation Therapy Treatments
Breast MRI Reimbursement Update

The Bill Box

Access to Medicare Imaging Act of 2007 Would Mitigate DRA Cuts

The 2007 version of the Access to Medicare Imaging Act, which would address the deleterious effects of the Deficit Reduction Act of 2005 (DRA) on imaging access, was introduced in the US House of Representatives on February 28 by Representative Carolyn McCarthy (D-NY). The bill calls for a 2-year moratorium on the steep cuts to Medicare reimbursement for imaging services mandated by the DRA, and would require a Government Accountability Office (GAO) study to analyze the impact of the cuts on patient access to medical imaging services, especially in rural and medically underserved areas.

“Congress must put a halt to further payment cuts in medical imaging services for Medicare patients until the GAO can sort through just how this will affect Medicare patients’ access to these life-saving services,” McCarthy said in a statement. “Our legislation recognizes the importance of imaging services and puts the brakes on these cuts while the Federal government studies the real impact of this poorly conceived policy.”

In 2007, 89% of the services affected by the DRA will be paid at rates lower than the cost of performing the service, according to a report by research group The Moran Co, Arlington, Va. The report was released by the Access to Medicare Imaging Coalition (AMIC), Fairfax, Va.

“The effects of the DRA imaging cuts are, and will be, deeper and more far reaching than anyone involved in the formulation of the DRA could have imagined,” said Arl Van Moore, Jr, MD, FACR, chair of the Board of Chancellors of the American College of Radiology, Fairfax, Va. “We believe the pause called for in this legislation will allow Congress to get all the facts and receive input from radiologists, the medical experts in this area, and other stakeholders. It will enable the creation of a more effective approach to these services.”

To read The Moran Co report, visit AMIC online at www.imagingaccess.org.

Single-Payor Legislation Reintroduced

On February 27, California lawmakers reintroduced last year’s controversial bill calling for the elimination of private health insurers in California and the institution of single-payor, state-run health coverage. This is the third consecutive year that State Senator Sheila Kuehl (D-Los Angeles) has introduced the legislation, SB 840, which was vetoed in 2006 by Governor Arnold Schwarzenegger.

According to the Los Angeles Times,1 a 2004 study by the Lewin Group, Falls Church, Va, indicated that the single-payor plan could extend coverage to California’s 6.5 million uninsured residents while saving $8 billion—4% of health care spending on the part of businesses and individuals in the state.

SB 840 has the endorsement of more than 400 entities, according to the Times, including the city of Los Angeles, the California Labor Federation, and 39 state lawmakers. But opponents of the plan, including insurance companies, argue that the lack of competition would lead to an ineffective bureaucracy on a par with Medicaid.

Kuehl, the new chair of the Senate Health Committee, admitted that she had not included the estimated $95 billion in taxes necessary to put the law into effect.

Utah Senate Passes Patient Choice Law

Senate legislation in Utah allowing patients to see out-of-network physicians and hospitals passed 18-11 on February 13, then moved to the House. SB 66, sponsored by State Senator Michael Waddoups (R-Taylorsville), would require insurance companies to offer employers an option for patients to pay extra for the privilege of choosing their own providers.

Insurance companies argue that to allow such freedom of choice defeats the point of managed care, which keeps prices down through negotiated discounts with physicians and hospitals. Other critics note that the bill could result in unnecessary referrals for tests and treatments at surgical and imaging centers in which the referring physicians have a financial interest.

Lawmakers attempted to address the latter issue by offering an amendment requiring physicians to disclose their financial interests in independent testing facilities.


  1. Rau J. Kuehl’s health plan to get new push. Los Angeles Times. February 27, 2007. B1. Available at: http://www.latimes.com/news/local/la-me-health27feb27,1,6321336.story. Accessed March 12, 2007.

Medicare Proposes to Expand Coverage of Percutaneous Transluminal Angioplasty

The Centers for Medicare and Medicaid Services (CMS) announced February 1 that it is proposing to expand its coverage policy for carotid artery stenting. The proposed National Coverage Determination (NCD) includes a coverage expansion reflecting the latest data on the effective use of stents, which can reduce the occurrence of stroke in the Medicare population.

“CMS is committed to providing broader access to appropriate and innovative care to our beneficiaries in the management of their carotid artery disease,” CMS Acting Administrator Leslie V. Norwalk said in a statement. “We are working with health professionals and others to reduce the occurrence of stroke in the Medicare population.”

According to the policy currently in place, patients who show no symptoms of carotid artery stenosis and who are at high risk for carotid endarterectomy are covered only when carotid artery stenting is performed as part of FDA Category B Investigational Device Exemption trials or FDA-approved postapproval studies, or in accordance with the Medicare clinical trial policy.

The modifications proposed by CMS would expand coverage of carotid artery stenting to patients with greater than 80% carotid artery stenosis and restrict it in patients who are 80 years of age or older, as recent research has found this group to be particularly vulnerable to adverse events after carotid artery stenting has been performed. The proposal also formalizes the certification process for hospitals inserting carotid stents.

“The evidence on carotid artery stenting demonstrates its effectiveness in improving health outcomes for certain patients,” noted Barry Straube, MD, chief medical officer of CMS. “By requiring hospitals to certify their competency, CMS can help ensure patient safety and quality care for those undergoing this procedure.”

A 30-day comment period garnered 119 public comments, most of them supportive of the expansion of coverage.

In-Depth Look: Summary of Proposed Changes

The following changes were proposed:

  • restrict the current coverage for patients who are at high risk for carotid endarterectomy and have symptomatic carotid artery stenosis greater than 70% to patients who are 79 years of age or younger;
  • expand coverage to patients who are at high risk for carotid endarterectomy and have asymptomatic carotid artery stenosis of more than 80% and are 79 years of age or younger; and
  • establish that the surgeon performing the surgical consultation, which determines a patient’s high-risk status, must be properly credentialed to perform carotid endarterectomy as determined by the facility.

The following clarifications were proposed:

  • carotid artery stenting is covered only when used with an embolic protection device and is, therefore, not covered if deployment of the distal embolic protection device is not technically possible; and
  • the five facility certification requirements are unchanged—CMS proposes to modify the process for completing the certification and recertification process in the NCD Manual.

CMS proposes to maintain current coverage for the following groups:

  • patients at high risk for carotid endarterectomy who have symptomatic carotid artery stenosis between 50% and 70%; and
  • Patients who are 80 years of age or older with either symptomatic stenosis greater than 70% or asymptomatic stenosis greater than 80%, in accordance with the Category B IDE clinical trials regulation, the clinical trial policy, or the National Coverage Determination on carotid artery stenting postapproval studies.

—C. Vasko

Current Reimbursement for Radiation Therapy Treatments

New Codes




Placement of interstitial devices for radiation therapy guidance, prostate, single or multiple


In 2008-2009, there will be new codes for chest, abdomen, and base of skull

Radiation treatment delivery, stereotactic radiosurgery (SRS), complete course of treatment of cerebral lesions consisting of one session, Cobalt-60-based


RVUs: 30.3

Radiation treatment delivery, SRS, complete course of treatment of cerebral lesions consisting of one session, Cobalt-60-based


RVUs: 23.06

Stereotactic body radiation therapy (SBRT), treatment delivery, per fraction to one or more lesions, including image guidance, entire course not to exceed five fractions


RVUs: 43

SBRT, treatment management, per treatment course, to one or more lesions, including image guidance, entire course not to exceed five fractions


RVUs: 18.3

Stereotactic placement of infusion catheter(s) in the brain for delivery of therapeutic agent(s), including computerized stereotactic planning and burr hole(s)



Codes with Interim RVUs



Physician Work RVUs

Year 2007 Transitional Nonfacility PE RVUs

Malpractice RVUs

Place radiation therapy device/marker, prostate





SRS, multisource





SRS, linear-based





SBRT management





Inpatient consultation





Inpatient consultation





Inpatient consultation





Inpatient consultation





Inpatient consultation





Changed Code


Former Code

New Code

Transperineal placement of needles or catheters into prostate for interstitial radioelement application, with or without cystoscopy



Fluoroscopic guidance for needle placement



CT guidance for needle placement, radiological supervision and interpretation



MR guidance for needle placement, radiological supervision and interpretation



CT guidance for stereotactic localization



T guidance for placement of radiation therapy fields



Breast MRI Reimbursement Update

On January 29, Aurora Imaging Technology Inc, North Andover, Mass, presented a Web-based lecture on 2007 changes to breast MRI coding and reimbursement. Led by the company’s reimbursement specialist, Barbara J. Ossias—an educator certified by the American Society of Radiologic Technologists and the Society of Nuclear Medicine—the seminar covered a variety of issues confronting breast imaging centers in 2007.

A new section in Current Procedural Terminology (CPT), entitled Breast/Mammography Procedures, encompasses all breast imaging procedures, including breast MRI, CAD for mammography, mammary ductogram or galactogram, and mammography.

“We’re now on CPT 4 and are working toward CPT 5,” Ossias noted. “As part of the CPT 5 remodeling, they’re trying to make it so the codes make more sense as they are processed by computers. Everything is now done electronically, and they want to make sure that things can be translated electronically to payors in a way that will facilitate quicker and more efficient reimbursement as well as quicker and more efficient gathering of data.”

The 5.1% reduction to the professional component, which was scheduled to go into effect January 1, is now delayed a year, with a zero update and reporting requirement that will provide 1.5% added payment on the professional component in 2007.

Ossias also noted that third-party payors may begin requiring accreditation. United Healthcare already has informed participating providers that beginning March 1, 2008, facilities must be accredited for CT, CT angiography, MRI, MR angiography, nuclear medicine/cardiology, PET, and echocardiography in order to bill outpatient studies. Failure to obtain this accreditation may result in refusal of reimbursement. Accreditation will be required only if a facility performs the following MRI procedures: 70336, 70540-3, 70551-9, 71550-2, 72141-58, 72195-8, 73218-23, 73718-23, 74181-3, 75552-6, 76093-4, 76393-400, and 76498.

Eight new codes have been introduced:

  • 77058: MRI, breast, without and/or with contrast materials; unilateral
  • 77059: MRI, breast, without and/or with contrast materials; bilateral (replaces CPT code 76094)
  • 76377: 3D rendering with interpretation and reporting of CT, MRI, ultrasound, or other tomographic modality; requiring image postprocessing on an independent workstation
  • 0159T: CAD analysis of MRI data for lesion detection/characterization, pharmacokinetic analysis, with further physician review for interpretation, breast MRI
  • Q9952: Injection, gadolinium-based MR, per mL
  • 77021: MR guidance for needle placement, radiological supervision and interpretation
  • 19102: Biopsy of the breast (percutaneous, needle, core) with imaging guidance
  • 19103: Biopsy of the breast (percutaneous, automated, vacuum-assisted) with imaging guidance

Finally, Ossias noted that a breast center performing an intake examination on a new patient can bill Evaluation and Management (E&M) codes.

The Webcast is archived at www.auroramri.com.

Cat Vasko is associate editor of Axis Imaging News. For more information, contact .