Looking for misvalued exam codes has contributed to outsized imaging reimbursement cuts

Increases in imaging utilization combined with the search methodology used by policymakers to look for misvalued medical services has resulted in disproportionate reimbursement cuts to diagnostic radiology services, according to a study published in the Journal of the American College of Radiology.

Relative value units (RVUs) are usually reviewed every five years, but in 2006 the Medicare Payment Advisory Commission established a new group to continually review codes amid concerns the five-year interval was too long.

The Relative Assessment Workgroup (RAW) implemented screening factors that flagged codes when they met certain criteria. Many of these conditions disproportionately flagged imaging, including:

• Rapid growth in volume.
• High utilization.
• Frequent performance of two codes in combination.
• A shift in a service’s most commonly performed specialty.

A review of the CMS Requests and Relativity Assessment Issues Status Report found 46 percent of diagnostic imaging exams were flagged for review, compared to 22 percent of all remaining codes. Computed tomography (CT) was the most likely modality to be flagged with 82.1 percent of codes flagged, while breast exams were flagged 90 percent of the time, the highest of any body region.

The individualized nature of radiology exam coding makes it particularly susceptible to being caught in RAW’s dragnet, according to Andrew Rosenkrantz, MD, lead author and associate professor of radiology at New York University School of Medicine, and colleagues. Other contributors include Ezequiel Silva, III, MD, adjunct clinical professor at the University of Texas Health Sciences Center, and C. Matthew Hawkins, MD, assistant professory from Emory University School of Medicine.

“This granular approach enables fairly specific reporting of services performed together, such as CT scans of separate anatomic regions (eg, a CT scan of the abdomen and a CT scan of the pelvis), which is favorable for claims-based health services research,” wrote the authors. “As such, these code combinations are more frequently identified by screens designed to identify codes that are frequently reported together.”

The authors also took issue with flagging specific codes for utilization without considering costs.

“For example, a plain film of the abdomen performed 30,000 times would have the same charges as a splenectomy performed only 375 times. The plain film might be identified by a 30,000 utilization screen and the surgical code would not, despite the same financial impact on the Medicare program,” wrote Rosenkrantz et al. “In addition, radiology services tend to be capital intensive, leading to high practice expenses and high likelihoods of radiology codes being caught by the high expenditure screen.”

Compounding the problem is the tendency to review an entire family of codes when one is flagged, creating potential for scrutiny of individual exams to radiate out into the rest of the modality.

It’s imperative for imaging advocates to be vocal about the disparity in reimbursement cuts, especially during a time when value-based reimbursement is becoming standard. If the reimbursement cuts continue as is, radiology could be squeezed from both sides according to the authors.

“Disproportionate payment reductions to radiology could stifle investment in technologies that could improve patient experience and outcomes at the same time that new payment models are placing a premium on these metrics,” wrote Rosenkrantz et al. “Policymakers should consider new approaches, other than the relativity screen process, to address perceived physician overpayments or to enable higher payment to certain specialties, such as primary care.”