American College of Radiology loses fight with CMS over ultrasound payment restriction

The American College of Radiology said it has lost a dispute with the Centers for Medicare & Medicaid Services over restrictions around payment for certain ultrasound exams.

ACR filed the appeal in October, hoping to overturn a determination that providers would only receive payment for one duplex scan of extremity veins per beneficiary in a single visit. CMS would likely deem any such imaging beyond that amount “medically unlikely” and deny the claim, the college said in a March 24 update.

“Our CPT Advisors (physician volunteers representing multiple radiology societies) believe there are many clinical scenarios where it would be reasonable to perform a bilateral upper extremity deep vein thrombosis exam on the same day as a bilateral lower extremity DVT exam, or a unilateral DVT exam of an arm on the same day as a unilateral DVT exam of a leg,” ACR said Wednesday.

However, CMS denied the initial appeal and stuck with the decision after a recent face-to-face meeting, the college reported. Officials made the call, despite advisors citing several scenarios where duplex ultrasound of all four extremities might be medically necessary. COVID-19 patients can often experience dangerous blood clotting—a major cause of death—with providers performing more than one exam to determine location and extent of the issue.

Despite the denial, ACR said it will continue fighting “misguided proposed edits,” having scored victories a “significant” percentage of the time in such appeals.

“Unfortunately, due to confidentiality rules within [the National Correct Coding Initiative], we are not allowed to publish those ‘wins’ when proposed edits are not enacted,” ACR said.