New CPT codes raise rates, but billing problems remain

March 4, 2008

Cardiac MR codes grant a victory despite continued Medicare ban on blood flow measurement payment

Eight replacement CPT billing codes and a nearly twofold increase in relative value unit rates used to calculate payments for cardiac MR imaging have raised the spirits of physician users about the modality’s prospects. Medicare still refuses to pay, however, for cardiac MR blood flow measurements, a key component of valvular and congenital abnormality studies.

“The change in the reimbursement circumstances is a very tangible thing,” said Dr. Charles Higgins, president of the Society for Cardiovascular Magnetic Resonance. “This is something that we hope will have a cascading effect to encourage more physicians to enter the field and for the manufacturers to further develop their cardiac MR products.”

The new codes place more emphasize on functional assessments and flow than the five codes they replaced, said Dr. Edward Martin, SCMR’s representative on the intersociety committee that lobbied for them. The old series had been in place since 1993, long before many popular MRI applications were introduced.

The new series is organized around  two base codes: 75557 for cardiac MRI for morphology and function without contrast and 75561 for morphology and function with contrast (see table). The base codes cover the acquisition of images that enable clinicians to evaluate the heart’s anatomy, motion, and ventricular function.

Each base code was assigned three variant codes for additional sequences that may be required during the exam. One covers flow/velocity   quantification, another was designated for stress, and a third addresses flow/velocity quantification and stress.

“A number of the new codes specifically address patients with ischemic heart disease and applications, such as dobutamine stress testing, that we weren’t able to bill for before,” Martin said. “The new codes apply to areas the old codes didn’t cover.”

But questions remain about how providers can bill Medicare for cardiovascular MR procedures involving any of the four new codes related to flow/velocity qualification, according to Dr. Pamela Woodard, president of the North American Society for Cardiac Imaging.

A noncoverage policy for flow quantification and velocity assessments has applied to Medicare Part B since the publication of a national coverage determination for cardiovascular MR in 1997. The Centers for Medicare and Medicaid Services ruled specifically in the 2008 Physician Fee Schedule that the four flow/velocity CPT codes were not reimbursable, she said.

In a letter to CMS, Woodard noted that flow quantification and velocity assessments generate essential data about the status of cardiac valve function for determining the extent of valvular insufficiency and stenosis. The functional measures are also critical for assessing the severity of intracardiac shunting (Qp/Qs ratio) for some congenital heart conditions.

Because of Medicare policy, the new codes force providers into a conundrum, Woodard said. They can perform and code the complete exam and not be reimbursed. They can perform the complete exam and downcode the exam to codes that do not include velocity determinations, but that approach puts them at risk of Medicare billing fraud. Or they can perform an incomplete MRI exam and refer the patient to costly echocardiography or cardiac catheterization to gather the data.

“Who knows what’s going to happen? Because of these new codes, it is a little trickier,” she said in an interview with Diagnostic Imaging .

The higher RVU rates reflect the increased work involved with cardiovascular MR exams, Martin said. Current cardiovascular MR technology requires clinicians to gain expertise in a broader range of applications than when CPT codes were first developed for the modality 15 years ago. The extent and intensity of physician effort have increased during actual imaging and afterward as the images are reconstructed and evaluated.

The new codes and RVU rates were developed through collaboration involving the American College of Radiology, American College of Cardiology, SCMR, and NASCI. Planning began in 2004 when the previous CPT code series came up for a standard five-year review. The American Medical Association’s Relative Value Scale Update Committee approved the new codes in January 2007 and approved their RVU valuations in midsummer.

New codes and higher rates could draw more physicians to cardiovascular MR practice and potentially make it accessible to more patients, according to Martin.

“This is a significant victory,” he said. “It bodes well for the field of cardiovascular MRI as we go into the future.” 

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