New CT Abdomen/Pelvis CPT Code Changes Cut Reimbursement

April 26, 2011

CMS's new abdomen-pelvis CT scans combined-code requirement halves reimbursement, reducing payment for tumor, cancer, or similar scans.

As of Jan. 1, 2011, the Centers for Medicare & Medicaid Services (CMS) changed the way you code for abdomen and pelvis CT scans performed together. The new combined-code requirement slices reimbursement for these services in half.

Each time you run these scans together, for the same reason and on the same service date, you lose between $200-400 in reimbursement, depending upon whether the test requires a contrast agent. That’s a 50 percent payment reduction each time you scan for tumors, cancer or other such problems.

Although the original codes for abdomen and pelvis CT scans conducted separately still exist, CMS now mandates that services performed together at least 75 percent of the time must use one CPT code. Assigning one code in these instances is the agency’s way of eliminating what it considers double payments for similar scans conducted at the same time.

The American College of Radiology (ACR) has opposed the move for the past five years, citing concerns over lost reimbursement, potential confusion over using new codes correctly, and frustration that consideration wasn’t given to the physician time needed to read scans.
In fact, the ACR has actively campaigned for CMS to re-evaluate how you are reimbursed for the time you spend reading both abdomen and pelvis CT scans.

“Bundling of these codes does makes sense when these services are performed for certain clinical indications. However, the diagnostic interpretations are separate; they are for the same patient encounter and are performed for the same reason." said Kim Snyder, CPC, CPS, Partner Coding at Zotec Partners. “The radiologist is getting a much lesser amount for the same work.”

You can maximize your reimbursement while still billing correctly, however. Katherine Abel, CPC, director of curriculum for the American Academy of Professional Coders, recommends ensuring your staff knows the original codes are still valid for procedures performed alone.

“Radiologists are getting hit pretty hard on this because many of them perform these services quite frequently,” Abel said. “Practices should know that both sets of codes exist, how much reimbursement is attached to them, and how to use the codes appropriately.”

She suggested posting a chart that includes the old and news codes, as well as the circumstances in which you should use each one.

Snyder also advised you ignore previous talk of altering clinical practices to secure reimbursement for both scans. For example, earlier industry discussions toyed with conducting one test on one day and the other on the next service date. That’s a bad idea, she said.
“That just isn’t the answer,” she said. “We need to be considerate of patients, and we also have to monitor exposure to radiation, as well.”

Working with payers and carriers to closely examine your reimbursement stream could also be helpful, Snyder said. But, she stressed, the best bet to increase reimbursement is to support the ACR as it pushes CMS to adequately compensate physician work time.