Struggle for reimbursement demonstrates pitfalls for industry

A new CPT code set to take effect July 1 might serve as an added incentive for the purchase of computer-aided detection systems for breast MR. But Confirma, the leader in MR CAD, isn't counting on it to boost sales.

Cutting interpretation time from more than a half hour to 10 minutes for an increasingly popular MR procedure will drive the expansion of Confirma's 400-plus installed base, according to Dan Bickford, Confirma sales and marketing vice president. Of course, getting a CPT code pertaining specifically to Confirma's CADstream wouldn't hurt that effort. At least it shouldn't.

The struggle to gain acceptance and reimbursement for this new CAD code may be an evolving case study of how reimbursements can affect the adoption of other imaging technologies.

It all began late last year, when the American Medical Association released the Category III Current Procedural Terminology (CPT) code 0159T. The code, which will be implemented July 1, is to be listed separately from the primary procedure code for breast MR. The new code calls for "computer algorithm analysis of MRI data for lesion detection/characterization, pharmacokinetic analysis, with further physician review for interpretation, breast MRI."

Not many payers have heard of it. Marsha Eastman, reimbursements manager for Seattle-based First Hill Diagnostic Imaging, a premier site for breast MR and CAD interpretation, has had no luck getting payers in her area to recognize the code, even though the AMA released it several months ago. That might change in midsummer, when the code is officially implemented. Or it might not.

Category III codes are at the bottom of the CPT heap. They are manually submitted by billing managers and, when submitted, typically do not trigger payment.

"Category III codes are used to get a feeling for how often the procedure is being utilized," Bickford said. "They are reviewed by the payers typically once a month, and if there is no precedent to pay them, they won't pay them."

The money typically begins to flow only after a code gets to Category I, is loaded as an electronic code, and is widely recognized. This can have an effect on the purchase of capital equipment.

"It helps when figuring return on investment, if you can add another $80 or $100, especially in a sweet spot like CAD, since all our customers do it," he said.

But getting to that point could take as long as four or five years, according to Bickford. Confirma is now talking with customers, asking them to start using the Category III CPT code as a first step to getting recognition for this application of CAD.

"It is a long, tedious process, and I am not counting on that code and its availability in the short term to help us further commercialize CAD for breast MR," he said.

Instead, Confirma is focusing on productivity benefits and the several reimbursement codes already in place for breast MR. Code 76093 (unilateral) and 76094 (bilateral) are the two primary codes available.

First Hill Diagnostic Imaging never uses the "93" code, as all exams are bilateral, "even if the patient has a mastectomy, because you have to look at that site when you do an exam," Eastman said.

If it's a new diagnosis, First Hill bills out for a chest MR, as well. Several others, including codes for subtraction, reconstruction, and the administration of a gadolinium agent, are also billed.

"There are six or seven different codes," she said. "These are for all the things involved in the process of doing a breast MRI."

Ultimately, the availability of a Category I CPT code widely recognized and reimbursed for CAD during breast MR should add to the attractiveness of Confirma's product. But it won't necessarily put more money in the pockets of practitioners.

Reimbursement policies have a way of changing to reflect new circumstances. Eastman worries that the inclusion of another code for breast MR will come at the expense of an existing one, a possibility that looms larger as U.S. regulators seek ways to stem rising medical costs.