Starting January 1 2013, coronary intervention codes in use since 1992 are replaced by new codes with new values.
Jim Blankenship MACC, FSCAI
Director of Cardiology and Cardiac Cath Labs
Geisinger Medical Center
Dr Blankenship is a member of the AMA/Specialty Society Relative Value Update Committee (RUC) representing the American College of Cardiology.
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Coronary Intervention Codes and Reimbursement: Two Decades of Effective Advocacy Why have interventional cardiologists’ salaries ranked at or near the top compared to other specialties for the past decade (1)? Long hours under high stress using extreme skills to perform dangerous procedures? Yes, but there is more. Effective advocacy by the Society for Cardiac Angiography and Interventions (SCAI) and American College of Cardiology (ACC) has played a large role. This is the story. Medicare, enacted in 1965, based reimbursement for physician services on the actual charge on the current bill, the customary charge over the past year, or the local medical profession’s “prevailing” charge over the past year, whichever was lowest (2). This system was chaotic and confusing. In response, the Omnibus Budget Reconciliation Act of 1989 switched Medicare to the Resource Based Relative Value System (RBRVS). This used Hsaio et al’s estimates of physician time and effort to assign Relative Value Units (RVUs) to physician services (3). In 1991, the Center for Medicare and Medicaid Services (CMS) convened a series of Technical Expert Panels (TEP) to refine Hsaio’s initial estimates of work for selected procedures. One of these was percutaneous transluminal coronary angioplasty (PTCA). A representative of the SCAI/ACC convinced the TEP to increase reimbursement for PTCA from Hsaio’s estimate of 9.5 RVU’s to 10.5 RVU’s. The 20 million or so coronary angioplasty and stenting procedures performed in the US since 1992 have all been reimbursed at a rate reflecting that 1 RVU increase granted by the TEP in 1991. Thus, this one instance of effective advocacy by SCAI/ACC increased reimbursement for these 20 million coronary intervention procedures over two decades. Now jump to 1994 when STRESS (4) and BENESTENT (5) compared elective stenting to balloon angioplasty, and a randomized trial compared then state-of-the-art Palmaz-Schatz and Gianturco-Roubin II stents (6). Elective stenting was just starting; most stents were placed to bail out failed balloon angioplasty. In this milieu a code for coronary stenting was developed. The expert panel that advised CMS on reimbursement estimated that the average stenting procedure required 120 minutes of physician time from first injection of lidocaine to last catheter withdrawn (diagnostic catheterization not included), 45 minutes of preparation time before the procedure, and 60 minutes of physician work after the procedure, for a total physician work time of 225 minutes per coronary stenting case. Thus, interventionists have been paid for coronary stenting at a rate based on almost 4 hours per procedure for the past 17 years. New Coronary Intervention Codes and Values
For the past several years, CMS has attempted to curb Medicare expenditures by identifying and reducing payment for over-priced services. In 2011 CMS identified coronary stenting as possibly over-priced and required that it be re-valued. The value of a service depends on the time required to perform it, and to a lesser extent the intensity of the work. SCAI and ACC knew that invasive cardiologists were reimbursed for 4 hours of work per stent case since 1994, and that procedural times might have shortened since then. A re-valuation could significantly decrease the RVUs paid for a coronary stenting procedure. Interventional cardiologists were also keenly aware of problems with the existing coronary intervention codes (Table 1). Reimbursement for an emergency...