For the last 20 years, interventional cardiologists have coded and billed for their interventional services using codes constructed 18 to 20 years ago. Medicare has paid for these services using values that were assigned when the codes were created — also about 2 decades ago. During this period, everything about the practice of interventional cardiology has changed, except for the codes and their values. Cardiologists have not lobbied for changes because they perceived reimbursement as generally appropriate.
Background for Change
For the past several years, CMS has employed various strategies to decrease reimbursement for procedures it suspected of being over-reimbursed and developed screens to identify such potentially overpriced services. Coronary stenting was caught by one of those screens, and CMS notified the Society for Cardiovascular Angiography and Interventions and the American College of Cardiology that coronary stenting would be re-valued. In the current health care environment, where Medicare may be headed for bankruptcy, re-valuing usually leads to devaluing. Although devaluing a procedure is entirely appropriate if that procedure can be performed faster and requires less work than when it was originally valued, many experts feel this process routinely and unfairly devalues procedures in which work and time have not changed.
To reassess the physician work of a procedure, practicing physicians are surveyed about the time and work required to perform the procedure. The results of the survey are evaluated by a committee sponsored by the American Medical Association. That committee, known as the AMA Relative Value Update Committee (RUC), makes a recommendation to CMS regarding the physician work required for the procedure. CMS may accept that recommendation, or reject it and substitute CMS’s estimate of the work involved (although CMS does not have any other reliable method for estimating physician work).
Physician work is measured in relative value units (RVUs). CMS changes the value of an RVU yearly; for 2012 it was $34.04.
Faced with the prospect of CMS devaluing the procedure on which the entire specialty of interventional cardiology is based, representatives from SCAI and ACC considered their options. As practicing interventional cardiologists, they were aware of inconsistencies with the current codes that had been tolerated by cardiologists for more than a decade (Table 2). For example, reimbursement for an emergency middle-of-the-night STEMI stent procedure was the same as for an elective stent procedure done on a healthy outpatient at 9 a.m. Another example is that treating a complex left anterior descending bifurcation lesion and two diagonal lesions with 100 mm of stents was reimbursed the same as stenting one discrete left anterior descending lesion with a single 12-mm stent. It seemed logical that if interventional procedures were to be re-valued, then it was time to also get codes that more appropriately describe the procedures performed by interventionalists.