Downloaded from http://jnis.bmj.com/ on March 5, 2016 - Published by group.bmj.

com

History

REVIEW

Component coding and the neurointerventionalist:

a tale with an end
Joshua A Hirsch,1 William D Donovan,2 Thabele M Leslie-Mazwi,1 Greg N Nicola,3
Laxmaiah Manchikanti,4 Ezequiel Silva III5

been identified as ‘potentially misvalued’ by the

1
Neuroendovascular Program, ABSTRACT
Massachusetts General Component coding is the method NeuroInterventionalists RUC through their ‘75% reported together’ screen.
Hospital, Harvard Medical
School, Boston, Massachusetts,
have used for the past 20 years to bill procedural care. The societies argued that the multiple individual
USA The term refers to separate billing for each discrete component codes were originally valued independ-
2
Norwich Diagnostic Imaging aspect of a surgical or interventional procedure, and has ently, and on their own merits; therefore, there
Associates, Norwich, typically allowed billing the procedural activity, such as were no inherent efficiencies when the services
Connecticut, USA catheterization of vessels, separately from the diagnostic were performed together. Supported by survey data
3
Department of Radiology,
Hackensack University Medical evaluation of radiographic images. This work is captured from practicing physicians, the RUC agreed that
Center, Hackensack, by supervision and interpretation codes. Benefits of when a new code bundle involves a single proced-
New Jersey, USA
4
component coding will be reviewed in this article. The ure and its S&I code, the new code RVU value
Pain Management Center of American Medical Association/Specialty Society Relative should be the sum of the two ‘old’ code values.
Paducah, Paducah, Kentucky,
USA
Value Scale Update Committee has been filtering for The RUC forwarded these recommendations to the
5
South Texas Radiology Group, codes that are frequently reported together. Centers for Medicare and Medicaid Services
San Antonio, Texas, USA NeuroInterventional procedures are going to be caught (CMS).
in this filter as our codes are often reported CMS did not agree, categorically stating that “We
Correspondence to
simultaneously as for example routinely occurs when believe efficiencies are gained when services are
Dr J A Hirsch,
Neuroendovascular Program, procedural codes are coupled to those for supervision bundled”.2 Accordingly, CMS lowered the RUC’s
Massachusetts General and interpretation. Unfortunately, history has shown that recommended values for the new cervicocarotid
Hospital, Harvard Medical when bundled codes have been reviewed at the RUC, code set in the November 2012 Final Rule—unilat-
School, Boston, MA 02114, there has been a trend to lower overall RVU value for erally rejecting the notion that work efficiencies did
USA; [email protected]
the combined service compared with the sum of the not exist between procedural codes and S&I codes.
Received 26 November 2012 values of the separate services. The reductions for diagnostic cervicocerebral angi-
Revised 26 November 2012 ography are large. For example, a four vessel diag-
Accepted 26 November 2012 nostic cerebral angiogram now suffers a 44%
Published Online First
19 December 2012
INTRODUCTION reduction in payment compared with the prior con-
Component coding refers to separate billing for each ventional component coding structure.
discrete aspect of a surgical or interventional proced-
ure, and has been the de facto method of document- BRIEF HISTORICAL BACKGROUND
ing the panorama of neurointerventional (NI) care In December 1989, President George H W Bush
for 20 years.1 It has usually entailed separate billing signed the Omnibus Budget Reconciliation Act of
of the surgical/procedural activity, such as catheteriza- 1989 into law. This act established a Resource
tion of vessels, from the diagnostic evaluation of Based Relative Value System (RBRVS) as the basis
radiographic images (supervision and interpretation for Medicare physician reimbursement, which took
code (or S&I)) performed for an NI service. For effect on January 1, 1992.
most practicing NeuroInterventionalists, component Prior to 1992, interventional services were
coding represents the only system we have ever used reported using two different methods: complete
for billing procedural care. NI specialists might be procedure coding or component coding. At that
surprised by the relative youth of component coding, time, the vast majority of percutaneous vascular
and the peril that this now established billing system interventional procedures were performed and
currently faces. coded by radiologists (with the exception of cardi-
ology procedures). Thus professional radiology
REAL LIFE SCENARIO organizations had a central role in developing a
In April 2012, the American Society of working plan for interventional and NI coding.3
Neuroradiology and the American College of Having two separate coding conventions led to
Radiology (ACR), as well as a litany of other soci- significant variability in the reporting of procedures.
eties including the Society of Interventional Furthermore, different insurance companies—
Radiology and the American Association of including regional Medicare contractors—would
Neurological Surgeons, presented a new set of reimburse variably and sometimes uniquely for the
To cite: Hirsch JA,
bundled carotid angiography code services to the services performed. Some would pay as if only a
Donovan WD, RUC (the American Medical Association/Specialty single procedure had been performed whereas
Leslie-Mazwi TM, et al. Society Relative Value Scale Update Committee) for others reimbursed separately for the different com-
J NeuroIntervent Surg recommendation of relative work value units ponents of the interventional procedure. This was
2013;5:615–619. (RVU). The cervicocerebral angiography codes had confusing to providers as well as payers.

Hirsch JA, et al. J NeuroIntervent Surg 2013;5:615–619. doi:10.1136/neurintsurg-2012-010606 615

 Downloaded from http://jnis.bmj.com/ on March 5, 2016 - Published by group.bmj.com

History

Prior to and during the 1980s, the ACR crafted its own combination of components, was appropriate for the service
Radiology RVS through tremendous research, survey, and ana- performed.
lysis efforts.4 Based on the strength of the proposed system, in These aspects of the component coding system—that each
1989 the Health Care Financing Administration (HCFA, now code’s value is inherent, and that multiple component codes
CMS) agreed to adopt the Radiology RVS essentially wholesale may be used for a single patient interventional visit—has been
into its prospective RBRVS. The ACR’s RVS focused on diagnos- of great value to the practice of radiology and other procedural
tic procedure valuation but the ACR did recommend the elimin- specialties. However, of late, they have also become the nexus
ation of complete procedure codes in favor of a component of unflagging criticism from health care pundits and CMS
coding system. However, HCFA could not make such a large policymakers.1
change to the coding system as only the American Medical
Association’s (AMA) Current Procedural Terminology (CPT)
Editorial Panel (EP) could delete and add CPT codes. Therefore, THE TIDE TURNS
the ACR assigned relative values to the interventional radiology In this era of diminishing Federal resources, a growing number
codes which existed in 1989. of voices have raised concerns that component coding has led to
Between 1989 and 1992, the Society of Cardiovascular and inappropriate reimbursement. MedPAC (the Medicare Payment
Interventional Radiology (SCVIR), now the Society of Advisory Commission) and the Government Accountability
Interventional Radiology, proposed to the CPT EP a system in Office, among others, have reiterated that the current health
which both complete and component coding methods would be care system is financially unsustainable.5 6 They have included
used to describe interventional procedures. The AMA rejected this radiologist reimbursement in general—and component coding
proposal as too complex. in particular—as harvest ready, low hanging fruit to redistribute
In 1991, SCVIR and ACR developed a second, simpler pro- payments to other physicians.
posal establishing component coding as the basis for reporting A little more background: to preserve the rigor of the RUC
interventional radiology procedures. This proposal was accepted database, a ‘5 year review’ (5YR) process was statutorily man-
by both HCFA and the AMA. This was a watershed moment in dated at the inception of the RBRVS, and has taken place every
radiologist reimbursement, thanks to the prolonged efforts of 5 years through the RUC. Designed to maintain relativity in the
SCVIR and ACR physician volunteers and staff; it heralded the face of changing practice and evolving technology, the first 5YR
20 year run of the component coding classification which has took place in 1995. By 2005, critics such as MedPAC charged
been the basis of describing most NI procedures—until recently. that the RUC was not reviewing codes often enough or critically
enough.5 CMS and the RUC agreed. Thus, following the third
ADVANTAGES OF COMPONENT CODING 5YR, an ongoing review process was instituted.7 Originally
There are multiple benefits of component coding: termed ‘the rolling 5YR,’ it was immortalized in 2009 as the
1. It allows separate billing of surgical/interventional codes Relativity Assessment Workgroup (RAW), a standing subcommit-
and S&I codes—particularly important when different tee of the RUC, with ongoing recommendations.8
physicians carry out these services on the same patient. RAW’s mandate from CMS has been to review ‘potentially
2. The detail built into the system allows separate reporting misvalued services’. CMS directed RAW toward several different
for procedures performed in different vascular beds (eg, categories of services by means of ‘screens’ or ‘filters.’ Of par-
carotid vs vertebral arteries), which was generally not a ticular interest to neurointerventionalists is the screen of ‘codes
part of the prior reporting conventions. frequently performed together’. When CMS and RAW devel-
3. It allows for differential valuation for greater selectivity/ oped the screen for ‘codes frequently performed together,’ a
complexity (eg, catheterizing the internal carotid artery is joint CPT/RUC workgroup was formed to consider the complex
reimbursed higher than the common carotid artery). coding issues inherent to codes ‘reported together’. The hope of
4. It is substantially more comprehensive, leaving few clinical the radiology community was that any potential resource effi-
services undescribed, and therefore fewer clinical scenarios ciencies would be contextualized, given (1) the historic rationale
billed as an ‘unlisted procedure,’ subject to absent or for and development of component coding and (2) the poten-
irregular coverage by insurers. tially devastating effect that may befall a few procedural
5. Component coding facilitates adaptation to clinical devel- specialties.
opment and innovations: by allowing more efficient and The workgroup’s report to the RUC and CPT EP ‘called for
discrete tracking of work performed within a department, CPT coding change proposals to collapse code pairings into
resource planning and allocation is more refined. New fewer bundled services’. The reported together screen started at
technologies can integrated more rapidly into the existing 95% or more reported together; in 2010, the threshold was
coding structure, rather than facing the delays of new lowered to 75% or more reported together.9 10 Code pairs
code creation. meeting this criterion were sent to the joint CPT/RUC work
6. The increased granularity of the procedural tracking has group. In nearly all cases, such code pairs or families have been
important implications for research: research studies can reformulated as bundled codes. And in most cases, a new
focus on specific services by means of more specific CPT bundled code is valued less at the RUC and by CMS than the
codes, and research grants can be more effectively sought sum of the values of the previous codes.11 Given the prevalence
and awarded when the stakeholders understand what is with which NI procedures are reported with S&I codes, and
being proposed to a more detailed degree. only somewhat less commonly with each other, numerous NI
Throughout both the adolescence of the component coding procedures have been identified for examination—and have
structure, and whenever new technology has led to new CPT been or may ultimately be reimbursed less than they are
codes in the years since, the RUC has meticulously reviewed currently.
and valued each component service on its own merit. Thus the The family of cervicocarotid angiography codes is the most
reimbursement convention that has existed for two decades has important group of services to NI radiology that has been refor-
assumed that payment for each component service, or any mulated through this process to date (see box 1).

616 Hirsch JA, et al. J NeuroIntervent Surg 2013;5:615–619. doi:10.1136/neurintsurg-2012-010606

 Downloaded from http://jnis.bmj.com/ on March 5, 2016 - Published by group.bmj.com

History

Box 1 An example of the code bundling process: cervicocarotid angiography

Numerous code pairs from the family of diagnostic carotid artery procedures were identified in the ‘potentially misvalued’ screen of
‘codes performed together’ more than 75% of the time
▸ Code pairs were identified by Centers for Medicare and Medicaid Services (CMS) data analysis in February 2010.
▸ Reviewed at the Relativity Assessment Workgroup (RAW) meeting in April 2010. The RAW/RUC (American Medical Association/
Specialty Society Relative Value Scale Update Committee) agreed to schedule this family for Current Procedural Terminology (CPT)/
RUC review almost 2 years hence—because of the overall workload (including many other code families) being imposed on a
relatively small number of societies, especially radiology.
▸ Large number of societies (American Society of Neuroradiology, Society of Interventional Radiology, American College of Radiology,
neurosurgical, cardiology, and vascular surgery organizations) worked together to revise the current code structure, presented to CPT
in February 2012.
▸ New codes all include the radiological supervision and interpretation (S&I) code, fluoroscopic guidance, roadmapping, and initial
vascular access. Like the current code structure, the procedure codes are progressive—the service reflecting the highest order branch
vessel is coded, and also includes all work leading up to that level.
▸ Societies surveyed their membership, analyzed the data collectively, and presented their recommendations to the RUC in April 2012.
– Example from the RUC meeting: Complete right internal carotid artery angiography.
▹ Societies recommended value of 7.55.
▹ RUC agreed, forwarding that recommendation to CMS.
▹ Value diminished by CMS in Final Rule to 6.50.
▸ New code values were published in CMS Final Rule in November 2012, taking effect 01/01/2013**.
Examples:
1. Right internal carotid diagnostic angiography
Previous valuation: Catheterization of a third order brachiocephalic arterial branch (36 217) plus radiologic S&I (75 665)=6.29+1.31
relative work value units (RVU)=7.60 RVU.
New valuation (beginning 01/01/2013): Unilateral internal carotid artery angiography, includes catheter placement, arch and common
carotid artery angiography, S&I (36 224): 6.50 RVU.
Bundled code value discounted 14% from prior component code valuation.
2. Bilateral vertebral arteriography
Previous valuation: Right vertebral catheterization (third order) (36 217), left vertebral artery catheterization (second order) (36 216)*,
vertebral arteriography S&I (75 685×2)=6.29+2.64*+1.31+1.31=11.55 RVU.
New valuation: There are now separate vertebral angiography codes for non-selective (ie, injecting the subclavian artery for vertebral
artery evaluation (36 225)) and selective catheterization and angiography of the vertebral artery itself (36 226). The new codes no
longer refer to first, second, or third order anatomy.
Assuming selective bilateral vertebral artery catheterization: 36 226+36 226–50 (bilateral modifier)=6.50+3.25*=9.75.
Bundled code valuation decrease of 15%.
Note: Intracranial catheterization and angiography reported by means of an add-on code 36 228 (4.25 RVU), reporting limited to twice
per side.
Any endovascular interventions performed following these diagnostic procedures are still reported separately, except that carotid stenting
codes include preliminary catheterization and diagnostic arteriography.
Ultrasound guidance for initial vascular access (76 937) still reported separately.
Three-dimensional rendering (76376,76 377) still reported separately.
Upper extremity arteriography codes may still be reported separately.
*Most payers, including Medicare, discount the second procedure payment for a bilateral procedure.
**CMS reduced the value of CPT 36 224 stating that the 25th percentile survey value appropriately captures the work of the service,
‘particularly efficiencies when two services are bundled together’. The society recommended reference services were ignored and no
alternative reference codes provided by CMS (Reference: 2013 MPFS Final Rule, page 508)

WHY? overall RVU value for the combined service compared with the
There are both rational and emotional explanations for the tar- sum of the values of the separate services. This is exemplified by
geting of radiology and interventional codes by the payers and the story of inferior vena cava filter placement (see box 2), and
policymakers.12 on the diagnostic side, the combined codes for CT of the
The genesis of the ‘codes reported together’ screen was the abdomen and pelvis.11 This trend has been seen by policy-
concept that services that are reported together an overwhelm- makers as a justification for this process. Policymakers would
ing percentage of the time are not truly separate services, but point to the reduced value of the combined code as evidence of
different parts of the same procedure. This logic is difficult to overlap in work between the previously separately reported
refute. By bundling two or more such services into a single rede- codes—that ‘efficiencies’ have been captured. (Paradoxically,
fined entity, there is a presumed simplification of the coding code bundling has not reduced the number of CPT codes, but
structure. increased them. Many of the new code families are also
As it turns out, when bundled codes have been reviewed at complex and numerous; and many of the individual component
the RUC, there has been a steady trend for diminution of codes have been maintained in the code set to cover unusual

Hirsch JA, et al. J NeuroIntervent Surg 2013;5:615–619. doi:10.1136/neurintsurg-2012-010606 617

 Downloaded from http://jnis.bmj.com/ on March 5, 2016 - Published by group.bmj.com

History

Box 2 The code bundling process: a representative example (61% reduction in payment)

IVC filter placement

Inferior vena cava (IVC) filter placement is a commonly performed procedure in hospitalized patients. Neurologically impaired patients
are often the recipients of such devices. IVC filter utilization has increased as a method to prevent life threatening pulmonary emboli
associated with deep venous thrombosis, particularly in patients with a contraindication to anticoagulation, a frequent circumstance in
neurointerventional patients.13 14
Traditional coding ( pre-2010)*
36 010 (introduction of catheter, superior vena cava or IVC); 37 620 (interruption of IVC); and 75 940 (filter placement supervision
and interpretation (S&I)): combined relative work value units (RVU) value 2.43++11.57+0.54**=12.11
▸ Code pairs 36 010/37 620 and 37 620/75 940 were identified by the joint American Medical Association/Specialty Society Relative
Value Scale Update Committee (RUC)/Current Procedural Terminology (CPT) workgroup in the ‘codes performed together’ screen in
2010.
▸ American College of Radiology, Society of Interventional Radiology, and the Society for Vascular Surgery agreed to send the family of
codes to CPT for revision, bundled code creation.
▸ CPT approved new code set in February 2011; CPT deleted codes 37 620 and 75 490 from the CPT guidebook. 36 010 is maintained
as standalone codes.
▸ The same societies presented their survey results and recommendations to the RUC in April 2011. The intra-service times returned in
the surveys could not justify maintaining the existing values.
RUC recommendations to Centers for Medicare and Medicaid Services (CMS)
▸ 37 191 (IVC filter placement, including imaging guidance, roadmapping, S&I): 4.71 RVU
▸ 37 192 (IVC filter repositioning, including imaging guidance, roadmapping, S&I): 8.00 RVU
▸ 37 192 (IVC filter retrieval/removal, including imaging guidance, roadmapping, S&I): 8.00 RVU
CMS final determinations
▸ 37 191: accepted RUC recommendation, 4.71 RVU***
▸ 37 192: downvalued the RUC recommendation. 7.35 RVU
▸ 37 193: downvalued the RUC recommendation, 7.35 RVU
*Additional procedures were sometimes billed as well for this procedure. The four codes listed were for the most common coding
scenario.
**75 940 (S&I) was carrier priced from 2007–2011. 0.54 RVU was the CMS value prior to that time.
***A 61% reduction in payment from prior coding.

cases/scenarios. Nonetheless, more unreportable procedures signaling to some an attempt to show more backbone to its
have ensued, such as the new renal angiography codes where a detractors. In fact, the RUC recently approved two additional
right sided subselective and left sided superselective catheteriza- seats on the panel for primary care specialists.
tion is not reportable in the new bundled scheme for diagnostic
renal angiography.) MULTIPLE PROCEDURE PAYMENT REDUCTION POLICY
The less rational attractiveness of the code bundling move- Another tactic used by CMS to trim health care costs at the
ment has to do with a negative perception of the fee for service expense of radiologists and proceduralists is the progressive
structure of the American health care system, and the specialties expansion of the Multiple Procedure Payment Reduction policy
that have benefited most from this system—including radiolo- (MPPR). Rather than wait for RAW, CPT and RUC to address
gists and other proceduralists.15 The average primary care phys- the hundreds of codes on its agendas every year—only some of
ician is frequently limited to reporting a single evaluation and which lead to bundling and ‘captured efficiencies’—CMS has
management (E&M) code per patient visit. Such providers sought through its regulatory powers to unilaterally discount
shudder at the thought that neurointerventionalists may report ‘second and subsequent’ procedures on its own.
five, 10, or 20 codes for a single patient encounter. There is a In 2006, CMS begin discounting the technical reimbursement
perception that primary care providers are underpaid, and for second and subsequent imaging and surgical services pro-
medical students are turning away from those fields. Some go vided to Medicare patients by the same physician on the same
on to say that this is a ‘ticking time bomb,’ or evidence of a day—initially at 25%, subsequently raised by Congress to 50%.
failing American medical system.16 Other MPPR targets on the technical side have included
The concept that the fee for service system rewards those nuclear medicine codes (especially prior to recent code bund-
who can report more codes, regardless of the necessity for or ling), physical therapy services, and more recently cardiovascular
the quality of the care provided, is reinforced, detractors say, by and ophthalmology codes. Surgical services have had an MPPR
the RUC itself. The RUC has a plurality of specialists, and some in place for 90 day global codes since 1991, largely the basis for
assert that it is unwilling to address the pay gap in a meaningful the recent MPPR expansion.
way. The AMA and RUC itself have maintained a staunch In 2009, the General Accounting Office launched a direct
defense of their traditions, and of their fair and objective broadside against the component coding structure in a report to
approach to the valuation of medical and surgical procedures.17 Congress titled, ‘Fees could better reflect efficiencies when ser-
However, while CMS accepted greater than 90% of the RUC’s vices are provided together’.6 The basic argument was that phys-
RVU recommendations until a few years ago, it has of late more ician reimbursement should also be discounted when services
frequently adjusted the RUC’s valuations in its Final Rules— were provided together, just as the technical payments had been.

618 Hirsch JA, et al. J NeuroIntervent Surg 2013;5:615–619. doi:10.1136/neurintsurg-2012-010606

 Downloaded from http://jnis.bmj.com/ on March 5, 2016 - Published by group.bmj.com

History

CMS has taken up the challenge of finding efficiencies by providers, and for a non-aggressive approach toward review of
introducing a professional MPPR on advanced imaging services previously valued codes. The RUC, AMA, and many specialty
in 2012, and expanding it to include all members of the same societies have become concerned about maintaining the RUC’s
radiology practice for 2013.2 critical role in determining the value of physician services. The
While NI practitioners might assume that the expanded authors of this short review are convinced that the working of
MPPR might protect against future code bundling, in that it the RUC remains the most just way of maintaining relativity
would prima facie capture implied efficiencies of single encoun- across the spectrum of care. Recent initiatives by CMS and pro-
ter NI service, this has not been the case.18 Although the profes- visions of PPACA may further marginalize the influence of the
sional MPPR has reduced reimbursements on a case by case RUC, and by extension of physicians in general.
basis more than CMS has ever been able to logically justify, it As a matter of legislative policy, as well as precedent, the
has not been considered an adequate rationale for removing ser- RUC has increasingly focused on identifying ‘potentially misva-
vices from the ‘codes frequently used together’ RUC screens. lued services,’ many in the interventional area. The application
The RUC asserts that it does not address or respond to CMS and results have been far from uniform. The ‘frequently
policy, and will therefore continue its work to seek efficiency reported together’ screen used by the RAW and thus the RUC
through bundling, where appropriate. stands as a clear challenge to component coding. Many NI pro-
cedures have been or are at significant risk of being bundled. If
FUTURE CONCERNS past history is any guide, such bundling will result in significant
The Patient Protection and Affordable Care Act (PPACA, or downward revisions to reimbursements for NI coding.
‘Obamacare’) empowers the Secretary of the Department of
Contributors All authors contributed to this manuscript.
Health and Human Services, of which CMS is one department,
to ‘periodically identify services as being potentially misvalued’ Competing interests None.
and states that the secretary may consolidate ‘individual codes Provenance and peer review Commissioned; not externally peer reviewed.
into bundled codes for payment’—for example, potentially
bypassing the RUC–CPT process entirely.19 20 21
Another provision of PPACA due to begin its work in 2014 is REFERENCES
the Independent Payment Advisory Board (IPAB). The 1 Silva E III. Where have you gone, component coding? J Am Coll Radiol
2012;9:458–60.
President, in consultation with congressional leaders, would
2 Services CfMM. 2013 Medicare Physician Fee Schedule Final Rule [online].
have the authority to name 15 experts to serve on this commis- https://http://www.federalregister.gov/public-inspection (accessed 21 Nov 2012).
sion, whose purpose would be to seek cost savings from the 3 Donovan WD. The resource-based relative value scale and neuroradiology: ASNR’s
Medicare process. They would have almost unchallengeable history at the RUC. Neuroimaging Clin N Am 2012;22:421–36.
authority over a broad spectrum of reimbursement issues: from 4 Moorefield JM, MacEwan DW, Sunshine JH. The radiology relative value scale: its
development and implications. Radiology 1993;187:317–26.
resetting RVU values for individual procedures, to amending 5 Commission M. Report to the Congress: Medicare Payment Policy [online].
practice expense inputs, to setting new payment initiatives. This http://www.medpac.gov/documents/Mar06_EntireReport.pdf (accessed 20 Nov
institution could therefore further marginalize the RUC. The 2012).
AMA and virtually every medical specialty society has gone on 6 Office UGA. Medicare physician payments: fees could better reflect efficiencies
achieved when services are provided together [online]. http://www.gao.gov/new.
record opposing the IPAB, as it would potentially take medical
items/d09647.pdf (accessed 20 Nov 2012).
and surgical procedure valuation another step further away 7 Silva E III. New codes from a new source: the rolling five-year review. J Am Coll
from physician input. Radiol 2010;7:10–12.
CMS has also recently indicated that they have ‘entered into 8 Association AM. The RUC Relativity Assessment Workgroup progress report [online].
two contracts to assist us in validating RVUs of potentially mis- http://www.ama-assn.org/resources/doc/rbrvs/five-year-progress.pdf (accessed
19 Nov 2012).
valued codes’.2 No further details have been provided. 9 Manchikanti L, Hirsch JA. Patient protection and affordable care act of 2010:
a primer for neurointerventionalists. J Neurointerv Surg 2012;4:141–6.
COGNITIVE DISSONANCE 10 American Medical Association. The RUC relativity assessment workgroup progress
Component coding was specifically designed as granular and report. March 26, 2012.
11 Silva E III. CT abdomen and pelvis: a case study in devaluation. J Am Coll Radiol
highly detailed, and was instituted with the imprimatur of the
2011;8:300–1.
AMA and HCFA. Reporting certain codes together was innate 12 Silva E III. The search for misvalued services: why is radiology a target? J Am Coll
to the system. The component codes were properly and expli- Radiol 2012;9:7–8.
citly valued as discrete services when they were created, and 13 Kalva SP, Somarouthu B, Hirsch J. Inferior vena cava filters for the cerebrovascular
have been reviewed and reinforced regularly since.7 Now the patient. J Neurointerv Surg 2011;3:137–40.
14 Somarouthu B, Yeddula K, Wicky S, et al. Long-term safety and effectiveness of
powers that be have decided that component coding is ineffi- inferior vena cava filters in patients with stroke. J Neurointerv Surg 2011;3:141–6.
cient, and may be contributing to inappropriate reimbursement. 15 Donovan WD. What is the RUC? AJNR Am J Neuroradiol 2011;32:1583–4.
Thus numerous component codes have been identified on RAW 16 Replace the RUC [online]. http://www.replacetheruc.org/ (accessed 20 Nov 2012).
screens as ‘potentially misvalued,’ with specialty societies forced 17 Levy B. The RUC: providing valuable expertise to the Medicare program for twenty
years. [online]. http://www.kaiserhealthnews.org/Columns/2011/March/032811levy.
to work through a bundling process at CPT, and then a survey
aspx (accessed 21 Nov 2012).
process and presentation to the RUC for new valuation.12 18 Manchikanti L, Hirsch JA, Barr RM, et al. Physician payment outlook for 2012.
J Neurointerv Surg 2012;4:463–7.
CONCLUSION 19 Manchikanti L, Hirsch JA. Patient protection and affordable care act of 2010:
CMS is under tremendous pressure to redistribute payments to a primer for neurointerventionalists. J Neurointerv Surg 2011;4:141–6.
20 Public Law No:111–148:H.R. 3590. Patient Protection and Affordable Care
primary care physicians over specialists and, where possible, Act, 2010.
lower health care costs. Over the past several years, the RUC 21 House Resolution 3590. Misvalued codes under the physician fee schedule. The
has been challenged for favoring specialists over primary care Patient Protection and Affordable Care Act § 3134 (a) (K) (iii) (V).

Hirsch JA, et al. J NeuroIntervent Surg 2013;5:615–619. doi:10.1136/neurintsurg-2012-010606 619

 Downloaded from http://jnis.bmj.com/ on March 5, 2016 - Published by group.bmj.com

Component coding and the

neurointerventionalist: a tale with an end
Joshua A Hirsch, William D Donovan, Thabele M Leslie-Mazwi, Greg N
Nicola, Laxmaiah Manchikanti and Ezequiel Silva III

J NeuroIntervent Surg 2013 5: 615-619 originally published online

December 19, 2012
doi: 10.1136/neurintsurg-2012-010606

Updated information and services can be found at:

http://jnis.bmj.com/content/5/6/615

These include:

References This article cites 12 articles, 5 of which you can access for free at:
http://jnis.bmj.com/content/5/6/615#BIBL

Email alerting Receive free email alerts when new articles cite this article. Sign up in the
service box at the top right corner of the online article.

Topic Articles on similar topics can be found in the following collections

Collections History (8)

Notes

To request permissions go to:

http://group.bmj.com/group/rights-licensing/permissions

To order reprints go to:

http://journals.bmj.com/cgi/reprintform

To subscribe to BMJ go to:

http://group.bmj.com/subscribe/