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 III 5 1 Neuroendovascular Program, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA 2 Norwich Diagnostic Imaging Associates, Norwich, Connecticut, USA 3 Department of Radiology, Hackensack University Medical Center, Hackensack, New Jersey, USA 4 Pain Management Center of Paducah, Paducah, Kentucky, USA 5 South Texas Radiology Group, San Antonio, Texas, USA Correspondence to Dr J A Hirsch, Neuroendovascular Program, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, USA; Hirsch@snisonline.org Received 26 November 2012 Revised 26 November 2012 Accepted 26 November 2012 Published Online First 19 December 2012 To cite: Hirsch JA, Donovan WD, Leslie-Mazwi TM, et al. J NeuroIntervent Surg 2013;5:615–619. ABSTRACT Component coding is the method NeuroInterventionalists have used for the past 20 years to bill procedural care. The term refers to separate billing for each discrete aspect of a surgical or interventional procedure, and has typically allowed billing the procedural activity, such as catheterization of vessels, separately from the diagnostic evaluation of radiographic images. This work is captured by supervision and interpretation codes. Benefits of component coding will be reviewed in this article. The American Medical Association/Specialty Society Relative Value Scale Update Committee has been filtering for codes that are frequently reported together. NeuroInterventional procedures are going to be caught in this filter as our codes are often reported simultaneously as for example routinely occurs when procedural codes are coupled to those for supervision and interpretation. Unfortunately, history has shown that when bundled codes have been reviewed at the RUC, there has been a trend to lower overall RVU value for the combined service compared with the sum of the values of the separate services. INTRODUCTION Component coding refers to separate billing for each discrete aspect of a surgical or interventional proced- ure, and has been the de facto method of document- ing the panorama of neurointerventional (NI) care for 20 years. 1 It has usually entailed separate billing of the surgical/procedural activity, such as catheteriza- tion of vessels, from the diagnostic evaluation of radiographic images (supervision and interpretation code (or S&I)) performed for an NI service. For most practicing NeuroInterventionalists, component coding represents the only system we have ever used for billing procedural care. NI specialists might be surprised by the relative youth of component coding, and the peril that this now established billing system currently faces. REAL LIFE SCENARIO In April 2012, the American Society of Neuroradiology and the American College of Radiology (ACR), as well as a litany of other soci- eties including the Society of Interventional Radiology and the American Association of Neurological Surgeons, presented a new set of bundled carotid angiography code services to the RUC (the American Medical Association/Specialty Society Relative Value Scale Update Committee) for recommendation of relative work value units (RVU). The cervicocerebral angiography codes had been identified as ‘potentially misvalued’ by the RUC through their ‘75% reported together’ screen. The societies argued that the multiple individual component codes were originally valued independ- ently, and on their own merits; therefore, there were no inherent efficiencies when the services were performed together. Supported by survey data from practicing physicians, the RUC agreed that when a new code bundle involves a single proced- ure and its S&I code, the new code RVU value should be the sum of the two ‘old’ code values. The RUC forwarded these recommendations to the Centers for Medicare and Medicaid Services (CMS). CMS did not agree, categorically stating that “We believe efficiencies are gained when services are bundled”. 2 Accordingly, CMS lowered the RUC’s recommended values for the new cervicocarotid code set in the November 2012 Final Rule—unilat- erally rejecting the notion that work efficiencies did not exist between procedural codes and S&I codes. The reductions for diagnostic cervicocerebral angi- ography are large. For example, a four vessel diag- nostic cerebral angiogram now suffers a 44% reduction in payment compared with the prior con- ventional component coding structure. BRIEF HISTORICAL BACKGROUND In December 1989, President George H W Bush signed the Omnibus Budget Reconciliation Act of 1989 into law. This act established a Resource Based Relative Value System (RBRVS) as the basis for Medicare physician reimbursement, which took effect on January 1, 1992. Prior to 1992, interventional services were reported using two different methods: complete procedure coding or component coding. At that time, the vast majority of percutaneous vascular interventional procedures were performed and coded by radiologists (with the exception of cardi- ology procedures). Thus professional radiology organizations had a central role in developing a working plan for interventional and NI coding. 3 Having two separate coding conventions led to significant variability in the reporting of procedures. Furthermore, different insurance companies— including regional Medicare contractors—would reimburse variably and sometimes uniquely for the services performed. Some would pay as if only a single procedure had been performed whereas others reimbursed separately for the different com- ponents of the interventional procedure. This was 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 History copyright. on January 12, 2022 by guest. Protected by http://jnis.bmj.com/ J NeuroIntervent Surg: first published as 10.1136/neurintsurg-2012-010606 on 19 December 2012. Downloaded from