Quantifying Interventional Radiology’s Tangible Value

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In recent years, interventional radiologists have had an easier time with the long-standing challenge of impressing their diagnostic colleagues with the intangible worth of a clinical interventional-radiology service. A radiology practice with clinical feet on the street has at least a fighting chance of outrunning a remote teleradiology service. Gregory Soares, MD, director of interventional radiology at Rhode Island Hospital in Providence and a member of the megapractice Rhode Island Medical Imaging (RIMI) in Providence, took this mission a step further and devised a system for quantifying clinical interventional radiology’s tangible value. He shared the model that he used to measure interventional radiology’s contribution to practice RVUs at the Annual Summit of the RBMA in New Orleans, Louisiana, on June 6, 2011. “Diagnostic imaging groups devalue—and should—evaluation/management services,” Soares says. During the half hour that an interventional radiologist spends on an initial evaluation/management visit, which is worth 3.93 RVUs in the 2009 Medicare Physician Fee Schedule (MPFS), a diagnostic radiologist can read four noncontrast brain CT exams (worth 6 or more RVUs in the 2009 MPFS). The value, he continues, is not in the initial episode of evaluation/management; it is the downstream revenue generated by the clinical contact. The tangible value of a clinical interventional-radiology service includes direct revenue generation (procedural and evaluation/management reimbursement) and indirect revenue generation (imaging and downstream imaging) that Soares calls the ripple effect. Barriers to Clear Soares emphasizes that anyone interested in applying the algorithm first needs to establish certain measurement assumptions. In order to identify the interventional-radiology revenue bucket, the practice must define what interventional radiology is in the practice. “Is it the interventional radiologists in the fluoroscopy suite, doing traditional interventional-radiology procedures, or does it include the people down in CT and ultrasound, doing biopsies and drainages?” he asks. “Are ablations interventional-radiology procedures?” For the purpose of understanding the costs of the interventional-radiology program, a practice must identify those radiologists who do interventional procedures. This could be restricted to radiologists defined as interventional radiologists or could include all radiologists with interventional-radiology fellowships, those who have a certificate of added qualification in interventional radiology, or anyone who puts a needle in a patient. In order to perform appropriate assignment of the dollars attributed to interventional radiology, a practice must establish a revenue center that is a hospital-based revenue center, a modality revenue center, an office-based revenue center, or a combination of all three. In a complex practice such as Soares’ environment, this can be challenging, but it is not impossible. Other requisite tools include people with interventional-radiology coding expertise; a billing program with basic data-mining capabilities (for instance, the ability to identify procedures by patient and define where this work was done); someone in the IT department who is willing to perform the searches; and time. The Algorithm This algorithm is based on indexing the CPT® codes that define the patient’s initial clinical contact with your group during the time frame under investigation—2008, in the case of RIMI. With subsequent queries of the data, it is possible to identify the downstream revenue that each of those clinical contacts generates and to eliminate codes that are not attributable to the interventional-radiology practice. In preparation for applying the algorithm, compile an exhaustive list of the interventional-radiology codes for your practice, including everything that your interventional radiologists do and nothing that your interventional radiologists don’t do. For RIMI, that added up to 708 distinct codes, including procedural and evaluation/management codes. “This is what you are going to use to probe your group’s billing data,” Soares says. Query 1: This first query of the database defines all interventional-radiology charges performed during a designated time period, including all charge codes submitted for interventional-radiology procedures and evaluation/management work. It provides an initial list of interventional-radiology procedures, as well a list of all evaluation/management codes representing first patient visits and follow-up visits that occurred during that year. In subsequent queries, these will mark starting points for evaluations of downstream work generated by those visits. The result is the interventional-radiology direct revenue, which totaled 17,607 RVUs for RIMI in 2008 (see table). Query 2: The second query dives into that initial direct worklist to identify the initial patient visit codes, including many of the 99000 codes. Those initial visits are flagged to identify indirect revenue generated in caring for those patients in subsequent visits. Query 3: The final query will define indirect revenue generated subsequent to follow-up evaluation/management (indicated by CPT codes 99211–99215 and 99231–99238). By pulling the patient identifiers, a list of subsequent visits/procedures for each patient is generated from which all of the downstream revenue can be identified. Indirect-revenue Filter Of course, not all subsequent visits can be attributed to the interventional-radiology revenue bucket, which is why a two-part filtering process is necessary, The first part is automated and relatively painless: It involves filtering out those procedures that interventional radiologists don’t do, such as mammography, dual-energy x-ray absorptiometry, and breast biopsy.
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Table. Initial Clinical Interventional-radiology Contacts (Procedure or Evaluation/Management), 2008
The manual filter component is exactly that: Someone who understands the coding process must look through the data and eliminate the codes that are not relevant. Soares used the example of the patient who initially presented with menorrhagia. Under that person’s identifier, all of the subsequent work for that patient done by the group is listed, including codes for uterine artery embolization, a pelvic MRI exam, follow-up evaluation/management, a CT exam of the abdomen, and a chest radiograph. The first three are clearly related, but the last two are atypical procedures following uterine artery embolization. They are eliminated from the interventional-radiology revenue-center pool. The final tally delivered the following totals for the RIMI interventional-radiology revenue center in 2008: Direct interventional-radiology RVUs (procedures and evaluation/management), 87,251 (50%); indirect interventional-radiology RVUs (due to new patient evaluation/management): 62,256 (35.7%); indirect interventional-radiology RVUs (due to established patient evaluation/management): 24,794 (14.3%); and total interventional-radiology RVUs: 174,304. Soares was suitably impressed with that total until he had to demonstrate return on investment to his group, and the number fell a bit short. He notes that the picture has changed substantially since 2008. In conclusion, Soares emphasizes the importance of identifying the patient starting point, which (in turn) reveals the indirect component of the interventional-radiology revenue pool. “The numbers I shared with you bore out that 50% of the revenue was indirect,” he says. “This algorithm requires identification of the initial clinical contact: That’s how we find the starting point for all of the ripples that come out of interventional radiology.”