To understand what happened to the image-guided breast-biopsy CPT® codes (and their reimbursement) in the 2014 Medicare Physician Fee Schedule (MPFS), it’s necessary to delve into the history of the codes and the RBRVS. Learning about them won’t hurt a bit, but the new bundled codes have the potential to hurt a lot—and to affect the most vulnerable Medicare beneficiaries. 

The RBRVS system was built on component coding: Individual component services each had CPT codes that could be combined to reflect exactly what was performed. The value assigned to each component reflected the physician work and resources needed to perform that component—and only that. For a stereotactic biopsy, the imaging-guidance code reflected the cost of the stereotactic table, but the needle-biopsy code recognized the cost of the needle, gauze, and gloves actually needed to sample the tissue.

Despite this methodology’s use for many years, CMS recently decided to change the rules. CMS now maintains that there must be some duplication of effort when codes are typically performed together. When a radiologist performs two services together (such as needle biopsy using imaging guidance), there must be some double-dipping overlap. 

The ACR has argued vigorously (but to no avail) that this is not the case. In fact, this duplication was explicitly avoided in the original construction and valuation of the component codes. We also protested that the ability to track what was performed will be lost, but again, this fell on deaf ears.

CMS mandated that new bundled codes be created for image-guided breast biopsy because these codes were often used together. CMS has the authority to set values for the MPFS, so if breast interventionalists had decided not to comply, the bundling would have happened notwithstanding. 

How It Came to Pass

A hurdle-strewn path led to the extremely unsatisfactory result. The CPT editorial panel wants to make sure that everything that you might possibly do is reflected by a code. For image-guided breast biopsy, that meant not only that new codes were created for very common services (such as ultrasound-guided biopsy), but that codes also were created for much less common scenarios (such as second-clip placement in a previously biopsied lesion under MRI guidance). In order to assign values to each new code, surveys are performed. 

The principle is to ask survey respondents to compare the new codes with familiar codes. If one service is harder than another, the respondent estimates comparative times and work values. The catch, with the new breast-biopsy codes, was that they all were surveyed simultaneously. Breast interventionalists, many of whom haven’t seen or biopsied another organ in years, were forced to choose comparisons such as liver biopsy.

As a result, the ACR Economics team faced a process that replaced established conventions with irrelevant comparisons (in a complex survey). The ACR team struggled to get the requisite number of surveys—going through the process twice, trying to get valid results. 

The only right answer, for CMS, would be a reduced value for the bundled codes, compared with the component codes. Of course, CMS got what it wanted. On average, we will see a 38% reduction in the professional component and an 8% reduction in global payments for breast-biopsy codes (a 17% professional-component increase and an 84% global-payment increase for clip-placement codes can be explained by the fact that there previously were no CPT codes for this activity).¹

Did CMS get what it needed? Has the relentless search for so-called misvalued codes misled it? We recognize the urgent need to deliver higher-value care at a lower cost, but image-guided biopsies have delivered this for years. 

Image-guided biopsy represents a huge advance. It helps in treatment planning before definitive surgery, and it reduces costs when it obviates the need for open surgical biopsy (which it has largely turned into a thing of the past).

Despite the cascading cuts of recent years, radiologists will do their best to maintain image-guided biopsy services. The real risk is at the margins, for rural practices and for hospitals serving the poor. 

With dwindling resources, difficult choices will arise. When an image-guided biopsy is not available for several weeks, will surgery start to look like an option, despite being more invasive and costly? As the population ages and more women need breast-imaging/interventional services, will facilities maintain the status quo instead of expanding their breast services? 

In the search for value over volume, this might be the triumph of a narrow focus on codes over the most effective care, as defined by expert physicians. It might be a triumph for CMS, but it is potentially a tragedy for our patients.  

Reference

1. ACR describes financial impact of new and revised CPT codes for 2014. ACR Advocacy in Action eNews. Published December 20, 2013. Accessed February 7, 2014.