By Eric Barnes, AuntMinnie.com staff writer

December 15, 2010 -- Across the U.S., Medicare is paying for more diagnostic virtual colonoscopy exams and is issuing fewer reimbursement denials, according to a new study of U.S. data. However, the trend varies substantially by geographic region, researchers said in a presentation at this month's RSNA meeting in Chicago.

Virtual colonoscopy (also known as CT colonography or CTC) is increasingly accepted as an alternative to optical colonoscopy for both screening and diagnosis of colorectal cancer. And although the U.S. Centers for Medicare and Medicaid Services (CMS) denied national coverage of screening CTC in May 2009, so-called diagnostic CTC for patients with symptoms suggesting a higher risk of colonic polyps and cancer is allowed on a case-by-case basis as an alternative to CT of the abdomen and pelvis without colonic insufflation for ruling out pathology.

"Anecdotally, I think all of us are aware that [CTC] is being performed increasingly by more centers and more providers, and accepted, hopefully, by more payors," said Richard Duszak, MD, from the University of Wisconsin in Madison, in his RSNA presentation. "But national utilization data are still lacking at this point."

Medicare reimbursement for new technologies has been slow going in general, and CTC has been no exception, he said. But advocacy in favor of CTC by clinical professionals as well as the Reston, VA-based American College of Radiology (ACR) "has resulted in the promulgation nationally of more favorable payor policies on a state-by-state basis with respect to Medicare," he said.

The researchers assessed national and regional trends in utilization and coverage for diagnostic CTC with Medicare claims data, using the annual Medicare Physician/Supplier Procedure Summary (PSPS) master files from 2005 to 2008, Duszak explained. PSPS data are public-use files without any specific patient or diagnostic information, but, importantly, they contain the location of service and physician specialty.

Category III CPT codes were issued for virtual colonoscopy in 2004, and new category I codes for VC were issued in 2009. This means that 2005 to 2009 were the years that could be reliably analyzed for the study, and the just-released 2009 data weren't available in time to be incorporated into the findings at this presentation -- though the study including 2009 data will be published in a peer-reviewed journal, Duszak said.

Using the 2005-2008 data, Duszak and colleagues David Kim, MD, and Perry Pickhardt, MD, extracted the frequency of billed and denied services for diagnostic CTC (CPT code 0067T), along with the interpreting provider's specialty (radiologist, gastroenterologist, or undetermined in the case of multispecialty practices and diagnostic centers) and site of service.

The group compared claims paid to claims submitted to calculate denial rates. Finally, they obtained comparative reference procedure measures for conventional abdominal diagnostic CT (CPT codes 74150, 74160, and 74170). (Diagnostic CT of the abdomen, used until 2004 to code diagnostic CTC exams, is still commonly used to rule out a wide range of abdominal pathologies in the clinical setting.)

Diagnostic CTC procedures reimbursed by Medicare
2005 2006 2007 2008 Total
Billed 3,660 5,538 8,048 10,802 28,048
Denied 2,562 3,066 3,731 4,692 14,051
Allowed 1,098 2,472 4,317 6,110 13,997
Denial rate 70.0% 55.4% 46.4% 43.4% 50.1%

"This first year, 70% of claims for diagnostic CTC were denied," Duszak said. Things got a little better each successive year, leading to "substantial improvement by 2008, though we've got a long way to go yet," he said.

Overall, claims for diagnostic CTC services for Medicare fee-for-service beneficiaries rose from 3,660 in 2005 to 10,802 (+195%) in 2008, a significantly greater increase than with abdominal CT exams, which rose from 4,856,987 to 5,264,921 (+8.5%, p < 0.001).

Meanwhile, the number of denied CTC claims as a percentage of the total decreased from 70.0% in 2005 to 43.4% in 2008 (2,562/3,660 to 4,692/10,802, p < 0.001), whereas denials increased minimally for abdominal CT from 4.2% in 2005 to 4.4% in 2008 (202,348/4,856,987 to 231,310/5,264,921, p < 0.001), the authors reported in an accompanying abstract.

Most CTC exams are being performed by radiologists. Of all 28,048 CTC claims, 25,893 (92.3%) were submitted by radiologists, 286 (1.0%) by gastroenterologists, and 369 (1.3%) by other specialists (5.5% were undetermined). The dominant site of service was the patient office, with almost half of all exams performed in office settings (n = 13,764; 49.1%) and the rest in outpatient hospitals (n = 12,110; 43.2%), inpatient hospitals (n = 1,768; 6.3%), and miscellaneous settings (n = 406; 1.4%).

Change in percentage of diagnostic CTC claims denied
Region Total claims % denials, 2005 % denials, 2008
Boston 2,240 26% 38%
Dallas 2,108 98% 54%
Chicago 5,122 90% 34%
Denver 380 97% 45%
Kansas City 1,185 81% 31%
New York City 5,414 46% 50%
Philadelphia 4,085 85% 29%
San Francisco 2,987 47% 48%
Seattle 905 > 95% 44%

Regionally, Denver had a marked increase in overall claims during the study period, while the denial rate dropped from 97% to 45%, Duszak said. But success was generally less steady on the Eastern Seaboard: for example, in Boston, where denials rose from 26% to 38% of claims. In the West Coast, the San Francisco region had 2,987 total claims for diagnostic CTC during the study period, while Medicare denials actually increased from 47% to 48% during the study period.

Diagnostic CTC is being performed with increasing frequency and increasingly as a payable service, Duszak said.

"Diagnostic CTC increased more than threefold during the first four trackable years, and radiologists are overwhelmingly the predominant service providers," he said. "However, despite the nearly threefold increase in diagnostic services, it's really pretty uncommonly performed for Medicare beneficiaries: one service annually per 3,000 Medicare enrollees," he said. In comparison, CT of the abdomen is performed in one in six beneficiaries per year.

Still, denial rates have decreased considerably. "I think that reflects increasing payor acceptance, but there is significant regional variation in regional denial rates, and I think it highlights the opportunities we have collectively to educate our local carriers," he said. As for the reasons for denial, the local Medicare carriers don't always understand radiology practice and new technologies.

Despite perceptions throughout the provider community that new technology tracking codes are rarely paid, more than half of all examinations are now reimbursed by Medicare, Duszak said. "We have a long way to go yet, but we've made a lot of progress here."

By Eric Barnes
AuntMinnie.com staff writer
December 15, 2010

VC in Medicare patients doesn't lead to more imaging, December 1, 2010

VC advocates tout aggressive strategy for screening coverage, October 26, 2010

Study: VC improves colon screening rates, October 21, 2010

Higher colonoscopy complication rates found in seniors, October 19, 2010

VC screening maintains performance in Medicare population, November 9, 2009

Copyright © 2010 AuntMinnie.com


Last Updated np 12/14/2010 3:02:30 PM

2 comments so far ...
12/16/2010 8:20:42 AM
telemed
I was part of the pre-2005 era in Denver when denials by medicare and by private insurance was >97%. What was particularly outrageous was the fact that most of the patients were told the procedure was
experimental/investigational giving them reasons to be unhappy with the service.

Of course, it was gastroenterologists who did their best in a turf-protective manner to promote the idea that the procedure was inadequate led by the American College of Gastroenterologists, who even marketed the "superiority" of optical colonoscopy in places like USA Today---replete with purposeful mischaracterizations of VC (an FTC violation, by the way).

The same gastroenterologists who did everything to make sure the procedure would not be covered were the ones who explained to patients "you don't want to get a VC---it won't be covered"...and then complain when the very few referrals (failed colonoscopy) to my facility resulted in an insurance denial.

Colorado remains one of the states where coverage of VC is not required by insurance. So, in one state it will be covered and in another state, it is "experimental".


12/16/2010 8:49:22 AM
Wilhelm Roentgen-the original
it sucks



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