"Radiology Bundling Rule Reimbursement Reduction" for Obstetrical Ultrasound Studies

This White Paper will deal with the “Radiology Bundling Rule” (RBR) to provide the SMFM Coding Committees recommendations for the optimal reporting and obtaining proper reimbursement for multiple obstetrical ultrasounds performed on the same day with special focus on avoiding second and subsequent procedure payment reductions.  The intent of this document is to alert Physicians, Billing Managers, Coders, and Billers about the RBR and to provide with a clear understanding on how to identify and appeal that reduction rule.  The SMFM Coding Committee has been alerted that two payers are currently applying this rule to obstetrical ultrasounds.    

What is “The Radiology Bundling Rule?”

The “Radiology Bundling Rule” (RBR) is the provision when a payer decreases reimbursement for the second and subsequent imaging procedures done on the same day.  The rule dictates that the first procedure be reimbursed at 100% of the carrier’s contracted rate, the second procedure at 50% of that rate, and subsequent procedures possibly even less. This is easily identified in your practice by looking at the reimbursement for the second and subsequent ultrasound procedures billed with the different carriers and verifying whether reimbursement is less than the global or professional negotiated rates.

How is the “RBR” applied to obstetrical ultrasound studies?

In this example Medicare’s National Global Payment (both TC and PC) amount was utilized to provide a baseline.  Medicare currently reimburses $117.56 for (76816), $92.42 for (76819), and $46.89 for (76820).  The following illustrates how the rule may be applied for one case:

76816 - $117.56 reimbursed at 100% of $117.56

76819 - $46.21 reimbursed at 50% of $92.42

76820 - $11.72 reimbursed at 25% of $46.89

Reduction amount = $81.37

When this is done repeatedly for many patients each day, the potential revenue loss could be immense.

The loss becomes even greater with multiple gestations since in the second and subsequent study RVU values are already reduced. For example, PC work RVU for 76811 is 1.90, which is reduced to 1.78 for 76812 without the use of a modifier. Second example, TC work RVU for 76801 is 2.41, and already reduced to 0.86 for 76802.  Third example, TC work RVU for 76805 is 2.97, and already reduced to 1.47 for the 76810.  Applying the RBR would decrease this further.

What are the implications nationally? 

·         Significant Revenue Loss if all Commercial Carriers apply the RBR.

·         The risk of Medicare (CMS) following Private Payer initiatives

Important points of note:

·         The RBR was implemented by private payors unilaterally  without review, discussion or approvlal by  providers of these services.

·         CMS does not mandate this for Obstetrical Ultrasounds.

·         The RBR does not follow correct coding initiative.

·         Appealing the reduced scans will not help if the physician, practice, or hospital has already signed a contract stipulating the inclusion of the “Radiology Bundling Rule”. 

·         It is the position of the SMFM Coding Committee that this is an unacceptable practice.

SMFMCoding Committee’s Position

1)       In the case of obstetrical ultrasounds or ultrasound guided procedures, additional studies are often performed for separate and distinct reasons. A fetus is its own entity which requires a separate evaluation in addition to the evaluation of the mother. Several studies may be performed in one session due to several indications and/or suspicion of maternal or fetal abnormalities.  In most cases, this does not create efficiencies in physician time, supplies, or other costs.  The RBR was implemented  without review/discussion or approval of the providers. Each component is performed  and analyzed individually to provide specialized care, and plan for effective treatment and prevention options. The SMFM Coding Committee does not agree that performing multiple procedures on the same day necessarily or universally yields resource savings in areas such as clerical time, preparation, and supplies when studies or procedures are performed on contiguous body areas on the same day with the assumption that the patient has already been prepared for the second and subsequent study or procedure.  Ultrasound requires continuous data acquisition and is dissimilar from other imaging modalities like MRI and CT scan in which once image acquisition is done, the patient is sent away and then the data is reviewed.

2)       MFM specialists often perform multiple procedures on the same day to provide improved care and patient convenience, but yield no reduction in costs. Therefore, the SMFM Coding Committee doesnot believe that these services should be arbitrarily included in any future expansion of the RBR policy.  In some cases, work may actually increase if the additional procedure is done on the same day, whether for medical urgency or patient convenience, necessitating additional clerical and scheduling efforts to rearrange other scheduled patients and accommodate the additional procedure on the same day.

3)       Several codes that yield a decrease in work load have already been decreased in value without the use of a modifier.  Such is the case for codes used with multi-fetal pregnancies (76801-76802, 76805-76810, etc.).  Further reduction in work value by 50% or more of the second and subsequent studies is unacceptable since it does not match actual work provided.

SMFM Coding Committee’s suggested corrective action plan:

It is imperative that all Maternal-Fetal Medicine (MFM) practices review their payer contracts and have the radiology bundling rule removed. Examine  the Explanation of Benefits (EOBs) to determine if the “RBR” is being applied to their ultrasound services currently. If the “RBR” is being applied to the claims, the Medical Director of the plan should be approached with this White Paper.  Do not enter in any payer contract without a thorough review, particularly if a “RBR” stipulation is present in the contract.  Additionally, it is strongly suggested that the following guidelines  be followed:

·         Practices must ensure that all ultrasound studies are sequenced in Highest RVU order for billing. Most current RVU information may be obtained at http://www.cms.gov/apps/physician-fee-schedule/overview.aspx

·         Separate indications should be provided and respectively linked to the different studies performed

·          

·         Example of correct RVU sequencing and diagnosis linkage

1)       76816 Ultrasound, pregnant uterus, real time with image documentation, follow- up (RVU 3.46)

·         656.63 Large for dates

2)       76819-59 BPP without NST (RVU 2.72)

·         648.03 Pregnancy complicated by diabetes

·         250.01 Diabetes mellitus, Type 1

3)       76820-59 Fetal Umbilical Artery Doppler Velocimetry (RVU 1.38)

1. • 657.03 Polyhydramnios

·         Each study should be reported separately or at least have a separate header on the ultrasound report.

·         Unfortunately, the use of modifier “59”, may not bypass the application of this rule even when medically necessary indications are provided for each scan performed.  SMFM still recommends the usage of Modifier “59” for scans that are performed for separate distinct reasons and multiple gestations.

Download the PDF