L. Swan, MD, FSIR, a member of the CPT Editorial Panel. “I know several nonphysician coding experts who could write code change proposals, but none have the clinical insight into the physician work being described in the proposal that a subspecialty physician has.”


During his time working with the SIR workgroup, Dr. Ayyagari helped develop descriptions of the proposed codes, reviewed drafts and ensured that everyone involved understood the steps, process and reality of utilizing this procedure in practice.


During code creation, it’s not uncommon for SIR to work with other specialties or associations who have an interest in the procedure in question. In the case of the code that Dr. Ayyagari worked on, the procedure in question has overlap between IR and other specialties; as a result, Dr. Ayyagari worked on multiple versions of coding for the same procedure, depending on which physician specialty was performing the procedure.


The code that Dr. Ayyagari worked on was accepted by the CPT and then moved on to the AMA/Specialty Society Relative Value Scale Update Committee (RUC) to make recommendations to CMS on the physician work relative value units (RVUs) and direct practice expense inputs for this code. Dr. Ayyagari continued to work as a clinical expert during the RUC part of the process.


“It was very interesting to see how everything works behind the curtain, and it made me realize that all specialties are dealing with reimbursement struggles,” Dr. Ayyagari said.


Valuing a code If a Category I code is approved by the AMA, it then goes to the RUC for valuation—and this is where the wider SIR community plays a key role.


The first step is a survey of SIR members. This anonymous survey is sent out via the specialty societies to providers to determine the time, intensity and work required to perform the procedure. This feedback is collated by SIR’s RUC Workgroup who then present their proposed code value to the RUC panel.


“In my opinion, coding advice is probably one of the more important member-facing services the SIR Economics Committee provides.” —TIMOTHY L. SWAN, MD, FSIR


The RUC process is complicated, in-depth and, according to Dr. Ayyagari, very detail oriented. While working to determine code value, Dr. Ayyagari said he was surprised by the level of detail required and how granular the discussions became.


Once the RUC panel, which is composed of multi-specialty physician volunteers agree upon a relative value, that recommendation goes to the Center for Medicare and Medicaid Services (CMS) for final decision. At this point, CMS determines if they will accept the RUC recommendations, or if they will value codes differently.


Each year, CMS releases the Physician Fee Schedule (PFS)—first as a proposed rule, then as a final rule. The PFS dictates the reimbursement value for all codes and medical procedures


and has increasingly involved substantial cuts to IR reimbursement. This is where SIR’s Health Policy and Economics team springs into action again—writing comment letters, providing literature and joining coalitions to argue against the cuts.


“Unfortunately, the pool of money given to the CMS for physician reimbursement is a Congressionally mandated, fixed, annual amount that has no inflationary factors built into the funding mechanism,” said Dr. Swan. “That means this dedicated PFS is fixed.”


As a result, the money allotted does not grow to accommodate any new CPT code independently valued by the RUC, Dr. Swan said. Nor does the PFS increase to cover increased utilization of Medicare coverage.


In addition, when new CPT codes are created or modified, the RUC almost always requires revaluation of related codes, Dr. Swan said. This revaluation ensures that codes within the same family maintain their relative value. In addition, the RUC flags services that are new or include new technology to determine if a resurvey and revaluation is necessary after 3 years of utilization data.


“Because IR is one of the most innovative specialties for service development, we need to be very


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