So this topic would actually take at least half a day, maybe a full day, to really delve it into it so that I can only touch on a couple of major points. I am not going to go into all the nuances of it with you. I have no conflicts of interest. I have been on the RUC now for a couple of decades and co-chaired the ACC Coding and Relative Value Task Force, which includes members of SCAI. The objectives here, first of all, understand why the CPT meeting is important, understand why it is difficult, and then I am actually going to take a straw poll here, so listen carefully. I am going to give you option A and option B, and I want to know what you guys think, because even as we speak at this very meeting, Ed Tuohy and Monica and I have been trying to figure out the next coding proposal for PCI. So this is the process that we just heard about. The CPT application goes to the RUC. The physicians from the RUC go to CMS, and then CMS does whatever they want to do with it. They run it through their conversion factor, and then it ends up in the form of dollars that go to you or your institution. So I am going to talk about the AMA, the CPT panel, and the CPT codes. Dr. Box has already talked about the physician survey part of this. So key point number one, if you don't code for your procedures, you don't get credit for doing them. This came out in cardiovascular business recently. The Bureau of Labor Statistics says that cardiology is the highest paid profession in the country. I have never seen that before, but that is what they say. But if you get paid in dollars in private practice, then you are maintaining your position as one of the highest paid professionals in the country. For those of us who are in employed models, there are expectations by your employer. I am in a university setting, so the American Association of Medical Colleges publishes their productivity survey. In our case, if we get above the 50th percentile, there is a very small incentive payment. If we don't hit the 50th percentile, then people come around and knock on the office door and ask you why you are not doing that, and maybe you should be working harder. So there is accountability. No matter what model of practice you have, this is important. Another point, if you delegate coding to the cath techs, they will get it wrong. We have this paper billing ticket, which is antiquated, but every time we do a procedure, we fill this out. Often the cath techs will take a stab at filling it out, and at least half the time they get it wrong. They won't code for the second vessel that you ivist, or if it is a STEMI, they will just code it as a regular stent at a lower value. So it pays to do it yourself. If you delegate the coding to administrators or coding professionals, most of them will get it wrong. Usually you never find out about it, because it goes straight from them to the financial people. The few times I have looked behind the curtain there, it shows that they really don't understand it and they often do get it wrong. So it is best if you lay it out yourself. The point is that it is complicated, and that is why they get it wrong. I am going to give you an example or show you a little bit how you know it is complicated. This is the CPT coding manual, the top right there. It weighs about 2 pounds. It probably has 1,000 pages in it of fine print. Right here you see the section on diagnostic cath coding. In the red boxes are all the diagnostic cath codes, and the part that you see now is the coding policy. So you have to know the codes, but you also have to know when to use them, when not to use them, how they apply, and so on. There are lots of arcane and sometimes obscure reasons about why this works. Ken Brin, who was an interventionalist a few years ago on the CPT when the cath codes were written, laid it out in tables to make it a little bit simpler. This is the section on interventional coding. You see here these are not all of the interventional codes, but some of them. Then the related policy part is here. The policy of what you code, when you code it, how you code it, when you don't code it, is very, very complex. Dawn Gray, who was an advisor to SCAI for many years, sitting in the audience, knows this well. Monica here knows it full well, too. It is very complex, so it is complicated. That is why if you have your cath staff do it, they will often get it wrong and why it is confusing for us. These are the common codes, left or diagnostic, right or not all but the bread and butter intervention codes in the red box here. The problems with them, you have additional branch codes. Back when they were developed in 2011, we valued each additional branch intervention, but CMS said you guys are just going to do branches gratuitously, unnecessarily, and we are not going to pay for it. They took the value that we thought should have gone to the branch codes and put it into the main vessel codes, but what they did with the branch codes is they assigned them all zero. You can code an additional branch code, but you don't get anything for it. Private payers generally follow suit with that. It ends up just being confusing. Second problem, again, 10 years when we last designed the code set, our CTO colleagues said we should have a retrograde CTO code for obvious reasons. We didn't think there were enough cases to be done, so we said no, we are not going to do that. But as it has become more common, it is a bigger problem. Again, bifurcation stenting, again, if you spend an hour doing all 16 steps of the DK crush technique, you probably deserve more than if you just slam a single stent in in 10 minutes, but there is no compensation for that extra complexity. As I mentioned, the IVL code, which is just hammered out, went to the CPT panel. They approved it, but they also said, well, you guys, now you need to revise all of your PCI codes. That is why we are harping on the survey, because they are going to send out a survey, and right now we are figuring out what coding proposal to make to CPT that CPT will accept. It is not quite as contentious a process as you see here, but we have gone through several iterations of this in the past few weeks. Again, Monica knows this full well. Myself and Dr. Toohey have been involved. At this point, we are down to option A and option B. Option A is just modifying the current code set by adding a retrograde CTO code and a two-stent bifurcation code. Option B is taking the current stent code and doing what CPT suggested, which is unbundling it to a straightforward stent code and a complex stent code. Listen carefully, because this is the options. This is the bread-and-butter intervention codes. The simple change is simply to make the current CTO code antegrade, add in a retrograde CTO, and then a bifurcation two-stent one. The other one is, as you see here on the right, you still have angioplasty. You have straightforward PTCA, which we are currently thinking of defining as a lesion or lesions with one contiguous 45 millimeters or less stenting. Everything else is complex, which would include bifurcation stenting, a lesion over 45 or 50 millimeters, multiple lesions and aorto-osteo lesion, left-main stenting, and antegrade dissection reentry CTO. We still have a stent arthrectomy, acute MI, graft, and then we have a CTO retrograde code. So that is option B, and this is the current iteration that we are thinking of proposing to CPT. So, again, I am going to ask you to give a straw vote on this, what you think. Option A, we tweak the current code set. That will increase RVUs for retrograde CTO and two-stent bifurcation stenting. It is relatively little risk, although probably every time you resurvey, the codes go down a little bit in value. Option B is that you break off a complex stenting code and a straightforward stenting code. The value of straightforward stenting will go down, so low-volume operators who just do an occasional type A lesion will get substantially less. Complex operators, probably everybody in this room, will get a little bit more, not a lot more, but a little bit more. CMS budget neutrality means that the total number of RVUs that the family of codes gets will be the same. So, anyway, again, option A, you tweak the current code set. Option B, you have a new stent code based on complexity. So let me ask, I would like every interventional cardiologist in the room to go with A and B. Which do you think is better? Do you think we should just add the bifurcation and retrograde CTO code or have a complex and straightforward stenting code? So let me ask, how many like option A, the minimalist version? So, okay, wow. The panel votes for it. Just keep your hand up for a second because we're going to take this back and talk about it. 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20. Okay. How many like option B? So 1, 2, 3, 4, 5, 6, 7, 8. Okay. 21 to 8. Well, thank you for that. We'll take that back and chew on it a little bit. So just to summarize here, CPT coding is complex. Find your own Yoda and learn, you will. CPT coding policy determines the use of the codes. So you not only have to know the codes, but the policy surrounding how to use them. And then one way or another, we are going to make a proposal to CPT. Something will come out of it. You will be getting a survey sometime in the next six months. And as Dr. Box has said, please do complete it. Go through the whole thing. And we really value your input. And again, oftentimes, we only get 40, 50, 60, 70 respondents. So you may be providing 150th or 130th of the input that will determine how the values come out. Thank you.

CPT coding

medical field

cardiology procedures

coding complexities

CPT coding manual