In 1966, The American Medical Association (AMA) working with multiple major medical specialty societies developed an iterative coding system for describing medical procedures and services using uniform language, the Current Procedural Terminology (CPT) system. The current code set, CPT IV, forms the basis of reporting most of the services performed by healthcare providers, physicians and non-physicians as well as facilities allowing effective, reliable communication among physician and other providers, third parties and patients. This coding system and its maintenance has evolved significantly since its inception, and now goes well beyond its readily perceived role in reimbursement. Additional roles include administrative management, tracking new and investigational procedures, and evolving aspects of 'pay for performance'. The system also allows for local, regional and national utilization comparisons for medical education and research. Neurointerventional specialists use CPT category I codes regularly--for example, 36,215 for first-order cerebrovascular angiography, 36,216 for second-order vessels, and 37,184 for acute stroke treatment by mechanical means. Additionally, physicians add relevant modifiers to the CPT codes, such as '-26' to indicate 'professional charge only,' or '-59' to indicate a distinct procedural service performed on the same day.

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The Relative Value Scale Update Committee (RUC) plays a critical role in determining physician payment. When the Centers for Medicare and Medicaid Services (CMS) transitioned to paying physicians based on the ResourceBased Relative Value Scale, the American Medical Association developed this unique multispecialty committee. Physicians at the RUC determine the resources required to provide physician services and recommend appropriate payment for those services. The RUC then submits its recommendations to CMS. Physicians have thus been important in determining relative value and hence payment for the services they provide.

Physician spending is complex and intrinsically related to national health care spending, government regulations, health care reform, private insurers, physician practice and patient utilization patterns. Consequently, since the inception of Medicare programs in 1965, several methods have been used to determine the amounts paid to physicians for each covered service. The sustainable growth rate (SGR) was enacted in 1997 to determine physician payment updates under Medicare part B with an intent to reduce Medicare physician payment updates to offset the growth and utilization of physician services that exceeds the gross domestic product growth. This is achieved by setting an overall target amount of spending for physicians' services and adjusting payment rates annually to reflect differences between actual spending and the spending target. Since 2002, the SGR has annually recommended reductions in Medicare reimbursements. Payments were cut by 4.8% in 2002. Since then, Congress has intervened on 13 separate occasions to prevent additional cuts from being imposed. This manuscript describes certain important aspects of the 2012 physician fee schedule.

Component coding is the method NeuroInterventionalists have used for the past 20 years to bill procedural care. The term refers to separate billing for each discrete aspect of a surgical or interventional procedure, and has typically allowed billing the procedural activity, such as catheterization of vessels, separately from the diagnostic evaluation of radiographic images. This work is captured by supervision and interpretation codes. Benefits of component coding will be reviewed in this article. The American Medical Association/Specialty Society Relative Value Scale Update Committee has been filtering for codes that are frequently reported together. NeuroInterventional procedures are going to be caught in this filter as our codes are often reported simultaneously as for example routinely occurs when procedural codes are coupled to those for supervision and interpretation. Unfortunately, history has shown that when bundled codes have been reviewed at the RUC, there has been a trend to lower overall RVU value for the combined service compared with the sum of the values of the separate services.

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Carotid and cerebral angiography have been a mainstay of neurointerventional and neuroradiologic practice for years. Centers for Medicare and Medicaid Services (CMS) and Relative Value Scale Update Committee (RUC) initiatives have compelled the professional societies to bundle component codes under threat of unilateral CMS revision and revaluation. Code bundling usually results in a decrease in the professional Relative Value Unit (RVU) valuation, and thus the MD reimbursement. The year 2013 saw a dramatic revision to the Current Procedural Terminology (CPT) code set that defines carotid and cerebral procedures. This paper reviews the process that led to that code set being revised and estimates the impact on professional reimbursement. We show the current and previous carotid angiography CPT codes and use clinical examples to assess professional RVU valuation before and after code revision.

SUMMARY:We describe a crucial but little-known constituent of the Medicare payment system. ABBREVIATIONS: ACR ϭ American College of Radiology; AMA ϭ American Medical Association; ASNR ϭ American Society of Neuroradiology; CMS ϭ Centers for Medicare and Medicaid Services; CPT ϭ current procedural technology; MedPAC ϭ Medicare Payment Advisory Commission; RBRVS ϭ RVS: Resource-Based Relative Value Scale; RUC ϭ AMA/Specialty Services RVS Update Committee; RVU ϭ relative value unit A ssuming that you are not asking about the Royal Ulster Constabulary, RUC is an acronym for the AMA/Specialty Society RVS Update Committee.1-3 RVS, also known by its longer acronym RBRVS, is short for the Resource-Based Relative Value Scale. The RUC (verbalized colloquially as "the ruck") debates the RVU values for medical/surgical procedures and makes recommendations to the CMS. It is a crucial but little-known component of the Medicare payment system.A RUC meeting resembles a group of concentric circles. The actual RUC (the central circle, if you will) is a committee including 23 practicing physicians and a few allied health specialists. Representatives from the CPT panel and from the AMA are also on the committee. CMS representatives are nonvoting members.A larger concentric circle consists of individuals (advisors and alternate advisors) who are sent by more than 100 medical specialty societies (including the American Society of Neuroradiology, ACR, the Society of Interventional Radiology, and the Association of University Radiologists) as representatives to the RUC meetings. These advisors present specific code summaries and recommendations to the central committee but cannot themselves vote on final valuation. This second circle also includes nonphysician staff representatives from the societies, who are essential in preparing the presentations.An outer circle includes observers from other groups interested in medical payment policy who attend at the request of or through permission of the RUC: These can include the Government Accountability Office, MedPAC, and Medicare carriers. Who Is On the RUC?Twenty of the 29 seats on the RUC are assigned to specific medical specialty societies, including 1 for radiology. The specialty society (ACR for radiology) nominates a RUC member (as well as an alternate member), who serves at the approval of the AMA. There are 3 rotating seats on the RUC, which are filled by election, and there are additional seats assigned to representatives from the AMA, CPT Panel, the American Osteopathic Association, and 1 seat for a group representing allied health care professionals (eg, podiatry, physician assistants, speech-language pathology, and so forth). How Does the RUC Interdigitate with CPT? (Wait, What's CPT?)The CPT panel meets 3 times a year in sequence with the thrice-yearly RUC meetings. The CPT panel debates and approves new procedural codes, revises codes that are already in use, and deletes obsolete ones. Typically, a code that has been revised or newly approved by the CPT will then be reviewed at...