2024 Noninterpretive Skills Study Guide
effort, and skill (the work RVU); 2) costs of
maintaining a practice, such as equipment,
supplies, and nonphysician staff (practice
expense RVU); and 3) professional liability
expenses (malpractice RVU). Work RVU is used
by many practices to track physician
productivity. Although the Centers for
Medicare and Medicaid Services (CMS)
ultimately sets the valuation of RVUs, it has
historically accepted the AMA RUC
recommendations in the vast majority of cases.
Once an RVU is determined for a specific
service or procedure designated by its CPT
code, a multiplier called the Conversion Factor
(CF) is used to determine the actual
reimbursement. Thus, to obtain the actual
reimbursement for a specific procedure, the
RVU for that procedure is multiplied by the CF.
Payment = RVU x CF
The conversion factor is set annually by CMS in
Final Rule of the Medicare Physician fee
schedule. For example, the CF for 2020 was set
by CMS at $36.09 and in 2021 this fell to $34.89.
CMS and private insurers generally pay only
for services deemed medically necessary. CMS
defines medical necessity as “healthcare
services or supplies needed to prevent,
diagnose, or treat an illness, injury, condition,
disease, or its symptoms and that meet
accepted standards of medicine.” In
practicality, the determination of medical
necessity is usually a rules- based
administrative exercise performed at the time a
claim is submitted to a payer, wherein a CPT
service code must match a pre-approved
diagnosis code list. Those diagnosis codes must
be in the form of the International Classification of
Diseases (ICD) system, established by the World
Health Organization, currently in its 10th
revision (ICD-10). ICD-10 codes describe the
signs, symptoms, or specific diagnosis of a
patient that form the indication for a healthcare
service. Terms such as “rule out” or “consistent
with” are not capable of being coded by ICD-10,
and therefore do not meet medical necessity
criteria.
Reimbursement for radiology services is largely
predicated on the adequacy of documentation
within the physician report. Professional
coders, assisted by software tools, extract
information from radiology reports to assign
both ICD-10 and CPT codes. The Radiology
Coding Certification Board is the primary
organization that credentials professional
medical imaging coders. These individuals
extract ICD-10 information from radiology
reports using any statements 1) about
examination indication and clinical history
provided by the referring physician or patient
and 2) from any specific diagnostic information
located in the findings section or (preferably) in
the impression section of the radiologist’s
report. CPT codes are assigned based on the
specific details of the described service. For
radiography, more views generally translate to
higher complexity codes. For ultrasound, organ
inventory “checklists” apply to abdominal,
pelvic, obstetrical, and extremity imaging. For
CT and MRI, details of contrast administration
(i.e., without, with, or without and with
contrast) determine the CPT code for a specific
body part. Structured template reporting helps
radiologists comply with many of these
reporting requirements, facilitating appropriate
reimbursement and regulatory compliance.
Many private payers, Medicaid plans, and
Medicare Advantage (i.e., not traditional
Medicare indemnity) payers contract with
radiology benefit management (RBM)
companies, and require preauthorization (also
known as precertification) as a condition for
reimbursement for any elective outpatient
advanced imaging service. Before performing
advanced imaging services such as CT, MRI,