For over 4 decades, interventional radiologists, in conjunction with the Society of Interventional Radiology, have been creating, editing, campaigning and supporting new and evolving billing codes that reflect the full gamut of IR therapies. Today, CPT® codes describe healthcare services and procedures and are used by Medicare, Medicaid and private insurers to determine reimbursement rates.
“Interventional radiology early on was this innovative, almost niche, specialty—but from a policy perspective, we had to establish our identity,” said Ezequiel Silva III, MD, FSIR, who serves as the chair of the American Medical Association RVS Update Committee (RUC). “There were very practical considerations; for example, we needed to be separately identified by policymakers as interventional radiologists. We wanted to be able to bill for our services and have procedural codes that not only described what we did but also reimbursed fairly for what we did. We wanted to have consistent procedural codes for health-policy research.”
When billing for services, Dr. Silva said, IRs wanted a clear specialty identifier.
“It was a very important step for our specialty,” he said. “It took a lot of involvement and engagement—both at a specialty-society level and also getting out there in the trenches and working with regulators such as Medicare, as well as lawmakers, to have ourselves identified within statute and law. It took a sort of public relations campaign to get our name and recognition out there.”
Dr. Silva presented the 2024 Charles T. Dotter Lecture, which focused on the importance of IR coding advocacy, and reflected on how crucial these early coding achievements were for IR evolution.
“In 1990, William Hsiao was creating a new Medicare system that revamped how physicians were reimbursed,” Dr. Silva said. “IR made a play for the inclusion of component billing, rather than complete coding.” Essentially, this would allow for the creation of CPT® codes that better reflected the reality of IR procedures and described them alongside other procedural specialties, thus enabling more reliable reimbursement and better data for health-policy research.
“By the time 1992 rolled around, IR had achieved wins with component coding, surgical and radiology coding, meaningful valuation, and recognition as a specialty,” Dr. Silva said. “It was nothing short of remarkable.”
Kathy Krol, MD, FSIR, an ex officio member of SIR’s Economics Committee, began her journey through coding advocacy when she was a new volunteer with SIR—then the Society of Cardiovascular and Interventional Radiology—and had a front seat to the IR coding evolution.
“It became an area of interest for me. We could advocate for patients, but also for physicians, by aiming to get payments set at a point that services are available to patients,” Dr. Krol said. “If the payment is set too high, payors will not cover the service, and it won’t be available to patients. If the payment is set too low, providers will not perform the service, and it won’t be available to patients.”
Dr. Krol’s first coding experience was on a nephrostomy code; she was asked to partake in a survey by the RUC Panel, which was attempting to value all the existing codes when the RBRVS system was instituted. She then went on to write and present at a CPT® Editorial Panel meeting regarding dialysis access intervention codes.
Since then, Dr. Krol has served as the SIR CPT® advisor, as well as a member of the AMA CPT® Editorial Panel. She’s had a hand in almost all IR codes that have been developed since 1997.
“I took the first bundled IR code through the process, with TIPS being the first targeted service that was pushed to be bundled,” she said. “Getting the methodology correct for the bundling was important. Bundling was being mandated by national policy changes, and we developed a rationale for when to bundle, as well as a rationale to argue against bundling for some services.”
Dr. Krol also was part of the first multi-specialty collaborations, writing proposals for the first endograft codes alongside vascular surgery and cardiology. “That collaboration was important at a time when the specialties were very adversarial,” said Dr. Krol. “Accomplishing collaboration is one of the things I feel especially good about, as it was not easy, but was the only way to be successful.”
Following those codes, the lower extremity revascularization and carotid stenting codes were also pushed through with a collaborative effort led by SIR. Many of the code changes that occurred during Dr. Krol’s tenure are still in place, though some have been modified as technology advanced— such as codes for embolization, uterine fibroid embolization and dialysis access interventions.
“The House of Radiology has a very strong team and well-respected position at the AMA CPT and RUC meetings, with a long (some would say longest) history in the coding space,” said Julie Bulman, MD, RPVI, the current alternate advisor for SIR to the AMA CPT® Editorial Panel. “Being part of this collaborative family is a strong position for SIR to be in so that we can build new codes effectively and efficiently in our rapidly changing field.”
Proposing, valuing and editing codes is an arduous process, one that relies on substantial work from SIR’s economics division staff and member volunteers.
“This is the one area where no one else is going to do this for us. American College of Radiology (ACR) has a large and strong economics section, but their main focus is diagnostic radiology. In questions of policy that affect IR, other specialties can only support IR when the issue also supports DR or their main constituencies,” she said. “SIR has had to fight some of these battles alone.”
Representation and involvement in the coding and valuation space is as essential today as it was in the early days of IR, according to Dr. Bulman. “Given the complexity of IR's minimally invasive techniques, active participation helps avoid misclassification, under-coding and inadequate valuation, which could hinder the financial sustainability of our field and access for our patients to these essential procedures,” she said. “Additionally, IR engagement promotes recognition of the specialty's contributions and supports compliance with evolving healthcare policies.”
Every day, members benefit from the work put in by economics staff and volunteers, Dr. Krol said—and she encourages all members who want to make a change to get involved.
“Joining the SIR economics committee was a way for me to fight back,” she said. “Instead of being frustrated about what was happening to payments in IR, we actually have the power to influence payments and policy.”
