Q&A: Selecting revenue codes for cardiac CT services
Q: How has CMS addressed its erroneous revenue code edits for cardiac CT services, and how should we select revenue codes for cardiac CT now?
A: CMS included a request for information (RFI) in the 2025 Outpatient Prospective Payment System (OPPS) proposed rule to address an issue with revenue code assignment for cardiac CT services that may have affected payment. In the RFI, the agency stated that it has received comments noting that payment for these services has declined since 2017 and that the payment does not cover the cost of providing the services, as well as other concerns about coding for these services and edits applied to claims that affected revenue code reporting.
Stakeholders have repeatedly requested that CMS move cardiac CT services to a different clinical Ambulatory Payment Classification (APC). However, the agency maintained the classification because it was relying on claims data, NAHRI Advisory Board member John Settlemyer, MBA, MHA, CPC, CHRI, assistant vice president of enterprise revenue management/CDM operations at Atrium/Advocate Health in Charlotte, North Carolina, explained during the July 2024 members-only NAHRI Quarterly Call. Claims data forms the basis for numerous payment adjustments used to update OPPS payments, including geometric mean cost calculations and cost-to-charge ratio calculations—the latter of which are based on the revenue codes reported on claims.
CMS did respond to stakeholders’ concerns. Early in 2024, the agency acknowledged an outdated edit was at the root of the problem. In Transmittal R12421CP, CMS included a section on revenue code reporting for cardiac CT Current Procedural Terminology (CPT®) codes 75572, 75573, and 75574. In the transmittal, CMS stated: “We recently identified an outdated return-to-provider (RTP) HCPCS-to-revenue code edit that resulted in certain claims submissions being limited to specific revenue codes for CPT codes 75572, 75573, and 75574. These claims were returned to the providers for resubmission. The outdated edit has been removed; and providers, when appropriate, may begin billing these codes with any appropriate revenue code.”
Essentially, the erroneous RTP edit limited organizations’ ability to report any revenue code for those services other than a “CT scan” revenue code, Settlemyer explained during the July 2024 NAHRI Quarterly Call.
NAHRI responded to CMS’ RFI, among other issues, in a comment letter submitted on the proposed rule. As NAHRI noted, although CMS removed the erroneous edit, the edits remained in claims clearinghouses and with other payers, preventing hospitals from implementing the revenue code changes.
In the 2025 OPPS final rule, CMS stated that for 2025 and subsequent years it will use an alternative methodology to calculate payment for cardiac CT services and is finalizing a temporary reassignment of the cardiac CT codes (CPT codes 75572–75574) to APC 5572 (Level 2 Imaging with Contrast). Based on comments it received in the proposed rule, CMS anticipates that it will take several years to see an impact from changes in billing practices. Therefore, the agency anticipates using this alternative methodology until it has enough data. If, after three or four years, CMS does not see a significant increase in the geometric mean costs of these services based on claims data, it will revert payment for these services to the standard OPPS payment methodology and assign the cardiac CT codes to the appropriate APCs based on their geometric mean costs.
In the final rule, CMS acknowledged comments from stakeholders, including NAHRI, who pointed out that due to third-party edits and other issues, a majority of hospitals were not able to act on the changes announced in Transmittal R12421CP. The agency stated that it expects process changes to happen slowly as billing practices are updated. The agency reiterated its long-standing policy that hospitals must determine the most appropriate cost center and revenue code for cardiac CT codes and that it does not instruct hospitals on assignment of HCPCS codes to revenue codes. These established policies, as well as Transmittal R12421CP, should serve as sufficient education for third parties such as claims clearinghouses and other payers, according to CMS. However, CMS acknowledged that more may be required and that it will provide additional education and instruction through the Medicare Learning Network.
See p. 324 of the final rule for more details.
Editor’s note: This article was excerpted from “Unpacking new payment policies in CMS’ 2025 OPPS final rule” in the January 2025 issue of the NAHRI Journal. Published quarterly, the NAHRI Journal is a benefit of NAHRI membership and is free to members. Learn more about NAHRI membership and join here.