3:45 PM Abstract No. 332 Financial impact of unbundling moderate sedation from procedural codes in radiology

In 2017, moderate sedation (MS) was unbundled from procedural CPT codes and new MS codes were created. To assess the impact of unbundling, reimbursement for the new codes across major payors in an inpatient, academic radiology practice were evaluated to quantify the effects on revenue. Billing and reimbursement data for 23 months (available data from Fiscal Years (FY) 2018 and 2019, July 2017 – May 2019) of unbundled MS codes 99152 (initial 15 minutes of sedation administered by procedural operator) and 99153 (each subsequent 15 minutes) were analyzed for reimbursement rates and trends. Five index procedures were further identified and MS reimbursement for Medicare and the largest private payor were calculated. For the same five procedures performed in Fiscal Year 2016 (pre-unbundling), estimated MS reimbursement components were calculated. These values were then compared to the real, unbundled reimbursements for matched index procedures. Departmental reimbursement for unbundled moderate sedation in FY 2018 and 2019 totaled $669,701.34. When compared with the average reimbursement across all payors, Medicare reimbursed 22.8% and 0% per unit of 99152 and 99153, respectively, while the largest private payor, in line with the commercial payor average, averaged 235.3% and 218.1%. Across the five selected index procedures, Medicare reimbursement per case decreased by 1.3% after unbundling (range, 0.9-1.7) while private payor reimbursement increased by 11.9% (range, 5.8-16.4), resulting in a slight net increase in per case revenue. Revenue from moderate sedation accounted for 3.9% of procedural revenue (range, 1.2-5.6) from Medicare, and 5.5% of procedural revenue from the private payor (range, 1.0-7.9). After unbundling moderate sedation from procedural codes, average per case reimbursement from Medicare decreased, with losses fully mitigated by an overall positive but heterogeneous change in per case revenue from commercial payors. Departmental revenue from unbundling was significant, highlighting the need for consistent and accurate reporting of moderate sedation as Medicare reassesses MS valuation and adjusts reimbursement rates in the future.