The annual regulatory cycle of review, comment, planning and preparation has begun with the release of the Medicare Physician Fee Schedule (MPFS) Proposed Rule for 2018. In its preliminary review of those sections of the MPFS that will be of specific interest to radiology practices, The American College of Radiology (ACR) includes a statement that “the ACR is pleased with several provisions within the rule.” They highlight the planned implementation of the Appropriate Use Criteria and Clinical Decision Support rules beginning January 1, 2019 and the proposal to leave the technical component of mammography services unchanged rather than lowering it by 50% as previously discussed.
New information has been provided by The Centers for Medicare and Medicaid Services (CMS) that will supplement our article An Update for Radiologists on Appropriate Use Criteria and Clinical Decision Support. We can now update you from the recent release of the “Proposed Medicare Physician Fee Schedule (MPFS) for 2018” and the “Proposed Rule for Quality Payment Program Year 2.”
Patients in rehabilitation facilities sometimes need imaging services that cannot be provided within the facility itself. Imaging centers willingly accept these patients but they can inadvertently fall into a collections quagmire if they aren’t aware of the Medicare rules related to skilled nursing facilities.
Maximizing the patient experience is no longer limited to the achievement of clinical success. It is a critical component of the new, broader partnership between provider and patient – one that now encompasses conversations regarding not only service quality and cost, but also places a greater focus on practice billing processes in line with the higher demands inherent to the new patient consumerism trend.
Radiologists are understandably nervous about the Medicare rule requiring the use of Appropriate Use Criteria and Clinical Decision Support (AUC/CDS) systems.
There are circumstances where payment is expected to be denied by Medicare for radiology services to be provided to a Medicare patient. In such cases, the radiology practice must look to the patient for payment. However, without following proper procedures the practice will be precluded from collecting from either the patient or Medicare.
Accuracy and completeness in radiology reporting has taken on an even higher level of importance in order to maximize Medicare reimbursement. The Quality Payment Program (QPP) under MACRA highlights the necessity to meet new quality performance standards. While the benefits of structured reporting using templates have been discussed before, including in our article Reimbursement Benefits of Structured Radiology Reporting, reporting on quality measures under the QPP has to include very specific terminology in order to receive credit for the measure. This is an ideal time for radiologists to begin to use standardized reporting across their practice to ensure that all of the critical elements of documentation are met.
Before the days of managed care, insurance plans were “indemnity coverage” that reimbursed patients for their out-of-pocket costs. Physicians billed the patients and got paid when the patients felt like making payment, usually only after the insurance company had reimbursed them. Often, the insurance money went elsewhere in the patient’s budget and the physician waited for payment. The not-so-good old days! With the advent of managed care contracting where physicians were paid directly by the insurance company, patient balance collections mostly disappeared. Today the pendulum is swinging back in the opposite direction, requiring practices to once again face the necessity to collect significant balances from patients.
This is the third in our series of articles designed to help radiology practices prepare for the Merit-Based Incentive Payment System (MIPS). Previous articles covered the Quality Performance Category, which is the largest portion of the MIPS score, and the Advancing Care Information (ACI) Category. Quality will initially account for at least 60% of the total MIPS score and ACI will account for up to 25% of the total score. The Improvement Activities (IA) Category, originally called the Clinical Practice Improvement Activities in proposed regulations, represents 15% of the total score for 2017, the first year of MIPS participation. The fourth element of MIPS, the Cost Category, has been reweighted to zero for 2017.
Medicare publishes its rules and requirements for the coding and billing of medical procedures to obtain reimbursement under its programs, but many commercial insurers are not as transparent about their own requirements. This leaves medical billing professionals in the dark when there are new procedure codes or changes to existing coding in the American Medical Association’s CPT® code set or by federal regulation. Such is the case with mammography coding for 2017. Below we have summarized the key coding considerations for radiology practices billing mammography services this year. (Click here to read our complete article on the 2017 coding changes impacting diagnostic and intervential radiology.)