HAP Radiology Billing and Coding Blog

How the MPFS Rule for 2015 Will Impact Radiology Practices

Posted: By HAP USA on December 03, 2014

radiologistwithpatientMedicare’s Physician Fee Schedule (MPFS) for 2015 contains relatively few changes that will impact payments to radiology practices next year.  By revising some of the assumptions that go into the setting of the Relative Value Units (RVU), the allowed fees for diagnostic radiology professional services will decrease by 1% and imaging centers will see a 2% reduction, while interventional radiology and nuclear medicine services will remain unchanged.


These changes are calculated using a constant Conversion Factor to translate the RVUs into reimbursement dollars.  For 2015, the Conversion Factor (CF) will initially not be changed from its current level, thanks to a provision in the Protecting Access to Medicare Act (PAMA) of 2014 that fixed the CF through March 31, 2015.  Beyond that date, it will take another Congressional act to avoid a 21.2% cut in the CF for the remainder of the year under the Sustainable Growth Rate (SGR) formula.


Breast Tomosynthesis (3D Mammography)

New revenue opportunities will result from the decision by CMS1 to reimburse for Digital Breast Tomosynthesis (DBT, sometimes referred to as 3D Mammography) beginning in 2015.  This payment will be in the form of a code to be added-on to digital screening and diagnostic mammography services.  CPT2 Code 77063 (screening digital breast tomosynthesis, bilateral) may be added to the digital screening mammography code (G0202) to indicate DBT services.  Similarly, HCPCS3 Code G0279 (diagnostic digital breast tomosynthesis, unilateral or bilateral) may be added to the digital diagnostic mammogram codes G0206 (unilateral) and G0204 (bilateral).  By defining DBT using an add-on code, there is no way to report diagnostic breast tomosynthesis when it is performed separately from a full-field digital mammogram. 


The new add-on codes will be paid at $30.79 for the Professional Component and $25.78 for the Technical Component ($56.57 for global services) in addition to the regular payment for the screening or diagnostic mammogram.  These amounts are calculated using the national CF of $35.8013 but they will be adjusted for each geographic region when the actual fee schedules are published.


While CMS elected not to utilize newly-created CPT codes 77061 and 77062 (breast tomosynthesis diagnostic, unilateral and bilateral respectively) for 2015, commercial payers will have the option to do so.  This sets up the potential for confusion, as practices may have to use different billing methods for commercial payers than they do for Medicare. 



The 2015 Proposed Rules circulated earlier this year considered a change to the coding of mammography procedures by eliminating the HCPCS ‘G-codes’ for digital mammography and revaluing the CPT codes 77055, 77056 and 77057 to the same values that are currently used for the G-codes.  In its Final Rule, CMS elected not to make the change for 2015 but instead will consider a complete overhaul of mammography pricing and coding for 2016.


Interventional Radiology

Payment for epidural pain injections (62310, 62311, 62318 and 62319) will be reduced in 2015 due to bundling of the procedure with the associated imaging guidance.   CMS says that the values assigned to these codes already include fluoroscopic guidance and that separate billing for image guidance will be prohibited in connection with them.


The valuation of transcatheter placement of intravascular stents (CPT 37236 and 37237) was temporarily reduced in 2014 while CMS sought input information to establish a permanent value.  For 2015, the value of these procedures was finalized at the level established for 2014.  Minor adjustments were also made to breast biopsy codes that had been re-valued in 2014 and the resulting valuations will also be finalized at the adjusted 2014 levels.


New X-Modifiers Replace Modifier -59

Although not covered in the MPFS Final Rule, a recent announcement from CMS introduced the new –X{EPSU} Modifiers for 2015.   These will be used to define subsets of the CPT Modifier -59 for a “Distinct Procedural Service”.  More detailed information is contained in our article Is Your Radiology Practice Ready for the New HCPCS Modifiers?  We will be reporting on other 2015 coding changes in an upcoming article.



The Medicare Final Rule for 2015 contained fewer changes to payment policy than were expected at the time the Proposed Rule was published in mid-2014.  Many of the CMS proposals were deferred for further consideration, including the revision of mammography coding and pricing.   These will undoubtedly resurface in subsequent revisions of the rules.  As expected there was no expansion of the multiple procedure payment reduction (MPPR) rules.  The great unknown factor for 2015 is whether or not the SGR formula will finally be repealed or further patched when the temporary zero-update period ends on March 31st.  


In a future article, we will review the quality reporting provisions of the 2015 MPFS.  Practices will want to be sure and comply with these rules in order to avoid payment penalties in 2017.  However, application of the quality-tiering methodology under the new Value Modifier program might even generate an upward adjustment that will increase revenue for your practice!  Be sure to subscribe to this blog for our latest coverage and recommendations regarding Medicare rules changes.


[1] The Centers for Medicare and Medicaid Services

[2] Current Procedural Terminology is a copyrighted code set developed and maintained by the American Medical Association.

[3] HCPCS stands for Healthcare Common Procedure Coding System and herein refers to codes developed by CMS for payments under the MPFS.



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