HAP Radiology Billing and Coding Blog

In our recent article we wrote about The Case for Maintaining an Independent Radiology Practice in the Face of Industry Consolidation.  A radiology practice that has served the community with high quality services over many years naturally has developed relationships that can be drawn upon to strengthen its position, and avoid what might otherwise seem to be the imperative to become absorbed by some larger entity.   Some of those existing relationships include the hospital served by the group, its referring physician community and neighboring radiology practices.

The recent award of $10 million in a medical malpractice lawsuit is noteworthy not only for the high amount of the award, but also for what can be learned from the case.  It highlights the consequences of poor patient communication and lack of appropriate follow-up. 

The Centers for Medicare and Medicaid Services (CMS) announced that clinicians who participated in the Merit-based Incentive Payment System (MIPS) in 2018 can access their 2018 performance feedback by logging in to the Quality Payment Program website.   The information should confirm whether you or your practice will receive a positive, negative, or neutral Medicare fee schedule adjustment in 2020 based on the 2018 results.  According to a posting on the CMS website, 98% of eligible clinicians participated in MIPS for 2018, up from 95% in 2017, and 97% will receive a positive payment adjustment by virtue of exceeding the 15-point performance threshold. 

The Centers for Medicare and Medicaid Services (CMS) released their annual proposal for changes to the Medicare payment system for the coming year, and they also released new information about the existing mandate for the use of Clinical Decision Support (CDS) beginning in 2020.  The Medicare Physician Fee Schedule (MPFS) Proposed Rule contains not only proposed adjustments to Medicare reimbursement but also proposed changes to the Quality Payment Program (QPP) for 2020 and beyond.

We are clearly in an era marked by the consolidation of healthcare services into fewer but larger providers, involving not only hospital systems but physician groups as well.  Radiology practices are not immune to this trend.  The study Radiology Practice Consolidation: Fewer but Bigger Groups Over Time published in April by the Journal of the American College of Radiology shows that practices consisting of 100 or more radiologists grew significantly between 2014 and 2018, while practices of fewer than 100 radiologists declined.  There are many reasons local practices feel the need to become larger, but at the same time there is usually a lot of trepidation among the physicians about joining with another organization.  Before jumping on the merger bandwagon, be sure you’ve considered the ways you can achieve your goals while remaining independent.

Radiologists are most likely not paying much attention to the Merit-based Incentive Payment System (MIPS) Cost category because no specific action is needed to report data, and usually radiology groups have little control over the cost attributed to a patient.  The Centers for Medicare and Medicaid Services (CMS) has released a new MIPS resource on the Cost performance category that provides good information on this aspect of the MIPS scoring.  This affords a good opportunity to review the Cost category and better understand its potential impact on your practice.

Read our 2021 IR billing & coding article 

Proper coding of physician services is essential to efficient billing and the optimization of reimbursement from payers, including commercial and governmental entities.  The CPT^® codes issued by the American Medical Association (AMA) to describe physician procedures are supposed to be recognized as standards, but in practice they are not accepted equally by all payers.  One example is CPT codes in the range 99241-99255 that describe consultation services.  These are most often used by interventional radiologists, as described in our article Coding and Billing Considerations in Interventional Radiology.

Just as you were done revising your practice systems and processes for Meaningful Use and MACRA/MIPS, a new Medicare mandate came along.  One of the biggest challenges for radiology practices right now is to be able to comply with the requirement that ordering physicians use a Clinical Decision Support Mechanism (CDSM) to consult Appropriate Use Criteria (AUC) when ordering MR, CT, PET and other specified nuclear medicine exams.  This rule has been on the books since 2014, but it will begin to be implemented in 2020 followed by the imposition of penalties in 2021.  This is not a voluntary bonus like Meaningful Use, or the avoidance of a small fee reduction under MIPS, but rather it means there will be NO payment to the radiologist for procedures performed without using the appropriate process.  

It’s natural to want to compare one’s performance against others or to some standard.  Radiologists often chat among themselves about the number of exams per year they read or maybe the number of RVU’s (Relative Value Units) they generate.  While there are inherent problems with some of these comparisons as we outlined in our recent article Understanding the Value of RVUs in Radiology, measuring and monitoring productivity can be beneficial to a radiology practice and to the individual radiologist. 

There was a time when word-of-mouth from friends and family was enough to inform our decisions, but today advice from the internet has taken precedence over recommendations from those we know personally – and this is especially true in healthcare. Patients are turning to the internet to research physicians, practices, and procedures before they even call the office to make an appointment. Individuals seeking care are more likely to choose physicians with high ratings and positive reviews over physicians with a less-than-stellar online presence.  Physicians need to be serious about their online reputation and take the necessary steps to ensure it is positive.