HAP Radiology Billing and Coding Blog

During 2016 we worked hard to provide our readers with information and advice that would allow them to maximize their performance under the Physician Quality Reporting System (PQRS) and therefore to maximize their reimbursement in 2018 under the associated Medicare Value-based Payment Modifier (VM).  The results have just been announced by the Centers for Medicare and Medicaid Services (CMS), and are available in a CMS Fact Sheet.

With the release of the final Medicare Physician Fee Schedule for 2018 (MPFS), we learned that application of the Appropriate Use Criteria/Clinical Decision Support (AUC/CDS) requirement that was originally scheduled to begin in 2018 has been deferred until January 1, 2020.  Nonetheless, since AUC/CDS is embodied in the Protecting Access to Medicare Act (PAMA 2014), CMS has no choice but to implement it at some point.  While radiologists can breathe a sigh of relief for the moment, setting up and testing their system should be an ongoing project over the coming years.

The first performance measurement year of the Medicare Incentive-based Payment System (MIPS) was 2017, the results of which will be used to determine Medicare payment adjustments in 2019.  This was considered a “transition year” that allowed practices to “pick your pace,” ranging from a streamlined path that would simply avoid penalties in 2019 to full participation that could generate positive payment adjustments in 2019.  The bar has been raised for 2018 performance measurement, and it will continue to be raised again in 2019 as the program reaches full implementation as required by law.  This article summarizes the changes for 2018 that will affect the performance of radiology practices as they work to maximize their reimbursement in 2020.

Click here to read our 2024 code changes update article.

The recently issued Medicare Physician Fee Schedule (MPFS) Final Rule for 2018 tells us which of the revisions to the Current Procedural Terminology[i] (CPT)^® have been adopted for use in the Medicare system, and how Medicare values those codes.  The diagnostic radiology changes are fairly straightforward, but the Interventional Radiology (IR) coding for Endovascular Repair has been drastically altered with 20 new or revised codes. 

The regulations that will affect Medicare reimbursement for physician practices in 2018 have been released.  They include the Medicare Physician Fee Schedule Final Rule  (MPFS), the hospital Outpatient Prospective Payment System Final Rule (OPPS), and the Quality Payment Program Final Rule (QPP). 

Physicians participating in Medicare’s Merit-based Incentive Payment System (MIPS) have the option of reporting data for 2018 as an individual Eligible Clinician (EC), as part of a group practice that bills Medicare using the same Taxpayer ID Number (TIN), or as part of a Virtual Group.  The latter option is available to a group with 10 or fewer ECs, or an EC in solo practice, who might want to join forces with at least one or more similarly-sized practices for the purpose of reporting their MIPS data for a performance year.  A solo practitioner participating under two TINs may even form a virtual group across both practices.  

When people are referred by their personal physician to a specialist, they usually see the specialist in his or her office for a consultation.  Following the office visit, if the patient and physician deem a procedure to be appropriate, the procedure is scheduled in a facility such as an ambulatory surgicenter or hospital procedure room.  Interventional radiologists, on the other hand, most often see their consultation patients at the time of the procedure in the hospital setting where the procedure will be performed, rather than in their own office.  Changing this approach can yield benefits for the radiology practice, as well as for the patient.

Click here to read our October 2020
y-90 radioembolization article 

Our 2014 article "Interventional Radiology Meets Radiation Oncology – The y-90 Story” focused on the documentation requirements that will assist coders to maximize reimbursement for this complex procedure.  Those documentation tips are still valid today.  This update reviews the 2017 state-of-the-art in coding for y-90 procedures.

As MACRA heads down the homestretch of its first implementation year, providers across all specialties are assessing the status of their practice and looking for guidance as to what the future holds. Understandably, concern and confusion remain. While most major players involved in healthcare delivery agree with the move to value-based compensation conceptually, the constant evolution of what is now the Quality Payment Program (QPP) has in many ways created more questions than it has answered. Specialty physician practices looking for certainties amidst the complexities should focus on this important factor: value-based payment models, in theory, have bi-partisan support. This is not expected to change despite the continuing ACA debate in Congress. Implementation delays and grace periods may indeed make it into ongoing legislation. However, proactive physician practices are realizing that the wait-and-see era is over. Maximizing reimbursements in the QPP in the years to come requires planning and implementing a compliance program right now.    

If you currently outsource your revenue cycle management, you know that the performance of your billing company is paramount to your practice’s financial success. Reimbursement continues to decline, and the migration to value-based payments from fee for service will continue to jeopardize your practice finances if your revenue cycle partner is not performing.