HAP Radiology Billing and Coding Blog

Radiologists considering the use of an outside service for final reads will have questions that include not only quality and cost but also the impact on the group’s relationship with its hospital and referring physician community. The answer will not be the same for every radiology practice.  Here we present some of the pros and cons for consideration in the decision-making process.

 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.  

With the first year of the Merit-Based Incentive Payment System (MIPS) already well underway, the Centers for Medicare and Medicaid Services (CMS) began sending out MIPS Participation Status Letters in April. The letters were sent to each Eligible Clinician (EC) associated with a group Taxpayer Identification Number (TIN).  An EC can also check the Medicare Quality Payment Program (QPP) web site to determine his or her eligibility.  The letter and web site contain general information about participation in MIPS, along with email and telephone contact information that should be used if a provider feels his or her status is incorrect.

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. 

The Medicare Physician Fee Schedule (MPFS) for 2017 contained some revisions to the coding and reimbursement for moderate sedation that will potentially impact radiology practices. Previously, moderate sedation was not separately reimbursed for many of the procedures listed in Appendix G of the CPT®[i] codebook.  Sedation was bundled with the basic procedure, but now it will be reimbursed in addition to the basic procedure.  There are important guidelines and documentation that must be met in order to use these codes, and radiologists interested in maximizing their reimbursements should review their reporting to be sure it supports proper coding under the new rules.

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. 

If you follow the leading voices in the radiology community, you know that the topic of “value” is a recurring theme of current conversations. It is a core concept behind Imaging 3.0 and has dominated recent seminars, webinars, social media chatter and more for months thanks to MACRA and the many changes it is bringing to provider compensation models. And whatever changes the next wave of governmental healthcare policy washes into the boardrooms of group practices, when the murky waters recede, it is a safe bet that proof-of-value will still remain on the table as a mandate for radiologists going forward. 

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.