HAP Radiology Billing and Coding Blog

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.

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.