HAP Radiology Billing and Coding Blog

Since its first appearance in the Medicare rules, the radiology community has been quarreling with CMS about the Multiple Procedure Payment Reduction (MPPR) on the professional component of certain diagnostic imaging services.  Finally, Congress has taken steps to mitigate the impact of this rule. 

Our first article in this series provided a list of questions to ask when evaluating a professional services Revenue Cycle Management (RCM) vendor for your radiology practice.  If your current RCM vendor cannot answer all of them positively, it’s time to look for a new vendor.  With a large number of RCM companies available in the market, how should you decide which one to choose?

In our previous articles in this series, we covered the top two reasons for radiology claims denials, Patient Eligibility Problems and Lack of Proper Authorization.  The third biggest reason for insurance claims denials is failure to document the medical necessity for the exam. Let’s take a look at this issue in detail so that your radiology practice can avoid such claims denials. 

Under regulations proposed earlier this year, physicians will face up to a 4% fee schedule reduction in 2019 for failure to meet the reporting requirements of the new Quality Payment Program in 2017. Now the Centers for Medicare and Medicaid Services (CMS) has announced that it is going to revise those proposed regulations to make it easier to avoid the negative adjustment and perhaps even earn a slight positive adjustment in 2019.  The final rules will be published around November 1, 2016 and will take effect on January 1, 2017.

The grace period during which Medicare would not impose penalties for less-than-specific coding under ICD-10-CM* is expiring on October 1, 2016.  The change from ICD-9 to ICD-10 diagnosis coding that took place on October 1, 2015 was a major adjustment for most physicians and their practice staff.  The Centers for Medicare and Medicaid Services (CMS) recognized some of the difficulties that were going to be faced in the transition, and in response they issued a document of guidance describing certain ‘flexibilities’ that would initially be allowed.

This article continues our series focusing on how to avoid radiology claims denials. In our first article, we covered Patient Eligibility Problems.  Now let’s look at the topic of procedure authorization, specifically the failure to obtain proper authorization before the service is performed.

The Centers for Medicare and Medicaid Services (CMS) has issued its proposed revisions to the Medicare Physician Fee Schedule (MPFS) for 2017, thus beginning the annual cycle of review, comment, planning and preparation that goes along with this release.  Missing from this year’s proposed rule are provisions related to the Medicare quality reporting programs (PQRS, VM, MU-EHR*) that have been a large part of the rule in recent years. 

When a major hospital-based radiology practice realized that their outpatient volume had dropped suddenly, their Revenue Cycle Management (RCM) company stepped up to quickly diagnose the problem. Using their analytic database, they produced a focused referring doctor report that revealed significant outpatient service volume declines concentrated among a handful of providers, one of which had decreased by 60%.  It’s this kind of responsiveness that sets a true RCM partner apart from the average vendor.

Claims for reimbursement of radiology services are most often denied by the payer, whether it is Medicare or a commercial insurance company, because they contain inaccurate information about the patient’s eligibility for coverage. This can occur for many reasons, some of which may not be within the control of the radiology practice, but it usually can be corrected by improving the process of recording data at the time of patient registration. In this new healthcare economy where radiology practices are under pressure to add value to the patient care delivery system, effective management of claims denials can strengthen the relationship between the practice or imaging center and the hospitals they serve.

The new healthcare economy is redefining many working relationships that have remained unchanged for years. As a prime example, radiologists are understandably concerned about becoming viewed as commodities rather than as physicians who fill a vital role in patient care. One way for them to escape this stereotype is to have more direct interaction with patients, which will also simultaneously achieve one of the goals of the American College of Radiology’s (ACR) Imaging 3.0 initiative – to provide patient-centered, value-based care.