HAP Radiology Billing and Coding Blog

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.

The goal of a well-managed radiology billing operation is to submit claims for services promptly and receive reimbursement as quickly as possible. Timely submission and prompt payment enhance the practice’s cash flow and keep the overall cost of billing at a minimum.  All too often, however, payment is delayed because the payer denies the claim for some reason. 

Along with the entire healthcare industry in America, radiology is increasingly being asked to standardize its methods of practice. Radiologists’ reports have traditionally been free-text documents in formats that vary from physician to physician, even within group practices.  This individual style of reporting has become the radiologist’s personal signature on the work he or she has done with each patient exam but it does not lend itself to meeting modern requirements. 

This year is the final reporting period under the now-familiar Physicians Quality Reporting System (PQRS). The Centers for Medicare and Medicaid Services (CMS) just announced proposed regulations that will govern new Medicare quality-reporting rules known as the Quality Payment Program (QPP) beginning in 2017.  This new system, which was enacted as part of the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), comprises both the Merit-based Incentive Payment System (MIPS) and Alternative Payment Models (APMs).  The final rules will be published later this year, but physicians can begin now to explore whether they want to join an APM or adapt to the MIPS reporting requirements. 

The Centers for Medicare and Medicaid Services (CMS) issued two reminders recently that physicians must be working constantly to maintain compliance with the Medicare quality reporting programs. The current regulations call for adjustment of the fees paid to physicians for services to Medicare patients based on annual measurement of the physicians’ performance under quality and cost metrics.  Radiologists must focus on their quality measures because the system assigns them to an Average Cost pool by default since they have little or no control over this factor.