HAP Radiology Billing and Coding Blog

At Healthcare Administrative Partners, our mission is to educate practices on CMS Quality Programs and provide a path to optimized performance even in the most challenging markets. This is the final installment of our series of articles, “A Program for Successful PQRS Participation for Radiology Practices,” which was specifically designed to help you maximize reimbursement and reduce compliance issues under the Physician Quality Reporting System (PQRS).  So far we’ve covered...

The Acting Administrator of the Centers for Medicare and Medicaid Services (CMS), Andy Slavitt, recently posted this blog article that describes the successful transition to ICD-10 diagnosis code reporting on October 1, 2015.  In it, Slavitt writes, “For thousands of physicians and other clinicians around the country, the change to ICD-10 was a big undertaking, requiring time, planning and a period of adjustment.  But on October 1, proper execution and good implementation made all the difference.”

The Office of the Inspector General (OIG) is charged with auditing federal programs under the Department of Health and Human Services to identify waste, fraud and abuse in order to protect the integrity of these programs and the health and welfare of their beneficiaries. The OIG annually issues it’s Work Plan for the coming year, outlining the programs and specific areas that it will be investigating. Physician services paid by Medicare receive a major share of attention every year from the OIG.  In this article, we will describe some of the areas under review in the 2016 Work Plan that will be of interest to radiologists.

Nearly a year passed between the announcement by the Centers for Medicare and Medicaid Services (CMS) that Medicare coverage would be available for low-dose computed tomography (LDCT) lung cancer screening and issuance of the regulations that would allow claims to be submitted.  The patient eligibility requirements and the details for performing the exam were announced in February 2015 but it took the rest of the year before the billing and reimbursement particulars were known.  Finally, Medicare will pay for LDCT procedures performed on and after February 5, 2015 beginning in 2016. A 43-page decision memo from CMS defines in great detail the criteria that must be met by patients, physicians, and imaging centers in order for the scans to be eligible for reimbursement.  Here is a practical summary of the rules for performing and billing these screening services.

Now that 2016 is in full-swing, the new realities of our changing healthcare economy are becoming very apparent to providers across all specialties, and radiology is no exception. As physician practice leaders, assessing how to maintain and grow your practice as the transition to value-based compensation continues is not an easy task.  At Healthcare Administrative Partners, our mission is to educate practices on these matters and provide a path to optimized performance even in the most challenging markets.  Our continuing series of articles, “A Program for Successful PQRS Participation for Radiology Practices,” is specifically designed to help you maximize reimbursement and reduce compliance issues under the Physician Quality Reporting System (PQRS).  So far we’ve covered:

Congress has mandated that the Centers for Medicare and Medicaid Services (CMS) move forward with quality-based programs and associated payment models. In 2015, the Medicare Access and CHIP Reauthorization Act (MACRA) was signed into law, expanding the Medicare quality-reporting programs that began as a voluntary incentive ten years ago with the original Physician Quality Reporting Initiative (PQRI).  Today it is more important than ever to embrace and maximize success in these programs and be ready to move ahead as they evolve. 

One of the new coding requirements imposed by Medicare for 2016 is that practices attach a billing modifier to CT procedures performed with older CT equipment that does not meet the standards of NEMA XR-29-2013. Medicare’s payment for services billed with the new “CT” modifier will be reduced by 5% of the technical component.  Both the Radiology Business Management Association (RBMA) and the American College of Radiology (ACR) have posted blog articles this week about the new requirements. 

In our two recent articles we covered the effect of changes to codes in the Current Procedural Terminology¹ (CPT) for diagnostic radiology and radiation oncology. Now we turn our attention to CPT code changes for 2016 that affect interventional radiology (IR).  As before, our analysis focuses on the effect those changes will have on practice revenue.  Each practice’s experience will vary based on the volume of procedures that use the affected codes, and a volume-weighted analysis of the entire Medicare fee schedule is recommended to gain a complete understanding of the impact to the practice.

A variety of federal legislative activities during 2014 and 2015 contained rulings that will begin to affect Medicare reimbursement to physicians next year. Most recently, The Centers for Medicare and Medicaid Services (CMS) issued its Medicare Physician Fee Schedule (MPFS) Final Rule for 2016 that will govern its payments to physicians.  The overall impact of the final MPFS changes to radiology and radiation oncology practices compared with the proposed changes issued earlier this year, is estimated by CMS as follows:

There are relatively few CPT¹ coding changes for radiation oncology treatments in store for 2016, at least when compared with diagnostic and interventional radiology.  CMS, the Centers for Medicare and Medicaid Services, is still considering and revising a new set of codes for radiation treatment delivery that was proposed in 2015 but not yet implemented.  When implementation does occur, these codes will most likely not involve valuation differences, although this in an uncertainty until CMS takes action in some future year.