HAP Radiology Billing and Coding Blog

Buried in the 2014 legislation that delayed the Sustainable Growth Rate for a year was a provision that will penalize radiology groups that have not upgraded their CT equipment to the latest standards.  As described in the April 28, 2015 edition of Radiology Business,  “Beginning in January 2016, any exam acquired with a CT system that does not meet the XR-29- 2013 standard, also known as MITA Smart Dose, will be hit with a 5% penalty.  In 2017, that penalty jumps to 15%.  XR-29-2013 was published by the National Electrical Manufacturers Association’s Medical Imaging & Technology Alliance (MITA) in 2013, and is considered the industry standard for CT technology.”

Congress has enacted the “Medicare Access and CHIP Reauthorization Act of 2015” (MACRA), which makes sweeping changes to the Medicare payment system.  Initially conceived to put an end to the perennial struggle with the Sustainable Growth Rate (SGR) methodology, MACRA replaces the SGR with a valuation system that will minimally increment Medicare fees in the near term but which will eventually tie physicians’ fees to the quality measures they report. 

Will you have to be ready to use ICD-10 coding by October 1, 2015?  The answer is: "perhaps".  Current law says that this will be the earliest date for its implementation.  CMS, the Centers for Medicare and Medicaid Services, has stated that there will be no further extensions.  And, at the time of this writing, there is no indication that an ICD-10 extension will be included as part of legislation that would also extend the current Medicare fee schedule beyond its planned March 31^st expiration, but this could change as negotiations continue in Washington this week. 

As we have reported in a previous article, there are many good reasons to prepare for ICD-10 even if the Medicare program never requires it to be used!  The key to readiness is to improve clinical documentation so that the coding and billing team can do the best job possible to maximize your practice reimbursement, and this approach will also help improve your billing immediately.

The landscape of Medicare payment policy will be changing over the coming years as a result of actions taken in 2014 through the Medicare Physician Fee Schedule (MPFS) and the Protecting Access to Medicare Act (PAMA).  The MPFS for 2015 contained fewer changes to current payment policy than it did proposals deferred for future consideration.  The Protecting Access to Medicare Act of 2014 (PAMA) was initiated to avoid the significant Medicare payment reduction imposed by the Sustainable Growth Rate (SGR) provision in the Medicare law, but it also contained other provisions affecting payment under the Medicare program. 

The Centers for Medicare and Medicaid Services (CMS) announced that Medicare coverage for lung cancer screening using low-dose CT (LDCT) scans would become effective as of February 5, 2015.  However, according to the American College of Radiology (ACR), we are likely a few months away from publication of the details needed before radiology practices can begin submitting claims to Medicare for these scans.  They recommend that “physicians meeting the coverage criteria should hold all claims for low-dose CT lung cancer screening until further reimbursement instructions are released by CMS.”  The article “College Addresses Lung Cancer Screening Questions” appeared in the February 13^th edition of the ACR’s Advocacy in Action eNews. 

Good documentation is the key to optimal coding and reimbursement for radiology procedures.  By including all of the essential elements in the radiology report, physicians give their coders all of the information they need to get the billing done most efficiently.  But when the report lacks some required piece of data, the coders must contact the radiologist for clarification.  At best, this slows down the billing process but, at worst, it leads to under-coding and therefore lower payment than is possible for the procedure.

The stage is set for a new era of Medicare payment modification using data self-reported by physicians that measures the quality of their work.  The two programs already in place are the Physician Quality Reporting System (PQRS) and the Value-Based Payment Modifier (VM).  These two will work in concert to determine either a positive, neutral or negative payment adjustment to the basic Medicare fee schedule, generally two years following the reporting year.  Note that the rewards and penalties for these programs are cumulative; failure to meet the PQRS reporting requirements will invoke a penalty under both the PQRS and the VM programs.

The stage is set for an interesting year of coding, billing and reimbursement in radiation oncology.  The CPT¹ coding structure for radiation oncology services underwent significant revision in order to bundle certain services that are usually reported together and to clarify the meaning of some codes in the context of current clinical practice.  In some cases this required the creation of new CPT codes to describe these services, or revision of the descriptions of existing codes in other cases.  Medicare’s decision not to fully recognize these coding changes creates the potential for two different systems to be in place for 2015, and is sure to cause discrepancies between billing for Medicare and billing for other payers. 

Medicare will pay physicians a lump sum bonus equal to 0.5% of their 2014 Medicare reimbursement in exchange for successfully reporting data under the Physician Quality Reporting System (PQRS).   The PQRS program has been in place since 2007, but reporting for 2014 is the final opportunity to earn an incentive payment.  Failure to report PQRS data in 2014 will result in a 2.0% PQRS penalty through reduction of Medicare physician fee schedule payments in 2016, plus a possible additional 2.0% penalty under the new Value-based Modifier program.

According to the American College of Radiology (ACR), “The technical component for more than 200 imaging procedures will be cut by up to 55 percent in the final 2015 Medicare Physician Fee Schedule (MPFS) because of a decision to remove the direct practice expense of numerous film inputs that affected their reimbursement rates in favor of the cost of acquiring a desktop computer.”  The decreased reimbursement is sizable for such procedures as myelography, CTA and a variety of ultrasound studies.  The ACR’s analysis was released in their recent eNews article Analog to Digital Conversion to Cost Radiologists.  The article includes helpful impact tables showing the specific change in radiology reimbursement rates between 2014 and 2015 for each CPT code. 

The changes cited by the ACR are the result of Medicare’s attempt to recognize that most practices today use digital PACS technology rather than film.  They removed the costs associated with film production and storage, but replaced those costs with only the value of $2,501 to represent a typical radiology reading station.  No recognition was given to the overall cost of installing and maintaining the central PACS hardware and software.  The ACR reports that, as an example, CPT 76377 (3D Post-processing of tomographic modality) receives a 45.7% reduction for film-based costs offset by a gain of only 1.7% when the desktop computer is substituted.