HAP Radiology Billing and Coding Blog

When the dust finally settled, we could see how the 2014 Medicare Physician Fee Schedule (MPFS) would impact radiology reimbursement, and results were mixed. Hospital-based services came out ahead while imaging centers generally took a big hit. Due to the many factors that contribute to the calculation of the final fee schedule, a weighted analysis will help you determine the actual impact on your practice.

The Medicare Physician Fee Schedule (MPFS) contains lower reimbursement in 2014 for diagnostic imaging and interventional radiology due to revisions adopted by the Centers for Medicare and Medicaid Services (CMS) in the annual Medicare rules update published in December. Radiation oncology practices will see a slight increase in the fee schedule while freestanding radiation therapy centers are facing considerable reductions. Meanwhile, Congress took some action to defer even larger cuts but continues to leave the medical community uncertain of future payment rates for physician services.

CMS, the Centers for Medicare and Medicaid Services, has announced that it will begin full enforcement of rules concerning physician orders that have been in place since 2009. These rules will impact radiology billing. Beginning January 6, 2014, claims submitted for imaging services will be denied if they do not accurately report the name and NPI number of the ordering/referring provider.

Unfortunately denials are a fact of life, but in radiology billing, there isn’t much room for error. Due to the high volume nature of the work, errors can proliferate quickly. Denials not only represent lost revenue; the cost of resubmission or appeals can sometimes exceed the reimbursement value. Managing denials is an imperative, but without a smart strategy, they could be eroding your profitability.

In recent years, the Centers for Medicare and Medicaid Services (CMS) has broadened its use of the Multiple Procedure Payment Reduction (MPPR) methodology to reduce Medicare payments to physicians, but there may be situations where your practice can justify avoiding this payment reduction.

Imagine that your radiology practice realized a $750,000 in underpayments in two years. Now consider the impact such a shortfall would have on your practice’s ability to grow or even sustain itself. In this actual case, a payer was reimbursing 10 of the group’s physicians correctly while underpaying another 15 for the same procedures at the same time. This is a vivid lesson in the importance of continually monitoring third-party payments to ensure payers are reimbursing you at your contracted rates.

Physicians will begin to see their Medicare payments cut by 2% for services rendered beginning April 1st as the federal budget sequester takes effect. Their patients will still be responsible for co-insurance and deductibles at the same, pre-sequester level. For unassigned claims, reimbursements to beneficiaries would be subject to the 2% sequester reduction just like payments to physicians on assigned claims.

Radiology practices using teleradiology – servicing both hospitals and imaging centers – will have to consider whether they need to make any changes to their billing and reporting due to Medicare’s final Place of Service rules. CMS, the Centers for Medicare and Medicaid Services, has long been trying to establish rules for reporting the location of physician services. However, the rules have been delayed by questions and logistical problems that have been raised by those affected, primarily in the radiology community. Although many questions remain, CMS has issued what it considers to be its final set of rules, and they will become effective April 1, 2013. Practices should take a look at their service locations to see if they are operating in more than one payment locality and whether physicians are reading in locations other than where the patient was seen. If so, there is work to be done to prepare for the changes needed to submit radiology billing claims under the Medicare Physician Fee Schedule. 

Guest Author | by Elizabeth W. Woodcock, MBA, FACMPE, CPC

Improving patient collections may not be at the top of the to-do list in many radiology practices, but it should be. There’s no non-clinical activity more important to your practice’s future than taking action to get paid for the services you provide.

Clinical documentation is the foundation of the health record, while the conversion of this narrative description into codes serves as the basis for reimbursement, quality reporting and other administrative and research activities. While documentation is often adequate from a clinical perspective, payer requirements, quality programs and government regulations often dictate specific requirements for reimbursement.