HAP Radiology Billing and Coding Blog

Recently reported developments in federal health care policy could change the direction radiologists are taking to maintain maximum Medicare reimbursement. 

Click here to read our 2024 code changes update article.

The recently issued Medicare Physician Fee Schedule (MPFS) Final Rule for 2018 tells us which of the revisions to the Current Procedural Terminology[i] (CPT)^® have been adopted for use in the Medicare system, and how Medicare values those codes.  The diagnostic radiology changes are fairly straightforward, but the Interventional Radiology (IR) coding for Endovascular Repair has been drastically altered with 20 new or revised codes. 

The regulations that will affect Medicare reimbursement for physician practices in 2018 have been released.  They include the Medicare Physician Fee Schedule Final Rule  (MPFS), the hospital Outpatient Prospective Payment System Final Rule (OPPS), and the Quality Payment Program Final Rule (QPP). 

With the first year of the Merit-Based Incentive Payment System (MIPS) already well underway, the Centers for Medicare and Medicaid Services (CMS) began sending out MIPS Participation Status Letters in April. The letters were sent to each Eligible Clinician (EC) associated with a group Taxpayer Identification Number (TIN).  An EC can also check the Medicare Quality Payment Program (QPP) web site to determine his or her eligibility.  The letter and web site contain general information about participation in MIPS, along with email and telephone contact information that should be used if a provider feels his or her status is incorrect.

There are circumstances where payment is expected to be denied by Medicare for radiology services to be provided to a Medicare patient. In such cases, the radiology practice must look to the patient for payment.  However, without following proper procedures the practice will be precluded from collecting from either the patient or Medicare.

Accuracy and completeness in radiology reporting has taken on an even higher level of importance in order to maximize Medicare reimbursement. The Quality Payment Program (QPP) under MACRA highlights the necessity to meet new quality performance standards.  While the benefits of structured reporting using templates have been discussed before, including in our article Reimbursement Benefits of Structured Radiology Reporting, reporting on quality measures under the QPP has to include very specific terminology in order to receive credit for the measure.  This is an ideal time for radiologists to begin to use standardized reporting across their practice to ensure that all of the critical elements of documentation are met. 

Physicians and other Eligible Clinicians (ECs) who are participating in MIPS under the MACRA rules governing Medicare payments will face requirements that differ depending on whether they are deemed to be “patient-facing” or not.  This determination will affect the Advancing Care Information (ACI) and Improvement Activities (IA) components, but not the Quality Performance component of MIPS. In this article, we’ll break-down the key considerations for radiology practices. 

By now everyone involved in billing Medicare for physician services should be aware of the new Quality Payment Program (QPP) that will be in effect for payments in 2019 based on data submitted in 2017.  The proposed rules for the new system were outlined in our recent article Medicare Quality Reporting Rules are Changing.  The final regulations that will govern the new system were recently issued, and radiology practices will benefit from preparing as early as possible to capture the data they will need to report under the new system.  ­

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The Merit-Based Incentive Payment System (MIPS) is slowly being analyzed and absorbed by the medical community. This system, passed into law by the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), will begin to take effect for physician reimbursement in 2019 but those payment adjustments will be determined by performance in various categories for services rendered in 2017.  Regulations governing the application of this law have now been finalized and savvy radiology practices can begin to prepare to comply with the new system.

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.