HAP Radiology Billing and Coding Blog

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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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.

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.

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...

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:

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.

Participation in Medicare’s PQRS program is important to radiologists in order for them to maintain full reimbursement under the Medicare fee schedule, and to perhaps earn a higher level of payment in future years.  Radiologists providing services in Independent Diagnostic Testing Facilities (IDTFs) will not be able to participate in PQRS, according to a ruling described in the June 16, 2015 issue of the RBMA Washington Insider.  This most recent guideline issued by the Centers for Medicare and Medicaid Services (CMS) clarifies past guidance by stating, “After further review, CMS is announcing that EPs [eligible professionals] who provide services under an IDTF or an independent lab (IL) (and on behalf of services provided by that IDTF or IL) are not able to participate in PQRS.  Therefore EPs who provide services [billed] under an IDTF or IL will not receive the 2015-2018 PQRS payment adjustments for services associated with the IDTF or IL”.  This reverses CMS guidance issued as recently as March, 2015.

Reimbursement rates for both Breast Ultrasound and Digital Breast Tomosynthesis (DBT) received a boost from the Centers for Medicare and Medicaid Services (CMS) this year.  Medicare adopted new CPT¹ coding that provides enhanced reimbursement for ultrasound services, and coverage was newly approved for DBT as an add-on to screening and diagnostic mammography examinations.  These changes were described in our article, The Impact of Coding Changes on Radiology Practices in 2015.  In order to fully realize the benefit of these new billing opportunities, proper documentation is required within radiology practices.