Radiologists who perform venous ablation in a hospital outpatient department are now required to obtain prior authorization before performing such services on Medicare patients. This new requirement became effective for services performed on or after July 1, 2020, and physicians were notified by letters from the Centers for Medicare and Medicaid Services (CMS) late in June. The prior authorization requirement was included in the 2020 Hospital Outpatient Prospective Payment System (HOPPS) Final Rule, and encompasses the following procedures that might be performed by interventional radiologists:
In the final 2020 Medicare Physician Fee Schedule (MPFS), fee increases relevant to radiology overall outnumbered decreases. However, many of those increases were insignificant changes of less than 1%. There were 128 Professional Component (PC) codes decreased by more than 1%, with only 76 increased, while 430 Global codes increased by more than 1% and 346 Global codes decreased. Here are the details:
Our own Sandy Coffta, Vice President of Client Services, spoke with Aunt Minnie’s Brian Casey at the 2019 RSNA Annual Meeting in Chicago. In the interview posted on auntminnie.com, Sandy mentioned some of the highlights that practices should be concerned about in the coming year.
In the absence of federal regulation, states are adopting laws intended to protect patients from high out-of-pocket costs when they unexpectedly receive services from out-of-network (OON) providers. When a patient receives an unexpected bill following such OON services the situation is known as “surprise billing.” Not all OON billing falls into the category of “surprise billing,” however. In many cases, patients understand that the services they are receiving are OON and they expect to pay all or part of the bill.
Proper coding of physician services is essential to efficient billing and the optimization of reimbursement from payers, including commercial and governmental entities. The CPT® codes issued by the American Medical Association (AMA) to describe physician procedures are supposed to be recognized as standards, but in practice they are not accepted equally by all payers. One example is CPT codes in the range 99241-99255 that describe consultation services. These are most often used by interventional radiologists, as described in our article Coding and Billing Considerations in Interventional Radiology.
Just as you were done revising your practice systems and processes for Meaningful Use and MACRA/MIPS, a new Medicare mandate came along. One of the biggest challenges for radiology practices right now is to be able to comply with the requirement that ordering physicians use a Clinical Decision Support Mechanism (CDSM) to consult Appropriate Use Criteria (AUC) when ordering MR, CT, PET and other specified nuclear medicine exams. This rule has been on the books since 2014, but it will begin to be implemented in 2020 followed by the imposition of penalties in 2021. This is not a voluntary bonus like Meaningful Use, or the avoidance of a small fee reduction under MIPS, but rather it means there will be NO payment to the radiologist for procedures performed without using the appropriate process.
In September, we published the article Out-of-Network Balance Billing Laws Are Important for Radiologists to Be Aware Of about the New Jersey law that states patients receiving emergency or urgently needed services will not be required to pay any more than the deductible, copayment or coinsurance they would normally pay whether the hospital and/or its physicians are in-network or out-of-network with the patient’s insurance plan. Here are some more pieces of information we think you should know:
New Jersey is the latest state to pass legislation that will affect the amount a radiology practice can collect from patients whose insurance is not accepted by the practice. While an imaging center would be careful to work with their patients in advance of providing services, the hospital setting does not always afford that opportunity. It is imperative that you know the laws not only in the state(s) where you practice but also to keep abreast of federal regulations that might impact your billing and collections.
Our 2014 article "Interventional Radiology Meets Radiation Oncology – The y-90 Story” focused on the documentation requirements that will assist coders to maximize reimbursement for this complex procedure. Those documentation tips are still valid today. This update reviews the 2017 state-of-the-art in coding for y-90 procedures.
A radiology practice that performs interventional procedures will want to be up to date on the use of documentation and coding techniques for Evaluation and Management (E&M) services. These CPT® codes in the 99xxx range are less commonly utilized in radiology practices. Identifying circumstances where E&M services are billable, and then properly documenting and coding for them, will require a collaborative effort between the interventional radiologist (IR) and his or her coding team.