HAP Radiology Billing and Coding Blog

Physicians’ Medicare reimbursement in the coming years will be impacted by their participation in CMS quality programs in 2014. Quality reporting programs such as PQRS, Meaningful Use and the new Value-Based Modification Program have allowed physicians to earn incentives for compliance with their requirements, but beginning in 2015 that carrot will become a stick. Medicare will apply penalties that reduce reimbursement for physicians that are eligible but do not participate in the programs. Payment reductions for 2015 have already been determined by participation in 2013, but there’s still an opportunity to take steps in 2014 to avoid a reduction in 2016 payments.

On April 1st, President Obama signed into law the Protecting Access to Medicare Act of 2014 that delays for 12 months a permanent repeal of the SGR and averts a 24% Medicare physician pay cut that was scheduled to begin April 1st. The bill also extends the 0.5% provider update until March 31^st, 2015. Somewhat unexpectedly, the bill also delays ICD-10 implementation until at least October 1, 2015.

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.

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. 

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.