HAP Radiology Billing and Coding Blog

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y-90 radioembolization article 

Interventional Radiology Meets Radiation Oncology – The y-90 Story

When a physician is performing an interventional procedure valued in the range of $4,000 – $6,000 for the professional component, attention to thorough and accurate documentation is a requirement for maximal reimbursement.  Each case presents its own individual set of circumstances and a well-constructed operative report will tell the story of the case step-by-step.  Each artery or branch into which a catheter is placed for diagnostic imaging or intervention is assigned a separate CPT code, and so the operative report must describe with specificity each catheter placement.  When these descriptions are in a logical, sequential order, certified coders say that this allows them to better understand every aspect of the case so they can then accurately identify and apply up to 45 CPT codes to maximize reimbursement for it.  A descriptive evaluation of each artery supports payment of the codes that are submitted for reimbursement.

As private insurance payers begin adopting the Multiple Procedure Payment Reduction (MPPR) methodology that was implemented by Medicare several years ago, practices that are not ready could face a revenue loss of 25% or more for some services.  Of specific interest to radiologists is United Healthcare, which announced in its May 2014 Network Bulletin that it would be expanding its MPPR to the professional component of imaging services in alignment with Medicare’s policy.  This change will apply to United Healthcare’s Commercial and Community Plan. Originally the policy was to take effect in the third quarter of 2014 but under pressure from radiology advocacy organizations, United has now reported that implementation of the policy will be delayed until the fourth quarter of 2014.  This brief reprieve provides radiology practices with an opportunity to lessen this detrimental impact on their revenue by improving their current processing methodologies before these changes take place.

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.