HAP Radiology Billing and Coding Blog

The federal No Surprises Act (NSA) has been in effect for a few weeks and many practices are just now beginning to make adjustments to accommodate the law. The level of pro-active involvement might be different for practices working solely in a hospital system from those with a private office or imaging center.

Now that the final Medicare conversion factor (CF) for 2022 of $34.6062 has been established, following passage of the Protecting Medicare and American Farmers from Sequester Cuts Act, we can analyze the real impact that radiology practices can expect this year. We reported recently that the final CF is a 0.82% reduction from the 2021 rate. However, the CF is not the only factor that affects the Medicare fee schedule. CMS annually revises the pricing of various procedure codes due to changes in practice expense, which generally affects the Technical Component (TC) more than the Professional Component (PC). Accordingly, radiologists will see a different overall result for services in a private office or imaging center than they will for hospital services.

The No Surprises Act (NSA) was designed to protect patients from receiving large medical bills from a physician or facility that does not participate in their insurance plan. It was to provide a mechanism whereby the providers could receive a payment from insurers that reflects a reasonable market price, with a dispute resolution process to be used when the parties were too far apart to reach an agreement. While this all sounds very reasonable and good for patients, it always seemed like the insurance companies could use the law as leverage to terminate existing agreements with providers who had negotiated high fee schedules and force them into lower-rate contracts. And that is exactly what is beginning to happen.

On January 1, 2022, practices will have to comply with the federal No Surprises Act (NSA) unless their state has a similar law already in effect. The federal legislation that was passed in December 2020 is intended to allow providers to receive a reasonable payment from insurers for services to non-network patients without putting those patients in the middle of a payment dispute. At the end of September, long-awaited regulations that will govern the details of its implementation were issued and were met with displeasure by healthcare providers. For example, the American College of Radiology^® (ACR^®) wrote in its detailed summary of the rule that it “is disappointed that the regulations violate the intent of the No Surprises Act (NSA) by making the Qualified Payment Amount (QPA) the primary determinant of physician payment rates in the independent dispute resolution process.”

In our recent article on reimbursement for using artificial intelligence (AI) in radiology, Sandy Coffta mentioned the possibility of new codes proposed by the American College of Radiology (ACR) and other imaging societies. One of those new codes was approved and released on July 1, 2021, for use beginning January 1, 2022. HCPCS^[1] Level II code 0691T (CPT^[2] Category III) will apply to the use of AI for automated analysis of existing CT studies for vertebral fracture(s), including assessment of bone density when performed, data preparation, interpretation, and reporting.

Based on revised recommendations from the US Preventive Services Task Force (USPSTF), the Centers for Medicare and Medicaid Services (CMS) is considering an adjustment to its reimbursement policy for LDCT Lung Cancer Screening. CMS expects to complete its decision-making process before February 2022. In the meantime, many commercial payers have already expanded coverage by adopting the new recommendations.

The No Surprises Act* will become effective January 1, 2022. This is the first federal regulation that is aimed at protecting patients from receiving unexpected bills from healthcare providers who are outside of their insurer’s network. Review our recent article for an overview of its provisions.

The radiology community is abuzz with talk of artificial intelligence (AI) systems that can assist physicians with image interpretation and perform other tasks. Like any new technology, it will take time before AI gains widespread acceptance due to the cost of implementation. This is analogous to the early-day PACS, where the benefits of efficiency had to be proven in order to justify the expenditure for such a costly system. Today almost all imaging is interpreted on computer systems … when was the last time anyone looked at a piece of film?

The Quality Payment Program (QPP) continues to be modified due to the COVID-19 public health emergency. The Centers for Medicare and Medicaid Services (CMS) recently announced some leeway for clinicians affected by the pandemic in 2020 and 2021.

The issue of patients receiving large, unexpected medical bills from hospitals and physicians has been widely publicized. This situation, known as surprise billing, arises when a hospital or physician provides medical care to a patient but is not participating in a patient’s insurance network. We have reported on the many states that have put legislation in place to try and mitigate the problem for their own residents, but now there will be a nationwide policy thanks to recent federal legislation.