HAP Radiology Billing and Coding Blog

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.

Will you have to be ready to use ICD-10 coding by October 1, 2015?  The answer is: "perhaps".  Current law says that this will be the earliest date for its implementation.  CMS, the Centers for Medicare and Medicaid Services, has stated that there will be no further extensions.  And, at the time of this writing, there is no indication that an ICD-10 extension will be included as part of legislation that would also extend the current Medicare fee schedule beyond its planned March 31^st expiration, but this could change as negotiations continue in Washington this week. 

As we have reported in a previous article, there are many good reasons to prepare for ICD-10 even if the Medicare program never requires it to be used!  The key to readiness is to improve clinical documentation so that the coding and billing team can do the best job possible to maximize your practice reimbursement, and this approach will also help improve your billing immediately.

The landscape of Medicare payment policy will be changing over the coming years as a result of actions taken in 2014 through the Medicare Physician Fee Schedule (MPFS) and the Protecting Access to Medicare Act (PAMA).  The MPFS for 2015 contained fewer changes to current payment policy than it did proposals deferred for future consideration.  The Protecting Access to Medicare Act of 2014 (PAMA) was initiated to avoid the significant Medicare payment reduction imposed by the Sustainable Growth Rate (SGR) provision in the Medicare law, but it also contained other provisions affecting payment under the Medicare program. 

The Centers for Medicare and Medicaid Services (CMS) announced that Medicare coverage for lung cancer screening using low-dose CT (LDCT) scans would become effective as of February 5, 2015.  However, according to the American College of Radiology (ACR), we are likely a few months away from publication of the details needed before radiology practices can begin submitting claims to Medicare for these scans.  They recommend that “physicians meeting the coverage criteria should hold all claims for low-dose CT lung cancer screening until further reimbursement instructions are released by CMS.”  The article “College Addresses Lung Cancer Screening Questions” appeared in the February 13^th edition of the ACR’s Advocacy in Action eNews. 

Good documentation is the key to optimal coding and reimbursement for radiology procedures.  By including all of the essential elements in the radiology report, physicians give their coders all of the information they need to get the billing done most efficiently.  But when the report lacks some required piece of data, the coders must contact the radiologist for clarification.  At best, this slows down the billing process but, at worst, it leads to under-coding and therefore lower payment than is possible for the procedure.

The stage is set for a new era of Medicare payment modification using data self-reported by physicians that measures the quality of their work.  The two programs already in place are the Physician Quality Reporting System (PQRS) and the Value-Based Payment Modifier (VM).  These two will work in concert to determine either a positive, neutral or negative payment adjustment to the basic Medicare fee schedule, generally two years following the reporting year.  Note that the rewards and penalties for these programs are cumulative; failure to meet the PQRS reporting requirements will invoke a penalty under both the PQRS and the VM programs.

According to the American College of Radiology (ACR), “The technical component for more than 200 imaging procedures will be cut by up to 55 percent in the final 2015 Medicare Physician Fee Schedule (MPFS) because of a decision to remove the direct practice expense of numerous film inputs that affected their reimbursement rates in favor of the cost of acquiring a desktop computer.”  The decreased reimbursement is sizable for such procedures as myelography, CTA and a variety of ultrasound studies.  The ACR’s analysis was released in their recent eNews article Analog to Digital Conversion to Cost Radiologists.  The article includes helpful impact tables showing the specific change in radiology reimbursement rates between 2014 and 2015 for each CPT code. 

The changes cited by the ACR are the result of Medicare’s attempt to recognize that most practices today use digital PACS technology rather than film.  They removed the costs associated with film production and storage, but replaced those costs with only the value of $2,501 to represent a typical radiology reading station.  No recognition was given to the overall cost of installing and maintaining the central PACS hardware and software.  The ACR reports that, as an example, CPT 76377 (3D Post-processing of tomographic modality) receives a 45.7% reduction for film-based costs offset by a gain of only 1.7% when the desktop computer is substituted.

Radiologists concerned with maximizing practice revenue in 2015 would do well to understand the nuances of new coding changes that can impact reimbursements. The majority of coding changes for 2015 involve either bundling two codes into one when those codes are most often reported in combination or the creation of new codes to clarify their usage.  The resulting impact on an individual practice’s overall payment levels should be minimal but will depend on its actual procedure mix.   One major item of note is that Medicare will begin to provide reimbursement for Digital Breast Tomosynthesis (DBT, sometimes referred to as 3D Mammography) beginning in 2015 in the form of a code to be added-on to digital screening and diagnostic mammography services, although reimbursement from commercial payers is not guaranteed.