HAP Radiology Billing and Coding Blog

Understanding The Valuation Changes In The Final Medicare Fee Schedule For 2019

Posted: By Sandy Coffta on February 27, 2019

Understanding The Valuation Changes In The Final Medicare Fee Schedule For 2019 Healthcare Administrative PartnersOur review of the proposed 2019 Medicare Physician Fee Schedule (MPFS) showed that 201 Professional Component (PC) codes and 213 Global codes were to be decreased by at least 1% in the Diagnostic Radiology 70000-series of CPT codes.  In the final MPFS, only 46 PC codes were reduced by 1% or more, but 280 global codes were reduced by at least 1%.  The number of codes expected to increase in payment did not change as dramatically, but in both PC and Global billing fewer codes were increased than we expected.  Here are the details:

 

  Professional Component Global

Number of codes with a:

Proposed Final Proposed Final
Decrease of 1% or more 201 46 213 280
Increase of 1% or more 47 45 187 172
Change of less than 1%

342

474 150 77
Total Procedure Codes 590 565 550 529

Diagnostic Radiology

As we reported in our recent Coding Changes That Will Impact Radiology Practices in 2019, the two Breast MRI codes for unilateral and bilateral were replaced by four new codes that provide for the distinct billing of non-contrast exams, which previously had to be billed using the with/without contrast codes. 

 

  Professional Component Global
Description 2019 Comparable 2018 2019 Comparable 2018

77046 MRI Breast, without contrast, unilateral

$74.24 $83.52 $252.99 $552.23
77047 MRI Breast, without contrast, bilateral $82.17 $83.52 $259.84 $549.71
77048 MRI Breast, without and with contrast, unilateral $107.40 $83.52 $401.84 $552.23
77049 MRI Breast, without and with contrast, bilateral $117.49 $83.52 $410.49 $549.71

 

The result of these changes is a slight decrease in the ‘without contrast’ professional component and a significant increase in the ‘without and with contrast’ professional component.  The technical component was drastically reduced by 62% in the ‘without contrast’ exams and by 37% in the ‘without and with contrast’ exams, resulting in corresponding cuts in the global fees

 

Note that 77048 and 77049 also include computer-aided detection (CAD real-time lesion detection, characterization and pharmacokinetic analysis) when performed.  This bundling eliminates the separate use of HCPCS code 0159T, a locally-priced code that was previously added when performing CAD.

 

The proposed rule showed significant decreases for some neck and spine PC codes, but in the end those codes were actually increased slightly:

 

Description CPT Code Final 2019 Rate Expected Change Final Change

Neck Spine 4/5 views

72050-26 $16.22 (19.9%) +0.1%
L-2 Spine 4/> views 72110-26 $16.22 (19.9%) +0.1%
Neck Spine 6/> views 72052-26 $18.74 (19.1%) +0.1%
L-S Spine Bending 72114-26 $16.94 (19.0%) +0.1%

 

Other PC procedures that fared well in the final rule compared with the proposed rule included MRI Brain, both with and without contrast (70557 and 70558).  These had been scheduled for a 7% decrease, but instead ended up with a 0.3% decrease at the final fee schedule amount of $160.01 and $176.23, respectively. 

 

Procedures for which large increases had been proposed saw lesser increases, although the PC for CT Needle Biopsy was minimally increased, as was the global Transrectal Ultrasound.

 

Description CPT Code Professional Component Global
Expected Final Expected Final

Spine x-ray 1 view

72020 50.2% 0.1% 25.6% 3.3%
Elbow x-ray 2 views 73070 48.0% 0.1% 14.4% (1.2%)
Heel x-ray 73650 43.7% 0.1% 11.8% (1.2%)
Forearm x-ray 73090 37.7% 0.1% 24.8% 8.3%
Elbow x-ray 3+ views 73080 32.2% 0.1% 4.6% (5.5%)
Sacrum tailbone x-ray 72220 32.2% 0.1% 21.4% 7.6%
SI Joints x-ray <3 views 72200 32.2% 0.1% 21.4% 8.9%
SI Joints x-ray 3+ views 72202 18.7% 0.1% 13.0% 5.5%
CT for needle biopsy 77012 28.4% 29.0% 22.0% 21.1%
MRA Upper Extremity w/wo 73225 (0.7%) (1.1%) 17.5% 15.8%
MRA Spine w/wo 72159 0.5% 0.5% 21.1% 19.4%
DXA peripheral 77081 (6.3%) (6.3%) 20.2% 17.6%
Ultrasound AAA screening 76706 0.1% (1.2%) 19.5% 19.1%
Ultrasound transrectal 76872 (3.0%) (0.9%) 28.5% 31.8%

 

A few global billing codes experienced unexpected changes:

  • CT Angiography Abdominal Arteries (75635) received a 13.6% cut whereas the proposal had been for a 0.3% increase. The final fee is $323.27 for this procedure. 

  • CT Angiography Abdomen & Pelvis, without/with contrast (74174) received a 10.4% increase rather than a 5.1% decrease. The final fee is $402.20 for this procedure.

  • Cardiac MRI with stress imaging (75559) received a 21.6% increase rather than a 1.1% decrease. The final fee is $460.22 for this procedure.

It should be noted that all fees quoted here are from the national Medicare fee schedule, before adjustment for geographic indices. 

Interventional Radiology

Interventional Radiology took some losses in the 2019 fee schedule.  As proposed, the large decreases in PICC placements were retained in the final rule, and Nephrostomy catheter exchanges suffered a 9.1% decrease instead of a 10.4% increase.  Other proposed increases were retained but at a lower level:

 

Description CPT Code Proposed Final

Insert PICC catheter < age 5

36569 (61.3%) (61.3%)
Insert PICC catheter age 5+ 36568 (57.2%) (57.2%)
Fine Needle Aspiration w/o imaging 10021 (21.8%) (19.8%)
Exchange Nephrostomy catheter 50435 10.4% (9.1%)
Cystoscopy 52000 11.6% 14.1%
Injection for Cholangiogram 47531 11.7% 10.0%
Removal of biliary drainage catheter 47537 12.1% 10.6%
Replace PICC catheter 36584 70.4% 67.9%

Analyzing Your Practice

The result of all these changes on an individual practice can only be evaluated through a volume-weighted analysis.  This process involves gathering data from the previous year by CPT code that shows the number of times each procedure code was billed for Medicare patients.  The procedure volumes are multiplied by the 2018 Medicare fee schedule rates in one column, and again by the 2019 Medicare fee schedule rates in another column.  Totaling each column will reveal the total practice revenue for the previous year and the reimbursement that the practice could expect in the current year if the volume of each procedure was unchanged.   The percentage increase or decrease can then be calculated. 

 

Medicare’s data predicts that the resulting change between 2018 and 2019 will be 0% for both diagnostic and interventional radiology.  However, if your practice performs more than the average number of procedures that had a large increase or decrease, your individual results will reflect that variation.  The same analysis can be applied to commercial payer fee schedules that are calculated as a percentage of the Medicare fee schedule.

Conclusion

Understanding the annual changes in Medicare’s fee schedules is useful when analyzing areas where the practice’s revenue might be increasing or decreasing.  Many commercial payers base their fees on the Medicare table, although not all of them make exactly the same changes, or at the same time, as Medicare does.  The American College of Radiology (ACR) always prepares a detailed analysis of the MPFS that contains background discussion of the current Medicare changes as well as information about what might be coming in future rule-making.

 

HAP will continue to keep you abreast of the Medicare payment system, and subscribing to this blog is the best way to get the most current information available.

Sandy Coffta is the Vice President of Client Services at Healthcare Administrative Partners.

 

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Topics: MPFS, diagnostic radiology, interventional radiology, radiology, radiology reimbursement

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