Medicare Physician Fee Schedule Final Rule:
Impact on Radiology, Part 2

By Douglas G. Smith, FRBMA, Managing Partner of Strategic Positioning & Consulting Solutions

 

As a follow up to our first blog post regarding the 2017 Medicare Physician Fee Schedule highlights, you will find additional information and details below:

New Bundled Mammography Codes

CMS will also not make any changes to the technical component (TC) reimbursement for mammography with CAD, but CMS is changing the code definitions to match the 2017 CPT® codes. For example, code G0202 will now be defined as “screening mammography, bilateral (2-view study of each breast), including computer-aided detection (CAD) when performed” to match code 77067. The G codes will be used for both digital and non-digital mammograms. CMS expects to switch over to the CPT® mammogram codes in 2018.

CMS accepted the mammogram work RVUs proposed by the RUC (Relative Value Unit Update Committee) but is not accepting the practice expense RVUs as this would result in drastic payment cuts. Instead, CMS will use the PE-RVUs from the G codes. CMS notes in the Final Rule that there will not be significant payment reductions for mammography in 2017.

Reimbursement Reductions for Plain Film X-rays

CMS has demonstrated over the past two years its commitment to getting digital images into the EMR. While some entities may choose to take a hit in 2017 rather than make the capital investment in digital radiology, the penalties in the coming years may warrant the investment.

Delayed CDS/AUC Implementation

After consulting the appropriate use criteria (AUC), the ordering professional must communicate the results of the AUC consultation to the furnishing professional (imaging facility) at the time the advanced imaging study is ordered. CMS stated in the Final Rule it does not intend to establish any requirements as to how this communication takes place.

The furnishing professional is in turn required to report the results of the AUC consultation on the Medicare claim for the imaging exam, and CMS expects this requirement to go into effect on Jan. 1, 2018. CMS is considering various mechanisms for this reporting, including HCPCS G codes and HCPCS modifiers.

By 2020, the Protecting Access to Medicare Act (PAMA) requires that CMS identifies “outlier” order professionals who consistently fail to follow AUC recommendations. These outliers will be required to obtain pre-authorization for advanced imaging exams.

Ordering professionals will be required to consult AUC for all advanced imaging services that are furnished in an applicable setting, such as office or outpatient, and paid under an applicable payment system, such as MPFS or OPPS. However, in the 2017 Final Rule CMS designated eight “priority clinical areas” that will be the focus for identifying outliers:

  • Coronary artery disease (suspected or diagnosed)
  • Suspected pulmonary embolism
  • Headache (traumatic and non-traumatic)
  • Hip pain
  • Low back pain
  • Shoulder pain (to include suspected rotator cuff injury)
  • Cancer of the lung (primary or metastatic, suspected or diagnosed)
  • Cervical or neck pain

Moderate Sedation

CMS is decreasing the RVUs of codes that previously included moderate sedation, which will now be separately reportable with all procedures including those that were previously listed in Appendix G of the CPT® manual. For example, interventional radiologists who provide moderate sedation in conjunction with lower extremity revascularization or percutaneous biliary procedures should report the sedation service separately beginning on Jan. 1, 2017 using new sedation codes 99151-99157. Note that CMS has also created an HCPCS code (G0500) for moderate sedation, but this code is used only in conjunction with GI endoscopy.

Preliminary Comparative Analysis

We have performed a preliminary comparative analysis of 2017 versus 2016 with the “Imaging Cap” (lower of OPPS or MPFS) for all affected technical component CPT codes. There have been rumors in the marketplace that some MRI codes experienced cuts up to 58 percent in 2017 versus 2016. We do not see such drastic cuts in our preliminary analysis, but we do see certain MRI, CT and Ultrasound codes with reductions in the technical component from as low as .8 percent to as high as 19 percent (selected MRI codes). We also see some slight increases in technical component rates as well.

When a more complete analysis has been performed, IRP will publish the results. The full impact of the changes in the 2017 MPFS to practices will only be fully understood based upon their historical utilization volume by modality, by CPT code. It will also be important to factor in any changes to practices’ locality Geographic Practice Cost Index (GPCI).

To learn more about the 2017 MPFS Final Rule’s impact on radiology and other medical specialties, please contact us.