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

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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.

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

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Last month, the Centers for Medicare and Medicaid Services (CMS) released the 2017 Medicare Physician Fee Schedule (MPFS) Final Rule, which updates policies and payment rates for services provided on or after Jan. 1, 2017. CMS released the Proposed Rule for comment on July 7, 2016.

Overall, CMS estimates a 2017 conversion factor of $35.8887, a slight increase from the current conversion factor of $35.8043. This change reflects the .5 percent update included in the Medicare Access and CHIP Reauthorization Act of 2015, and will result in an estimated one percent decrease in radiology and interventional radiology payments. Radiation oncology and nuclear medicine payments will remain unchanged.

While this is an improvement from the proposed seven percent reduction in interventional radiology payments, starting in January, certain interventional radiology codes will be bundled, reducing reimbursement for some procedures. For example, cerebral arteriograms are currently reported with component codes, allowing doctors to receive payment for each vessel studied. Instead, procedures performed in 2017 will be reported wholesale, probably resulting in a lowered payment for half of the codes.

The Final Rule also confirmed that any relative value unit (RVU) reductions greater than 20 percent will be phased in annually; therefore, a code faced with a 50 percent RVU reduction would be limited to a decrease of 19 percent in total RVUs each year.

Below are additional changes and announcements from the Final Rule: 

New Bundled Mammography Codes
Starting in January 2018, codes for digital, film screen and computer-aided detection (CAD) mammography will be bundled into one set of three mammography codes. In 2017, CMS will continue using existing G-codes (G0202, G0204 and G0206). CMS will also not make any changes to the technical component (TC) reimbursement for mammography with CAD.

Practice Expense Inputs for Digital Imaging Services
CMS will price the professional PACS workstation at $14,616.93, and has provided a list of 426 radiology codes to which the professional PACS workstation will be added. They have also requested comment on additional codes. This change should result in a bump in TC.

Reimbursement Reductions for Plain Film X-rays
Reimbursement for X-rays taken with plain film will be reduced by 20 percent in 2017 and all subsequent years. In addition, reimbursement for computed radiography will be reduced by seven percent between 2018 and 2022, followed by a 10 percent reduction in 2023 and all subsequent years. To implement the plain film X-ray reduction, CMS has established a new modifier (modifier “FX”) to be used on applicable claims.

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
CMS has delayed the implementation of the clinical decision support (CDS)/appropriate use criteria (AUC) program to Jan. 1, 2018 as policymakers continue to debate what CDS vendors will qualify as CDS solutions as well as the role radiology will have in the CDS process. CDS implementation will apply to orders for all advanced diagnostic imaging services, not just priority clinical areas.

The final list of priority clinical areas includes 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), and cervical or neck pain.

CMS also finalized the requirements for the CDS/AUC reporting delivery mechanism. CMS will begin to accept the first applications for CDSMs immediately, with an application deadline of March 1, 2017. The qualified CDSMs will be announced by June 30, 2017.

Moderate Sedation
Medicare frequently pays for anesthesia services provided by an anesthesiologist or CRNA in conjunction with procedures that are defined as including moderate sedation. In order to eliminate this double payment, CMS is decreasing the RVUs of codes that previously included moderate sedation, and moderate sedation 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 a 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 effected Technical Component CPT Codes. When a more complete analysis has been performed, IMP will update our blog with the results.

Overall, the Final Rule presents several benefits to the specialty of radiology. In addition to phased-in RVU reductions and the delay in CDS implementation, the rule upholds the mandate to lower the existing professional component multiple procedure payment reduction (PC MPPR) from 25 percent to five percent effective Jan. 1, 2017.

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

Using Analytics to Reduce Unspecified Diagnoses

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While most physician practices and health systems implemented ICD-10 with only minor snares along the way, some groups did report a decline in productivity as coders rushed to become familiar with the new code set. Fortunately, the specialty of radiology only uses about 4 percent of the 68,000 codes within the ICD-10 set, significantly narrowing the learning curve for radiologists and radiology-focused coders.

The year-long grace period offered by the Centers for Medicare & Medicaid Services (CMS) served as another aid in the transition. For many payers, the use of unspecified ICD-10 diagnosis codes would lead to many claim denials for failing to meet medical necessity or the payer’s specific policy for the procedure performed. For this reason, CMS gave physicians and coders one year to become familiar with the new ICD-10 coding set and the greater level of specificity it required.

As of Oct. 1, 2016, however, that grace period came to a close. If there is an established policy in place (Medicare National Coverage Determinations (NCD) or Local Coverage Determinations (LCD)), Medicare may now deny certain unspecified diagnoses. If other payers offered a similar grace period, they also may follow suit and deny these claims.

To mitigate the impact this change may have on practice revenue and coder productivity, it is critical to develop and implement an advanced analytics platform to track and cut down on unspecified codes. Many industry leaders have already realized the potential of analytics to generate positive changes in healthcare: In a 2012 executive report titled “The value of analytics in healthcare,” the IBM Institute for Business Value states: “Using analytics to gain better insights can help demonstrate value and achieve better outcomes, such as new treatments and technologies. Information leading to insight can help informed and educated consumers become more accountable for their own health. Analytics can improve effectiveness and efficiency.”

Analytics can help to significantly reduce the number of unspecified diagnoses and therefore protect practices’ cash flow. Radiology groups should aim for unspecified codes to account for less than 10 percent of gross charges, keeping in mind there are times when radiologists do not have additional information regarding the patient’s condition or medical history, and that there are a few unspecified ICD-10 diagnoses that do not provide a more specific diagnosis option.

Achieve a 360-degree practice view
An advanced analytics platform that can leverage both structured and unstructured data can help physician practices better prepare for life in a post-grace period world. Because between 60 and 70 percent of all radiology exams are normal, it is critical for radiologists to obtain full clinical history to optimize the quality of care and minimize the use of unspecified codes.

Analytics are able to filter data by provider, modality, payer, location, place of service and referring provider, granting physician leaders and administrators a 360-degree view of their coding performance. These types of platforms can also help highlight areas of improvement down the line.

Gain recommendations to reduce unspecified codes
Analytics platforms can also sort the top 10 or 25 unspecified ICD-10 codes used by practices and make helpful recommendations to improve dictation and coding while reducing denials. These unspecified diagnoses are often missing anatomical- or morbidity-related information, such as laterality, body location and severity.

For example, the I65.29 code for occlusion and stenosis of unspecified carotid artery merely requires providers to document the affected carotid arteries (right, left or bilateral). By adding this piece of information, physicians can reduce claim denials and help drive uninterrupted cash flow.

While ICD-10 did not cause the turmoil many industry leaders anticipated, it did increase the workload of physicians and coders alike. To learn more about the power of analytics to reduce unspecified ICD-10 codes and increase practice and coder productivity, please email us at ContactIRP@IntegratedRP.com.

 

Radiology ICD-10 Readiness

August 31, 2015

Oct. 1 is rapidly approaching, and no medical specialty, including radiology, will be exempt from ICD-10’s industry-wide overhaul. Read More–>

Patient Empowerment Part III: Responding to Patient Choice

July 7, 2015

 

In last month’s installment of the Patient Empowerment series, we discussed how the rise of the new patient-consumer directly affects radiologists. Part III of this series will provide insight into what radiology practice leaders can do to not only adapt to this trend, but capitalize upon it to better serve their health systems and patients. Read More 

Patient Empowerment Part II: The Rise of Patient Choice

June 16, 2015

 

In April’s first installment of the Patient Empowerment series, we discussed how increased patient responsibility and widespread use of technology has led to the creation of the new patient-consumer. Part II of this series asks the question: So what? Read More 

What the Acquisition of vRad Means for the Practice of Radiology

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The entry of corporate management companies into radiology

May 19, 2015

 

On May 12, 2015, MEDNAX announced its official agreement to acquire Virtual Radiologic, commonly known as vRad, for $500 million. vRad is a leading outsourced radiology physician services company comprised of over 350 U.S. board-certified radiologists. It is also the largest corporate provider of national teleradiology services. Read more

Patient Empowerment Series: Part I

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April 22, 2015

 

The changing healthcare landscape has directly affected providers, hospitals and medical staff, but it also has had a profound effect on patients. The increase in patient responsibility for healthcare costs paired with the ease of sharing information via technology has created a patient population that is more aware, knowledgeable and concerned regarding the healthcare industry and their interaction with it. Read more

Radiology Leadership: Fulfilling the Hospitals’ New Needs

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March 12, 2015

The needs of the hospital have dramatically changed as the healthcare industry transitions to a value-based model. These changes have required a greater level of hospital physician alignment than ever before. Read more

The ICD-10 Readiness Checklist: Are You Prepared?

February 26, 2015

Group collaboration is growing and evolving as an effective business model. But whether you are pursuing a collaborative practice or not, all physician leaders are having to address the impending ICD-10 deadline. Read more

The New Competitive Landscape for Radiology

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January 27, 2015

The healthcare industry is rapidly changing for hospital-based physician practices. An overall trend of consolidation has emerged as the industry transitions to a value-based model.This has led to the creation of large, single-specialty companies with as many as 1,500 physicians, as well as large, multi-specialty management companies such as Sheridan Healthcare, Team Health and Mednax. Read more

Happy Patients, Maximum Revenue? No Longer Mutually Exclusive: Part 3 of 3

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October 13, 2014

 

A three-part discussion covering the leading trends in revenue cycle management for radiologists.

In this installment of our revenue cycle management (RCM) discussion, we would like to discuss three recommendations for applying technology to maximize revenue and patient satisfaction. As we discussed previously, it’s our opinion that technology is only as good as the people using it. Technology’s role in improving an RCM team is to enhance efficiency, accuracy and patient engagement. Read more

Happy Patients, Maximum Revenue? No Longer Mutually Exclusive: Part 2 of 3

September 26, 2014

 

A three-part discussion covering the leading trends in revenue cycle management for radiologists.

Many revenue cycle management companies tout “leveraging” industry-leading technology. In our opinion, technology is very important but ultimately only as good as the people applying it.

In this installment of our revenue cycle management (RCM) discussion, we’d like to address the balance of utilizing progressive technology and well-trained personnel to provide a superior patient experience which directly translates into higher patient satisfaction.

Many studies have shown that patients’ determination of “quality of care” is driven not only by the physician’s compassion and completeness of care, but rather a summation of the entire consumer experience from point of care to the paying of the bill for service.

The following outlines the people part of the equation. How to select the right people and provide the right training to build a team that consistently delivers a positive patient experience.
Read more

Happy Patients, Maximum Revenue? No Longer Mutually Exclusive: Part 1 of 3

September 11, 2014

 

A three-part discussion covering the leading trends in revenue cycle management for radiologists.

In today’s new healthcare landscape, patient satisfaction and revenue cycle management are not mutually exclusive goals. Over the next three posts, we will discuss how radiologists can successfully address both issues.

The primary driver of these changing dynamics is the 2010 Affordable Care Act, which to date has provided healthcare access for roughly 20 million Americans – many for the very first time.
As a result, providers are competing to treat all of these new patients, who also have unparalleled access to healthcare customer service data via social media and other online search tools like Healthgrades.com.

We believe that imaging centers in particular are uniquely positioned to take advantage of the fast-changing dynamics in healthcare. At first glance, patient choice could be seen as a roadblock to success for radiology practices in this new environment. However, we believe the true barrier to success lies within patient access errors. When imaging centers do not employ best practices from the beginning of each patient interaction, the entire process fails to deliver satisfaction and obtain maximum profit.

Here are our suggested steps to achieve both:
Read more

How Innovative Radiology Practices Meet Evolving Needs of Hospitals

July 17, 2014

 

What Innovative Radiology Practices Are Doing to Meet the  Evolving Needs of the Hospital

In our last blog entitled “The Top 10 Hospital Needs from Radiology”, we discussed some of the universal wants and needs the hospital C-Suite is seeking from its radiology partner. As a recap, they included the following:

1. Alignment with hospital strategic imperatives and initiatives
2. Quality metrics the hospital can use to differentiate from the competition particularly in key service lines
3. Avoid duplication of services – utilization management
4. Increased service coverage and sub-specialty access
5. Improved patient satisfaction
6. Improved medical staff satisfaction
7. Consistency of imaging service delivery throughout the continuum of care
8. Shared risk in emerging healthcare payment initiatives
9. Physician/Hospital “Partnership”
10. Positively contribute to the “Hospital Brand”
Read more

The Top 10 Hospital Needs from Radiology

For most radiology practices, the customer is the hospital or health system they serve. To ensure long-term success in this relationship, practices must gain an understanding of their customer’s evolving needs while providing proactive solutions that help address them. It is no longer feasible for radiology to take a passive role with medical staff and hospital leadership.

Read Full Article Here

Opportunity in Times of Change – Subspecialty Access – Part Two

May 29, 2014

It is the long history of humankind (and animal kind, too) those who learned to collaborate and improvise most effectively have prevailed. —Charles Darwin

In our first blog in the series, we discussed the emerging trend of radiology group collaboration and how the sharing of resources and talent can help alleviate one of the largest pain points in radiology – increasing access to subspecialists.  In this segment, we briefly discuss specifically how this is accomplished through strategic multi-group collaboration.

Today, it is critical hospitals possess enhanced access to radiology sub-specialists in order to effectively compete in their respective market for both top medical talent as well as patients.  As such, hospitals are demanding more specialized access from their radiology practices.  And by default, it is expected the radiology group will deliver.

 

Read more

Opportunity in Times of Change – Subspecialty Access

May 5, 2014

“Innovation is the ability to see change as an opportunity – not a threat”

–   Unknown

Radiologists are no strangers to change. They’ve watched their practices’ reimbursements diminish and payment options multiply beyond their control – and are searching for ways to regain a degree of normality.

In order to succeed in today’s market and reclaim that sense of stabilization, radiologists have to take change in stride by actively participating in and recreating the innovation seen in other industries.

Read more