New Proposed CMS Rule on Radiology Reimbursement Rates for 2015

The implementation of the Affordable Care Act has brought about a wide range of reimbursement changes including significant modifications to both the Medicare and Medicaid programs.

The implementation of the Affordable Care Act has brought about a wide range of reimbursement changes including significant modifications to both the Medicare and Medicaid programs.

On July 3rd, the Centers for Medicare & Medicaid Services (CMS) announced the 2015 Physician Fee Schedule Proposed Rule(PFSP).  Included are proposed payment system changes initiated by CMS to reflect government mandated reimbursement to medical practices. Also in this new schedule are additional telehealth procedures, transparency in the development of payment rates, implementation of separate payment procedures for chronic care management and new updates to ambulance fee schedule regulations.

Radiology billing will also be affected by these potential new regulations. Beginning in 2015 the following departments will see remuneration changes: Radiology, Radiation Therapy Center, Nuclear Medicine, Interventional Radiology and Radiation Oncology. Because the clock is ticking on the implementation date for these new payment regulations, CMS is also currently considering  the feasibility for Medicare to reimburse radiologists under PFSP when additional interpretations of an existing image are requested. The basis for this consideration is to determine the cost effectiveness of a standing Medicare payment for a second reading of an already existing image rather than the iteration of additional imaging studies.

Practice expenses are also under the gun with CMS suggesting classifying radiation treatment vaults as indirect practice costs rather than direct charges. To simplify their rationalization, CMS has, in the past, had concerns on whether a radiation treatment vault is in actuality a direct cost. Their stance is the specific structural components are more in line with building infrastructure guidelines rather than medical equipment costs. While many believe this boils down to a matter of semantics, CMS feels strongly the stringent building codes required to house the linear accelerator, which is a major component of the radiation treatment vault, should not be considered a practice expense direct cost. Due to their viewpoint, CMS has requested this cost be removed from over a dozen different radiation treatment procedures.

Also included in the upcoming 2015 PFSP are changes to numerous CPT codes. CMS has requested the deletion of the mammography G-codes which are at this time the only authorized method of radiology billing for services using tomosynthesis. Beginning in the new year, CMS has suggested all mammography services be billed under already established CPT codes. Under this proposed billing/payment schedule, a tomosynthesis mammogram would be billed at the same rate as a mammogram done with either standard digital or analog technology.

Part of these concerns are based on whether the prevailing mammography values truly represent both the professional and technical resources required to accurately provide tomographic services. The current CPT codes have not been reviewed nor have they been updated in recent years to reflect the significant amount of time a professional has invested in performing a tomosynthesis mammogram. Plus the cost factor involved with all the latest technological changes and updates associated with tomosynthesis, must be taken into consideration.

CMS is challenging the current mammography CPT codes as being misvalued. They are requesting a review to ensure three major factors are being taken into consideration when setting proper payment reimbursements. These are as follows:

• Billing costs set based on realistic work time.

• Correct and appropriate relative value units.

• Accurately reflected direct practice expenses.

While all this is being negotiated, and until this debate has been settled, CMS has suggested a temporary solution in which the relative value units initially associated with the above mentioned G-codes are used to value CPT codes. When radiology billing is submitted, small payment increases could be approved, possibly due to these interim coding changes.

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