Radiology Billing and Coding: Policy Matters Radiologists Can't Afford to Overlook
By Lonnie Johnson, MBA, and Missy Lovell, BSN, RN, MBA
Vol. 16 No. 10 P. 6
While there is much buzz surrounding ICD-10 implementation and ways radiology groups should prepare, it's important not to lose sight of other policy-related items that will impact the specialty of radiology. Outlined below are policy items of particular impact to the radiology community that groups should be informed about as the end of another year approaches.
CDS and Appropriate Use Criteria — Requirements Abound
In 2014, the use of clinical decision support (CDS) systems was mandated in the Protecting Access to Medicare Act, essentially requiring the use of appropriateness criteria in the ordering of advanced imaging exams (ie, CT, MRI, nuclear medicine, PET).
In the 2016 proposed physician fee schedule rule, the Centers for Medicare & Medicaid Services (CMS) begin the implementation process proposing "definitions for areas of the statute that require clarification" such as "provider-led entity," which pertains to organizations eligible to develop or endorse appropriate use criteria.
CMS describes the following four major components of the Appropriate Use Criteria (AUC) Program within a timeline:
• November 15, 2015 — Establishment of AUC for Advanced Imaging Services. Applicable AUC may be specified only from among AUC developed or endorsed by national professional medical specialty societies or other provider-led entities.
• April 1, 2016 — Identification of qualified CDS mechanisms for consultation with AUC. By early next year, identification of qualified CDS mechanisms that should be used by ordering professionals is mandated. CMS envisions a CDS mechanism for consultation with AUC as an interactive tool that communicates AUC information to the user. The ordering professional would input information regarding the clinical presentation of the patient into the CDS tool, which may be a feature of or accessible through an existing system, and the tool would provide immediate feedback to the ordering professional on the appropriateness of one or more imaging services.
• January 1, 2017 — AUC consultation by ordering professionals and reporting on AUC consultation by furnishing professionals. This is the implementation date of the requirement for an ordering professional to consult with a listed qualified CDS mechanism when ordering an applicable imaging service and for the furnishing professional to include on the Medicare claim information about the ordering professional's consultation with a qualified CDS mechanism.
• January 1, 2017 — Annual identification by CMS of outlier ordering professionals. After this date, "outlier" ordering professionals will be identified and as a consequence these outliers will be required to obtain a prior authorization for applicable services beginning January 1, 2020.
According to the AHRA, successful implementation and acceptance of a CDS system consistent with a January 1, 2017, implementation will require standardizing and automating the imaging order process and sharing of CDS' required data elements directly between the multiple systems involved. To accomplish this, providers and system developers need guidance from CMS on the required CDS data elements and their format. Without such guidance, information system providers cannot begin to develop the necessary software specifications and requisite programming for the various systems to share information. The CDS requirement for all advanced imaging goes into effect in January 2017, which means the technology should be tested and usable by October 2016.
Without specific standards and guidance, health care and system vendors cannot begin to develop the necessary software specifications and requisite programming for the various systems to share information. CMS missed an opportunity with the proposed rule to provide that guidance and instead appeared to only address the statutory provisions. The hope is that CMS will soon provide the necessary guidance on the format of the CDS information and its location on the Medicare claim form needed for preliminary testing next year.
New Place of Service Codes — Greater Specificity for Data Collection
In response to the discussion in the CY 2015 Medicare Physician Fee Schedule (MPFS) final rule, CMS is creating a new place of service (POS) code (POS 19) and revising the current POS code description for outpatient hospitals (POS 22) in order to differentiate between on-campus and off-campus provider-based hospital departments.
By collecting data on these new codes, CMS seeks to gain a better understanding of which practice expense costs typically are incurred by physician-owned imaging centers, which are incurred by the hospital, and whether there is a significant difference in resource costs associated with the differences in ownership arrangements. CMS acknowledged the growing trend toward hospital acquisition of physician offices and subsequent treatment of those locations as off-campus provider-based outpatient departments. Their goal is to better understand how this trend affects payments under both the MPFS and the Outpatient Prospective Payment System, as well as beneficiary cost-sharing obligations.
The new POS code and descriptors to be used by suppliers will be effective January 1, 2016. Hospitals and facilities will be required to use a new modifier and Part B providers will implement use of the newly created and revised POS codes. Those codes and descriptors are the following:
• Code—POS 19 Off Campus–Outpatient Hospital: A portion of an off-campus hospital provider-based department which provides diagnostic, therapeutic (both surgical and nonsurgical), and rehabilitation services to sick or injured persons who do not require hospitalization or institutionalization.
• Code—POS 22 On Campus–Outpatient Hospital: A portion of a hospital's main campus which provides diagnostic, therapeutic (both surgical and nonsurgical), and rehabilitation services to sick or injured persons who do not require hospitalization or institutionalization.
The payment policies will remain the same for POS 22 and now hold true for POS 19; Part B claims for covered services with POS 22 and 19 will be paid at the facility rate.
Practices are advised to undertake the research to determine their POS designations that are applicable to each of these codes and include them on claims starting in January 2016 to reduce the risk of denied claims and facilitate quicker reimbursement. The ACR is actively encouraging hospitals to ensure cost and charge data are accurately reported to CMS to aid them in the capture of appropriate data.
Digital Breast Tomosynthesis — Beyond Experimental
Digital breast tomosynthesis (DBT) has become more popular than digital mammography due to its improved accuracy percentages in breast cancer screening. In fact, it has shown fewer patient recalls for additional testing, which means more lives saved and a positive impact on patient care. The ACR recently presented this as important evidence during the evaluation process for the new CPT codes 77061, 77062, and 77063, which were developed for CPT 2015.
Because DBT has been shown to improve key screening parameters compared with digital mammography, it is believed by experts to be no longer investigational. While CMS made the decision to facilitate access to these exams by covering beneficiaries for DBT, private payers have been slower to pay for exams. The reason is because private payers believe the process is more experimental in nature. In turn, not surprisingly, this has created some difficulties for providers in balancing the demand for DBT with reimbursement.
Unfortunately, it takes time, evidence, and education for providers to accept state-of-the-art technology and approve for payment. A review and understanding of payer requirements and/or a discussion with the top payers is recommended. Providing clinical evidence to plan medical directors can be instrumental in overcoming resistance to reimbursement. To support discussions with payers, the ACR has compiled a resource packet, which includes a template letter requesting coverage for DBT, on their website.
In lieu of payer reimbursement, some practices are billing patients for the service. In doing so, groups must be careful to bill patients in accordance with payer policies, specifically where denials are concerned. If the test is denied as noncovered or experimental, typical patient notification obligations will have to be met in order to bill the patient. The practice needs to confirm that a patient responsibility notice, or ABN, is being provided to patients and administered according to payer requirements in this case.
— Lonnie Johnson, MBA, is vice president of corporate services with Zotec Partners.
— Missy Lovell, BSN, RN, MBA, is compliance manager with Zotec Partners.
1. ACR preliminary summary of radiology provisions in the 2016 MPFS proposed rule. American College of Radiology website. http://www.acr.org/News-Publications/News/News-Articles/2015/Economics/20150708-ACR-Preliminary-Summary-of-Radiology-Provisions-in-the-2016-MPFS-Proposed-Rule. Updated July 8, 2015.
2. Digital breast tomosynthesis. American College of Radiology website. http://www.acr.org/Advocacy/Economics-Health-Policy/Managed-Care-and-Private-Payer/Common-Coverage-Issues-with-Private-Payors/Digital-Breast-Tomosynthesis
3. Department of Health and Human Services, Centers for Medicare and Medicaid Services. New and revised place of service codes (POS) for outpatient hospitals. MLN Matters. http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM9231.pdf. Published August 11, 2015.