Making the Most of It
By Beth W. Orenstein
Vol. 24 No. 5 P. 22
How IR Practices Can Maximize Revenues in Today’s Economy
Historically, interventional radiologists have focused on delivering procedural services. By doing so, they have had less patient interaction than primary care providers and other specialists outside the procedure suite. That is changing.
“As I speak to major centers around the country, interventional radiologists have increased patient contact prior to and after the IR procedure and are telling me that up to 5% of IR revenues are from evaluation and management [E/M] services. They are billing for seeing patients in the clinic and doing inpatient consults rather than for IR procedures alone,” says Ammar Sarwar, MD, FSIR, codirector of the Liver Tumor Program at Beth Israel Deaconess Medical Center and an associate professor of radiology at Harvard Medical School in Boston. Sarwar was one of several speakers at the 2023 Society of Interventional Radiology (SIR) annual meeting in Phoenix, who discussed how interventional radiologists can maximize revenue in the current environment.
That interventional radiologists are interacting more directly with their patients is good for patients, as longitudinal care not only increases their visibility outside the procedure suite but also can help the revenue side of their practices, Sarwar says.
Physicians who provide nonprocedural services have long felt they were underpaid compared with those who perform procedures. SIR and leaders in IR have repeatedly stressed the importance of direct patient contact and the clinical practice of IR because of its benefit to patients, but adoption has been slow. Part of the reason is that the relative value unit (RVU) system, the basis for payment of physician fees by Medicare and other payers, is a zero-sum game, Sarwar says.
“If you increase one type of service, something else has to decrease,” he notes. To increase payments for nonprocedural services, payments for procedural services had to decline. And, in the last few years, “payments for nonprocedural services have started increasing quite rapidly,” he says.
In recent years, advocates were able to convince payers that changes in reimbursements were needed. Given the recent changes to RVUs, “close clinical care is finally aligned with financial incentives,” Sarwar says.
Sarwar refers to an example cited by Matt Hawkins, MD, FSIR, RCC-IR, SIR councilor for health policy and economics, another speaker at the SIR session, that demonstrates how interventional radiologists can get higher reimbursements when they add direct patient care to the services they provide through E/M: The TIPS procedure creates a shunt within the liver by linking the portal vein and a hepatic vein, a vein draining away from the liver, with a stent-graft. The stent graft supports the connection between the two veins. Patients who undergo a TIPS procedure are typically hospitalized for three or four days.
TIPS is one of the highest value procedures in IR, Sarwar says. The interventional radiologist who performs the TIPS procedure can bill for 16 RVU for that alone. However, if the same interventional radiologist also sees the patient beforehand in the clinic, every day while in the hospital, and in clinic for a one-week follow-up to be sure the patient’s TIPS is functioning properly and is well situated, the billable RVU could be as high as 42.
“You can get more RVUs just by seeing the patient appropriately in follow up,” Sarwar says.
While economics may be an incentive for more direct patient contact, interventional radiologists and their patients are benefitting from it, Sarwar says. “Patients like having that connection of seeing the doctor who performed their interventional procedure rather than someone else. Also, it is something that interventional radiologists are well-trained to do. And there are the patient benefits of being seen by a physician who knows the procedure that was performed as well as all of its potential complications.” Sarwar believes interventional radiologists coming out of training in the last 10 years or so “are particularly well-equipped to have that kind of practice,” and reap the benefits of spending additional time devoted to direct patient care.
Direct patient contact and follow-up care require additional time. Because most interventional radiologists are often busy performing procedures, direct patient care requires a commitment from practice leadership, Sarwar says. “I think it’s important that interventional radiologists practice leadership support more direct patient care, even if initially it’s not going to be fully funded or supporting its own revenue. Eventually, everyone will see that you are providing a highly valuable service that really can’t be provided by any other specialty.”
To generate more revenue, Sarwar also recommends that IR practices look at expanding the types of procedures they offer. “I think most IR departments really focus on two or three well-established service lines that they have been doing for a long time,” he says. Because reimbursements for procedures have been cut across the board, “practices really should be exploring getting into newer disease states.” Areas such as pain management and musculoskeletal procedures are underrepresented in most IR departments right now, “but they are areas where people can develop practices and offer something good for patients and the health care systems where they work,” Sarwar says.
Neurolytic procedures have been shown to substantially reduce pain and could be something that interventional radiologists add to their repertoire, Sarwar says. They might also consider a number of different percutaneous image-guided spine interventions, such as dorsal sacroiliac joint arthrodesis for dysfunction of the sacroiliac joint or percutaneous lumbar decompression for low back pain, which have recently been approved for Category 1 CPT codes.
“In the last few years, these procedures have been approved for reimbursement based off of solid clinical data and would be highly valuable to practices, if they develop a service line and reach out to referring physicians, making sure referrers are aware that these minimally invasive image-guided procedures are available,” Sarwar says.
Adding these new services and procedures may require some physicians in the practice to do some continuing education and additional training in them. IR practices also may want to identify what new procedures they would like to add and, when recruiting, look for physicians who have experience in them, Sarwar says.
Know Your Codes
Yet another way for IR practices to generate more revenue, Sarwar says, is to perform promising new procedures that currently have CPT Category III codes; Category III are temporary codes that allow data collection for emerging technologies, services, procedures, and service paradigms. These procedures and other services may not pay well initially, Sarwar says. However, if enough interventional radiologists use them regularly, it would make it easier for SIR to convince the American Medical Association panel responsible for converting them to higher-paying Category I codes, he says. He cites virtual reality (VR) procedural dissociation services provided by the same physician or other qualified health care professional performing the diagnostic or therapeutic service that the VR procedural dissociation supports as one example.
“If our members don’t use these category codes, we would never be able to convert these exciting technologies into Category I codes,” Sarwar says, adding that he is especially excited about using VR because “it is an effective method for keeping a patient comfortable without the use of narcotics or sedatives.”
Melody W. Mulaik, MSHS, FAHRA, CRA, RCC, CPC, CPC-H, president of Revenue Cycle Coding Strategies, who also spoke at the SIR seminar on IR economics, says many practices are leaving revenue on the table by not billing for all of the services to which they are entitled. “IR coding has changed a great deal over the years,” Mulaik says. “It has gone from component coding to bundled coding, which sometimes makes it difficult and challenging to identify areas for additional revenue.”
Like Sarwar, Mulaik believes that direct patient care—E/M—is an area where some practices have the most significant opportunities to increase revenue. In the past, documenting patient visits could be cumbersome, she says. “A lot of IR groups did not bill for many E/M services because it was cumbersome to document, and the criteria did not align with how they practice medicine.” However, the American Medical Association has changed the guidelines “and aligned them to be more about time and medical decision-making. The changes have opened it up for specialists such as interventional radiologists to be able to appropriately bill for E/M services.” Mulaik recommends practices look at the type of patient visits they have and “make sure they’re not missing any revenue.”
Whose responsibility is it to ensure that the practice physicians and nonphysician practitioners are billing for everything they are entitled to? “That depends on how the practice is set up,” Mulaik says. But no matter whether the job of billing is outsourced or in house, “it takes a team approach. Everyone has to support everyone else,” Mulaik says. She adds that it’s essential that coders are up to date on the new codes and the guidelines that apply to them. Providers should work collaboratively with their coding team “to make sure everybody is on the same page, in terms of what is being captured,” Mulaik says. And, if coders come to you with questions, don’t delay in getting them answers, she adds.
Health systems don’t always make it easy for providers to capture everything they do or bill appropriately, Mulaik says. Access to EHRs can be an issue. “For example, there are hospitals that use Epic medical software that won’t let anybody from outside the system use the [EHR],” she says. “And, if you’re a radiologist who utilizes an outside billing company, there is the potential that they will not be able to get into Epic.” It is best, Mulaik says, that IR practices try to “play nice” with health systems’ IT departments so the departments are responsive in a timely manner and provide radiologists and their vendors access to the billing information they need.
Another speaker at the SIR session, Kathy Krol, MD, FSIR, RCCIR, immediate past chair of the SIR Foundation, says that generating more revenue may be a matter of not losing any to an audit. By law, Krol says, CMS is required to audit 10% of its claims. “Those that are audited under this law may be randomly selected, and you can’t do anything to avoid a random audit,” she says. However, she explains, other practices and procedures can trigger audits, and IR practices should at least be aware of what those are.
One possible trigger is providing services at an unusual site. “For example,” Krol says, “if you go into nursing homes and try to provide services not routinely provided in that setting, that may raise some red flags.” Also, if a practice seems to be performing particular services at an unusually high rate, it could trigger an audit: for example, atherectomy, a minimally invasive procedure to remove plaque from arteries.
“My recommendation,” Krol says, “is that if you know you are doing something out of the norm, talk to the payer ahead of time so they understand what you’re doing, why you’re doing it, and who you’re providing it for.” She also recommends backing up your billables with clear documentation: “Why you saw the patient, what you did, and why you did it. Make it clear, ‘the patient had these symptoms,’ and ‘this is what I decided needed to be done.’”
Coding for IR services is more complex than most other specialties, Krol says. “You want an auditor looking at your record to say, ‘Ah ha, they did this, and this is why. So I’m not going to spend time looking at it further.’” Even if an outside firm is doing the billing and coding, the physicians in the practice are ultimately responsible, she notes.
Overall, Krol says, the chances of getting audited are relatively low. However, it’s not worth the risk if you can avoid it because audits go on for months and are highly stressful. “If you lose, you could have to pay back substantial amounts of money and even be barred from the Medicare system— or, even worse, go to jail,” she says.
Krol agrees with Sarwar and Mulaik that clear communication between coders and staff is essential. “Have a revenue cycle management plan in your practice,” Krol says. “Make sure it includes tracking billing, collections, and denials. Conduct internal and external audits. And be willing to help coders. Be very aware that documentation is critical every day and for every case.” Should you be audited, you will survive if your documentation is clean and clear, Krol says.
— Beth W. Orenstein of Northampton, Pennsylvania, is a freelance medical writer and regular contributor to Radiology Today.