For the second year running, the coding and reimbursement world is relatively calm for diagnostic imaging. Instead of seeing massive payment cuts or a slew of changes to codes this year, you’re simply going to have to wait longer for your money.
But, even that lag time can cause problems, industry experts say.
Over the next several months, there are a few things you should watch for—they could add dollars to your bottom line.
National Correct Coding Initiative Edits
If you do many chest X-rays with abdominal studies, chances are you’ve noticed your claims have been denied all year. According to Maria Tran, assistant director of coding for the American College of Radiology (ACR), the reason is simple. The Centers for Medicare & Medicaid Services (CMS) included unannounced edits in the 2018 final rule.
It’s an oversight that took the industry by surprise, and its schedule will be corrected by April 1 as part of the National Correct Coding Initiative edits. Still, until that date, getting reimbursement for those claims will be difficult.
You do have options, however, to facilitate payment:
1. You can hold on to any chest X-ray with abdominal studies claims from January 1 to March 31 of this year and submit them after April 1.
2. You can continue to have your staff submit the claims, receive the denial, and correct the claim for re-submission.
3. You can code for the procedure differently. Instead of using 71045, single view chest X-ray, to code for the procedure, submit 74018, one view abdominal X-ray, with a -59 CPT modifier. Pursuing reimbursement this way will ensure you’ll receive payment for both services provided between January 1 and March 31.
If you work for a practice that operates in several states, though, be sure everyone is consistent, says Karna Morrow, diagnostic coding trainer for CSI Coding Strategies. Otherwise, some of you will get paid, and others won’t.
Most importantly, she says, choose a claim submission strategy that works best for you. Assess your financial situation and what might be most beneficial for your practice.
“Evaluate your operational needs and make a decision,” she said. “That way, you can make a conscious decision instead of just pushing everything out the door and getting denials.”
In October, CMS asked you to use the ICD-10 code N63 and N63.0 for an unspecified breast mass/lump/swelling in an unspecified breast. However, Morrow says, the agency still has not officially added the code to its approved list. In many cases, you’re still getting denials.
“It’s frustrating because radiologists are expected to have new codes put into their system and to be on board,” she says. “But, in many instances, payers aren’t ready.”
Currently, many mammography centers are seeing a big chunk of their business put on hold. Unfortunately, for now, Morrow said, you’ll have to take a wait-and-see approach on these claims.
Mammography does get some good news this year, though, says Kathryn Keysor, ACR senior director of economics and health policy. In 2017, CMS floated the idea for new CPT codes that would have bundled mammography with computer-assisted diagnosis, cutting payments by up to 50 percent. Instead, the agency dropped this move, allowing mammography to side-step additional reimbursement decreases.
Diagnostic Imaging Site-of-Service Denials
Last fall, Anthem, the nation’s second largest insurance provider, announced it would no longer pay for CT and MRI diagnostic imaging services provided in hospital-based settings. Instead, these studies would need to be performed in free-standing, outpatient settings unless a provider offers documentation that a hospital setting is medically necessary.
The company’s reason, Keysor says, was higher prices for hospital-based services. The move will impact both hospital- and outpatient-based radiologists. Those of you in the hospital will see your referrals dwindle while outpatient radiologists could likely experience a significant uptick.
The policy could also hurt your existing relationships with referring providers, as well as hamstring patients.
“Regardless of relationships between referring providers and radiologists, this policy takes away patient choice,” she said. “We understand that hospitals might be more expensive, but the right way to handle this would be price transparency and to let the patient decide.”
The ACR is currently gathering information from its members about how this policy has affected referring providers, radiologists, and patients. Input will be used to possibly appeal Anthem’s decision, Keysor says.
Appropriate Use Criteria Mandate
For the past several years, appropriate use criteria and clinical decision support (CDS) software have been hot topics of conversation. Even though CMS isn’t scheduled to fully implement this mandate until 2020, Keysor says, July 1 marks the beginning of the voluntary reporting period. If you choose to participate, you will receive credit in the Merit-based Incentive Payment System (MIPS).
To have your compliance recorded, use the HCPCS –QQ modifier. Attach it to claims where you know your referring provider consults a CDS tool. It can be reported on the same line with the CPT code for the advanced diagnostic imaging service you provided in the appropriate setting, and it can be reported on both the facility and professional claim.
And, for the time being, Keysor says, Medicare Administrative Contractors will continue to pay for services within and outside of CPT code ranges for MRI, CT, PET, and nuclear medicine whether the -QQ modifier is included. So, while the next 18 months don’t affect your reimbursement dollar, she says, consider this a training period so you don’t miss out in the future.
Ultimately, Morrow says, you’re entering a time where your claims will be more heavily scrutinized than ever. Payers will be looking for both medical necessity and appropriate use. Unfortunately, in many situations, you won’t control whether there’s enough information available to ensure you’ll receive reimbursement. Much depends on whether your referring provider remembers to include enough data in his or her orders.
For example, she says, if your referring providers don’t include additional data about a patient’s headache, such as it’s lasted for more than two weeks and the patient has failed other treatments, payers can deny your MRI claim. In the near future, they can also refuse payment if you don’t provide evidence that your referring provider consulted a CDS tool.
The answer to this problem, she says, is increased collaboration between you and your referring providers.
“The most important thing impacting your reimbursement isn’t the increase or decrease in RVUs,” she said. “It’s the potential impact of incomplete orders. Now, we’re seeing this all come to fruition.”
But, until you create a more collaborative environment with your referring providers, she says, you’ll continue to struggle to capture all the reimbursement dollars you’re owed. Even in a year like this one where payments haven’t changed significantly, securing your dollars can be a chore.
“So, this is where we are right now with radiology reimbursement,” Morrow says. “We’re chasing it.”