Federal Regulations and Radiology

June 11, 2015

This edition of the Business of Radiology series focuses on policy in radiology.

Editor's Note: It’s no longer enough for radiologists to be imaging experts. Health care is becoming big business and radiologists need to understand how to navigate the system. Diagnostic Imaging’s Business of Radiology series provides radiologists with the business education they need to succeed.

Few things can impact radiology as directly or significantly as changes to health care regulations and policies. They’re initiatives that require you to change your workflow, to adopt new strategies, and even abandon long-used systems.

From the Affordable Care Act to coding overhauls to new value-based payment systems, industry experts are watching the next set of regulatory efforts to determine the impact on your daily practice.

“In many cases, you take the approach of preparing for the worst and hoping for the best,” said Tom Dickerson, MD, chief executive officer of Illinois-based Clinical Radiologists, SC.        

The coming changes will build upon an uneven playing field for radiologists and the patients who need imaging services.[[{"type":"media","view_mode":"media_crop","fid":"38437","attributes":{"alt":"","class":"media-image media-image-right","id":"media_crop_1373324358500","media_crop_h":"0","media_crop_image_style":"-1","media_crop_instance":"3813","media_crop_rotate":"0","media_crop_scale_h":"0","media_crop_scale_w":"0","media_crop_w":"0","media_crop_x":"0","media_crop_y":"0","style":"float: right;","title":" ","typeof":"foaf:Image"}}]]        

Despite long-standing fears that radiology volumes were lagging, the past four years have actually seen a nationwide bump of 8%. According to Sarah Mountford, client services manager with billing services company Zotec Partners, this boost can be attributed to the expansion of Medicaid services in some states, as well as the growth of health information exchanges and a recovering economy.

In fact, thanks to the Medicaid expansion, the percentage of uninsured patients using radiology services dropped from 7.5% to 6.5% between 2012 and 2014, respectively. On the flipside, states that didn’t expand Medicaid are seeing increases in uninsured patients accessing imaging services. That’s an uptick from 9% in 2012 to 12% in 2014 – more than 4 million patients.

Affordable Care Act
There’s no doubt that patient volumes under the Affordable Care Act have blossomed. But, even with the law’s success, there are still some hiccups with patient payments that impact a radiologist’s bottom line. Some patients are faced with higher deductibles, Dickerson said, forcing them to either forgo or delay imaging services.

Others opt to pay their fees up front with cash or credit cards, said Michael Mabry, executive director of the Radiology Business Management Association (RBMA), introducing a new challenge your practice might not be accustomed to or ready for. Collecting and processing these types of payments requires a system that can verify patient eligibility, deductions, and upfront costs. 

There are still some cases, though, when patients who do undergo imaging simply don’t pay for services rendered, said Mountford, who frequently speaks on health care reform issues at national radiology meetings. Without standing relationships with your patients, you could be frequently left with unpaid balances.

Coding
You’ll also need to alert your billing and coding staff to changes coming to yet undetermined intracranial intervention procedure codes. The Centers for Medicare & Medicaid Services (CMS) will also delete 20 current nephrostomy and biliary codes and will replace them with 28 new CPT and Category III codes. The overall effect, however, will be a drop in reimbursement, Mountford said.

Reimbursement Policies
One of the biggest changes coming for reimbursement deals is proposed payment site neutrality, said Melody Mulaik, president of Coding Strategies, Inc. Even though the shift deals only with the technical component payments, it’s an important policy to note.

“The whole issue of site-of-service payment is a big concern. This will affect more of the hospital side than the physician side,” she said. “But I’m a big proponent that both sides should care about what happens to the others.”

Currently, under CMS regulations, independent providers are prohibited from receiving greater reimbursement than facilities. However, under the new policy, hospitals and other hospital-outpatient facilities would be subject to the same restriction. The change requires a new modifier – voluntary this year, mandatory next year – for reimbursement. The goal, she said, is for CMS to pay the lowest reimbursement rates possible regardless of the service site.[[{"type":"media","view_mode":"media_crop","fid":"38438","attributes":{"alt":"","class":"media-image media-image-right","id":"media_crop_2168095739428","media_crop_h":"0","media_crop_image_style":"-1","media_crop_instance":"3814","media_crop_rotate":"0","media_crop_scale_h":"0","media_crop_scale_w":"0","media_crop_w":"0","media_crop_x":"0","media_crop_y":"0","style":"height: 263px; width: 250px; border-width: 0px; border-style: solid; margin: 1px; float: right;","title":"©Kev Draws/Shutterstock.com","typeof":"foaf:Image"}}]]

In addition, the sustainable growth rate (SGR) was permanently repealed, staving off any payment cuts associated with a fluctuating gross domestic product and setting a payment rate that will remain unchanged until 2020. But, alongside that comes changes under the Medicare Access and Children’s Health Insurance Act. Soon, quality performance programs, such as the Physician Quality Reporting System (PQRS), value-based modifiers, and meaningful use, will collapse into a single program – and they’ll shift from being incentive programs to punishment programs if providers don’t meet quality goals.

Based on the new system, she said, providers will receive a quality score between 1 and 100, and their payments will be linked directly to that number. Depending on performance, providers’ payments will be higher or lower than the stagnant reimbursement rate. In 2019, payments could fall within ± 4%; ± 5%in 2020; ± 7% in 2021; and± 9% in 2022.

Even though radiologist participation in value-based initiatives has been difficult, it’s something you should strongly consider, said RBMA’s Mabry.

“Most radiologists who are able to participate in the current value-based system should strive to participate because – assuming there’s no change – those current programs will be the basis for the Merit-Based Payment Incentive System,” he said. “And, if you’re participating in PQRS and value-based modifiers that would just give you a step up when the programs merge.”

One significant documentation change will affect radiologists and all other providers who work with them. As of Jan. 1, 2017, under the Protecting Access to Medicare Act, radiologists, referring physicians, and facilities will forego technical and professional component payment for outpatient, non-emergent services rendered if claims don’t include proper documentation that the referring physician consulted a clinical decision support tool.

The most immediate change, though, will be XR-29 – the Medical Imaging Technology Alliance Smart Dose standard. This initiative, set to go into effect Jan. 1, 2016, clumps together four key dose-optimization features meant to ensure your CT equipment complies with producing high quality images while protecting patient safety: DICOM Dose Structured Reporting, pediatric and adult reference protocols, CT dose check, and automatic exposure control. Failing to meet this standard will result in a 5% payment reduction in 2016 and a 15% reduction in 2017.

The biggest payment question mark looming in the near future is the implementation of the long-awaited ICD-10 coding system. As of Oct. 1, CMS will require physicians, including radiologists, to submit claims under this more-detailed, documentation-heavy system. Whether providers see a drop in reimbursement will depend on how well they’ve familiarized themselves with the new system.

Response to ICD-10, however, has been largely unenthusiastic throughout the health care industry.

“ICD-10 has to be one of the most complex and uniquely dissatisfying health policies to come out in a long time,” Dickerson said. “People aren’t prepared for it.”

In his experience, the payers that reimburse the 29 hospitals and more than 40 clinics with whom his practice works have already announced they won’t be ready by the ICD-10 deadline, meaning any claims must be submitted via ICD-9.

Switching to ICD-10 offers little benefit to patients or providers and is also unlikely to improve quality care delivery, he said. Any advantage will go to payers because they will have more opportunities to deny or delay payments.

Ultimately, Mulaik said, radiology can’t afford to put off preparing for these changes any longer. Even the ones that seem far off will take time and effort to avoid any negative repercussions.

“If you add all these things [changes] together – and they have to happen – it will be a substantial challenge,” she said. “Individually, these changes aren’t that bad, but you can’t look at them in silos.”