In the year ahead, radiologists must continue to adapt to changes and rise to the evolving challenges delivered by health care reform, including better utilization of available data that are necessary to inform practice decisions and make long-term, significant changes to sustain their businesses, according to Mark Isenberg, Partner of Client Services with Zotec Partners. Isenberg discusses five topics with imagingBiz that should be on the radar for all radiologists in the coming year.
Digital breast tomosynthesis
New revenue opportunities will result from the CMS decision to reimburse for Digital Breast Tomosynthesis (DBT) beginning in 2015. This additional reimbursement will be paid when the CPT Code 77063 or HCPCS code G0279 is added to the current digital screening and diagnostic mammography codes. The new add-on codes will be paid at $30.79 for the Professional Component and $25.78 for the Technical Component (National fee schedule) in addition to the payment for the screening or diagnostic mammogram.
“We view this as a positive outcome that 3D Tomosynthesis has been recognized as a reimbursable code. There are many hospitals that currently offer this service, but radiologists had been struggling to get reimbursement for the provision of the professional service,” said Isenberg.
Despite the good news on the decision, it should be pointed out that there is no way to report DBT when it is performed separately from a digital mammogram. In addition, the CMS decision to reimburse for the add-on code may cause some confusion, as commercial payers will have the option to utilize and reimburse newly-created CPT codes 77061 and 77062 for Breast Tomosynthesis Diagnostic, unilateral and bilateral, respectively. Practices may have to use different billing methods for commercial payers than they do for Medicare if they opt to recognize the CPT codes established for these services.
“It’s important to point out that this may be a short-term opportunity to benefit from this decision,” added Isenberg. “Under the misvalued code initiative, CMS proposed a 2015 revaluation of all the mammography codes. In the Final Rule, CMS elected not to make any changes for 2015 in that respect. The revaluation will occur during 2015 and assumedly take effect in 2016. The suspicion is there will likely be some type of bundled codes along with potential elimination of the G-codes, which would essentially drive down the value of those codes, but for now, the total reimbursement is up.”
Lung cancer screening
Lung cancer is the largest cause of cancer mortality in the U.S., killing more than 160,000 people per year. The CMS decision to reimburse lung cancer screening as a preventive services benefit under Medicare is considered another positive outcome. However, there are some strings attached to the victory. Patients will be allowed to enter a screening program only after undergoing a mandatory lung cancer screening, counseling and a shared decision-making visit with his or her physician. On the provider side, radiologists who conduct the CT screenings are required to collect and submit data to a CMS-approved national registry for each low-dose CT lung cancer screening exam they perform.
Screening is already included for eligible individuals in private health plans under terms of the U.S. Affordable Care Act (ACA), but up to now, CMS has not approved reimbursement for the screening of Medicare patients.
“From an operational standpoint, we’ve yet to see how the screening and reporting program will be carried out, but it’s definitely a step in the right direction to compensate it as a payable procedure for that particular situation,” said Isenberg. “My personal opinion,” he added, “is that we may be a long way from getting away from fee for service, and the CMS decision to pay for this service may still support the fee for service framework, but the fact that they are also collecting the result data implies that they are gathering information to support a more outcome-based payment model in the future.”
“In this day and age,” said Isenberg, “the person with the most information wins. But it’s important that radiologists are collecting the right pieces of data with the ability to recognize what the patterns or trends in that data can tell them about their business. From there, it’s important to have systems that are providing them with the information they need in order to make business decisions going forward.”
The industry is beyond the need for standard or generic reporting, according to Isenberg. “We’re getting inquiries from radiology groups to help them find ways to work more efficiently—without additional resources. We’re helping practices mine the data they are collecting and turn it into actionable information. ‘Is there anything here I can use to increase my rates with my carriers? What can I do to increase my staffing efficiencies?’ The types of information gleaned from our analytics services is far from basic at this stage in the game.”
“Take the emergency department (ED) for example,” offered Isenberg. “A hospital may have poor information collection at the ED point of care. Radiology groups may not have enough information on the patient to bill or get reimbursed. Using data analysis, the radiology group can not only track the amount of uncompensated services it renders to the ED, but it may also find ways to improve the collection of information and bring it to the attention of the facility. Situations like this would benefit both providers as well as improving the radiology group’s standing with the facility,” concluded Isenberg.
Because much of the health care financial burden has shifted to patients, health care providers need to step up their traditional collection efforts to include data collection.
In terms of traditional collections, current data indicates that physician groups’ rates of bad debt are steadily increasing. This is a result of the staggering shift of the health care financial burden to patients via high deductible health plans, and thus, indirectly, to physicians who need to collect payment from them. Stepping up collection efforts is a delicate dance, according to Isenberg.
“Self-pay after insurance, due to high deductibles, definitely has the potential of moving into bad debt more often,” reported Isenberg. “By being more aggressive in trying to get those payments from patients, it could increase the stress on a group’s relationship with the hospital facility or system it serves, and it increases the amount of complaints received. Payers will tell you they are allowing 100 percent, but tell you to get it from the patient. And what payers readily paid at 100 percent in the past, they’re now paying at 60 to 70 percent, so practices are spending more on collection efforts including sending out more statements, texts and phone call reminders.”
Despite the general bad taste left by the postponed implementation of ICD-10 coding, of those who remain concerned about implementation are preoccupied with the wrong end of the train, according to Isenberg.
“Everyone has been focused on the coding side at this point, but practice administrators should actually focus on the payment side,” said Isenberg. “If in fact ICD-10 does move forward, we expect to see a slowdown in timely reimbursement. Payers may adopt it at different times which will make it challenging for those providers submitting claims,” he added.
From a physician standpoint, there will need to be changes in dictation patterns, but the economic side of the equation will cause the real problems, according to Isenberg.
In closing, Isenberg adds that by preparing for and paying attention to these five things on the horizon, radiologists can be better equipped for financial success in 2015.