CMS published the 2018 Medicare Physician Fee Schedule (MPFS) Final Rule in November, leaving healthcare providers with a lot to think about before the holiday season. Tom Greeson, a healthcare lawyer and partner with the firm of Reed Smith, spoke with Radiology Business about what radiologists and radiology practices need to know about the final rule as they make plans for 2018 and beyond.

Radiology Business: What is the single biggest takeaway for radiologists from the 2018 MPFS final rule? Does anything in particular stand out?

Tom Greeson: The biggest takeaway for radiologists is that CMS is marching toward putting into place a requirement that ordering physicians must consult, using a clinical decision support (CDS) mechanism, appropriate use criteria (AUC) when they order outpatient advanced diagnostic imaging services. There is an opportunity for some ordering physicians to start using those CDS mechanisms next year, but the mandatory part of it will now begin in 2020.

Like you mentioned, the start date for this CDS mandate is now set for Jan. 1, 2020. That date has been pushed back several times over the years—it was originally Jan. 1, 2017. What do you make of these numerous delays?

I think CMS is probably aware that the ordering physician community hasn’t completely embraced this. Also, I think CMS has still been trying to make sure they are prepared for finding the best way to report that a CDS mechanism has been consulted with each order.

In the 2019 MPFS proposed rulemaking next summer, we’ll see CMS propose their instructions on how ordering physicians should submit a unique consultation identifier to imaging suppliers and how the performing imaging centers will then report that identifier when they submit their claims. The final process will then be described in the 2019 MPFS final rule published next fall.

It’s incumbent upon ordering physicians to understand how this will all work. If they don’t understand it, based on priority clinical areas that CMS has identified, they could find themselves to be outliers with respect to how they order advanced imaging studies. And then they could likely find themselves in the very difficult decision of, perhaps, having to obtain prior authorization before ordering an exam, which would not be a good position for any ordering physician to be in, especially a physician working in a hospital emergency department who orders non-emergent advanced diagnostic imaging tests. Radiologists will also need to help their ordering physicians understand that it’s not in their interest to do this incorrectly or sloppily.

With this final rule, CMS established a “FY” payment modifier to be used with all computed radiography (CR) examinations so the applicable payment reduction of 7 percent can be applied. Do you have any sense of whether or not radiologists and radiology practices are ready for these reductions to begin?

I think most radiologists will be ready for this. From what I understand, most radiologists and radiology departments have already moved to digital radiography (DR). Referring physicians, such as primary care or other non-radiologist physicians, however—those who have long self-referred patients for plain film X-ray studies performed in their own offices and have used CR to convert analog images to digital—are probably further behind.

What else stands out about this year’s MPFS final rule?

Another big thing is the movement toward site-neutral payments for certain newly-acquired, provider-based, off-campus hospital outpatient departments acquired after November 2015, which CMS calls “off-campus provider-based departments,” or “off-campus PBDs.” Right now, they are paid at 50 percent of the Hospital Outpatient Prospective Payment System (HOPPS) rate, but CMS has announced that, beginning in 2018, those off-campus PBDs will be paid at 40 percent of the HOPPS rate. What CMS is trying to do with this is remove the incentive for hospitals to open up new outpatient departments just to get paid by the higher HOPPS rates.

There was one other thing from the final rule that was really significant: CMS said it was less inclined to second-guess the expert recommendations on values made by the AMA’s Relative Value Update Committee when it comes to finalizing the RVUs of individual services.

I wanted to conclude by asking you a more general question about the future of medical imaging. Are there any specific legal trends or issues you are watching extra closely? What’s on your radar right now?

Everybody’s looking at artificial intelligence (AI) right now and I’m thinking about it as a legal and regulatory issue. It will be interesting to see how that plays out. Are there liability issues? And if AI can be used without a physician working with it, how can that be regulated? Another thing I’m watching is consolidation. I think mergers, integration and national radiology company growth will continue at a fairly rapid pace.

For a more detailed analysis of the 2018 MPFS Final Rule from Greeson, read the summary he co-wrote with his colleagues here.