CMS identified 80 more potentially “misvalued” codes in its proposed 2015 Medicare Physician Fee Schedule (MPFS), and 20% pertain to radiology. Mammography, chest x-ray, x-ray of the knee are all on the hit list, and you can thank PACS for that.

In justifying the cuts to radiography procedures, which account for the greatest impact on radiology reimbursement, CMS attributes efficiencies gained in the analog to digital conversion in its decision to adjust practice expense inputs for x-ray procedures. The RUC previously recommended that film supply and equipment items be replaced by minutes on a desktop computer, and CMS proposes to accept this recommendation.

According to a summary on the ACR web site, radiology would experience an overall  2% reduction under the proposed rule, but the biggest reductions are reserved for radiation oncology (-4% update) and radiation therapy (-8% update) centers.  A 1% reduction was proposed for interventional radiology, and nuclear medicine would receive an overall 1% increase, as would cardiology. Individual codes for which reductions have been proposed include MRI of the abdomen and CT of the thorax.

Savings gained through revisions to overvalued codes are earmarked for other physician fees services considered undervalued. For instance, family physicians will see a positive 2% update, some of which may be derived from proposed reimbursement for chronic care management.

In last year’s rule, CMS proposed reimbursement for care of beneficiaries with two or more chronic conditions that goes beyond the traditional face-to-face visit ; this year’s rule includes payment details. Chronic care management services include development and revision of care plans, communications with other treating health professionals and the management of medications.

CMS proposes a payment rate of $42.92 for the associated chronic care management code, which can be billed no more than once per month per qualified beneficiary. Additional EHR standards for those practices billing for chronic care management have been proposed.

The agency also signaled that it will take a close look at payment for secondary interpretation of images. Specifically, CMS is concerned that uncertainty about payment for secondary reads is inhibiting radiologists from “seeking out, accessing, and utilizing existing images” resulting in duplicative costs to Medicare, according to the summary on the ACR web site.

The ACR lists the following questions on its web site for which CMS seeks input:

• For which radiology services are physicians currently conducting secondary interpretations, and what, if any, institutional policies are in place to determine when existing images are utilized? To what extent are physicians seeking payment for these secondary interpretations from Medicare or other payers?
• Should routine payment for secondary interpretations be restricted to certain high-cost advanced diagnostic imaging services, such as those defined as such under section 1834(e)(1)(B) of the Act, for example, diagnostic magnetic resonance imaging, computed tomography, and nuclear medicine (including positron emission tomography)?
• How should the value of routine secondary interpretations be determined? Is it appropriate to apply a modifier to current codes or are new HCPCS codes for secondary interpretations necessary?
• We believe most secondary interpretations would be likely to take place in the hospital setting. Are there other settings in which claims for secondary interpretations would be likely to reduce duplicative imaging services?
• Is there a limited time period within which an existing image should be considered adequate to support a secondary interpretation?
• Would allowing for more routine payment for secondary interpretations be likely to generate cost savings to Medicare by avoiding potentially duplicative imaging studies?
• What operational steps could Medicare take to ensure that any routine payment for secondary interpretations is limited to cases where a new imaging study has been averted while minimizing undue burden on providers or Part B contractors? For instance, steps might include restricting physicians’ ability to refer multiple interpretations to another physician that is part of their network or group practice, requiring that physicians attach a physician’s order for an averted imaging study to a claim for a secondary interpretation, or requiring physicians to identify the technical component of the existing image supporting the claim.

The proposed rule will be published in the Federal Register on July 11, 2014; CMS will accept public comment on the rule until September 2, 2014.