The 2014 Medicare Physician Fee Schedule/ CPT Codes and Radiology
Like all specialties, radiology is affected by the 2014 Medicare Physician Fee Schedule (MPFS) as well as new 2014 CPT codes. In general, radiology will experience a reduction in reimbursement even though there are both increases and decreases in radiology rates for radiology plus some new and bundled codes.
CMS published the following impacts on radiology reimbursement for 2014 as indicated in the final Fee Schedule:
Here are some of the 2014 Fee Schedule provisions that were finalized and some up for comment concerning radiology services. The first section is for radiology as a whole followed by a section for Free Standing facilities.
Impact of Fee Schedule Rates
For the first 3 months of 2014 (inclusive of the “SGR fix” for that time period), the conversion factor is $35.8228.
The American College of Radiology (ACR) prepared the Tables at the links below to show the impact of the 2014 Medicare Fee Schedule on each CPT Code, compared to 2013.
CMS has identified the following radiology services where there may be a potential misvalue of codes. These services have not been finalized but were sent to the RUC (AMA’s Relative Value Scale Update Committees) for review. Radiology organizations have the comment period ending January 27, 2014 to address all issues that impact radiology reimbursement.
- Breast biopsy and stereotactic localization guidance
- Interventional radiology (embolization, intravascular stents, abscess drainage, chest tube placement, selective catheter placement, fluoroscopic guidance)
- Body imaging (MRI brain, MRI spine, CT head, extracranial studies)
- Radiation oncology (radiation treatment delivery, continuing medical physics consultation, IMRT, hyperthermia, high dose rate brachytherapy)
CMS did finalize several CPT ultrasound guidance codes as potentially misvalued services. (See our article in this edition of the LeadingEdge.)
Impact of 2014 New and Revised CPT Codes
The ACR has described the 2014 financial changes for the following radiology services here. The impact on each practice will vary based on the mix of services provided in 2014.
- Breast Biopsy and Clip Placement
- Body Imaging
- CT Head or Brain
- MRI Brain and Spine
- Extracranial Studies
- Interventional Radiology
- Abscess Drainage
- Intravascular Stents
- Chest Tube
- Selective Catheter Placement
- Fluoroscopic Guidance
- Radiation Oncology
- Respiratory Motion Management Simulation
Multiple Procedure Payment Reduction (MPPR) Policy
CMS deferred action on expanding the MPPR Policy for 2014 but this will likely come up again in future rulemaking.
Ultrasound Screening for Abdominal Aortic Aneurysms (AAA)
In 2014, CMS has modified coverage of AAA screening consistent with recommendations of the USPSTF (United States Preventive Services Task Force) to eliminate the one-year time limit for referrals for this service. This allows beneficiaries to receive an AAA screening without requiring a referral as part of the initial preventive physician examination (IPPE).
In 2013, AAA screening was covered for a beneficiary that met certain criteria including that he or she must receive a referral during the IPPE, and had not previously had an AAA screening covered under the Medicare program. However, the IPPE includes a time restriction and must be furnished not more than 1 year after the effective date of the beneficiary’s first Part B coverage period. This time limitation for the IPPE effectively reduced a Medicare beneficiary’s ability to obtain a referral for AAA screening.
The final criteria for those beneficiaries eligible for an AAA screening in 2014:
- May receive the AAA screening at any time and will not need a referral for the service
- Still requires that the beneficiary has not previously been furnished an AAA screening under the Medicare program; and
- Is included in at least one of the following risk categories:
- has a family history of an abdominal aortic aneurysm or
- is a man aged 65 to 75 who has smoked at least 100 cigarettes in his lifetime
Direct PE Inputs for Stereotactic Radiosurgery Services (CPT Codes 77372 and 77373)
Currently, Medicare uses HCPCS G-codes, in addition to the CPT codes for stereotactic radiosurgery (SRS) to distinguish robotic and non-robotic methods of delivery. Upon CMS’ review of these codes, it is their understanding that most services currently furnished with linac-based SRS technology, including services currently billed using the non-robotic codes, incorporate some type of robotic feature. Therefore, CMS believes that it is no longer necessary to continue to distinguish robotic versus non-robotic linac-based SRS through the HCPCS G-codes. (G0339 and G0340)
Before eliminating the G-codes, CMS wanted to be sure that the direct PE (Practice Expense) used to develop PE RVUs (relative value units) for the two CPT codes accurately reflect the typical resources used in furnishing the services that would be reported in the non-facility setting in the absence of the robotic G-codes.
CMS sought comment from stakeholders on this proposal and they did receive comments from the AMA RUC which suggested that the PE inputs for 77372 and 77373 do accurately estimate the resources used in furnishing typical SRS delivery. This proposal was not implemented in 2014 but has been flagged to obtain feedback from stakeholders. CMS will continue to evaluate this issue.
Free-Standing Radiology Facilities
90% Utilization Rate
The 2013 equipment utilization rate of 75% for “expensive” diagnostic imaging equipment (CT and MRI), will be increased to 90% in 2014. The American Taxpayer Relief Act of 2012 requires that fee schedules established for 2014 and subsequent years be based on the 90% utilization rate.
Many commenters on the proposed ruling objected to the change stating that a “90 percent equipment usage assumption for CT, MRI or any other imaging modality for that matter is arbitrary and inconsistent with standard practice in freestanding (non-hospital) imaging center.”
Ultrasound Room Equipment Recommendations
In the 2012 proposed Medicare Fee Schedule, CMS had the AMA RUC review all ultrasound equipment items described in the direct PE input database and whether the ultrasound equipment listed for specific procedure codes was clinically necessary. The AMA RUC came back to CMS recommending the creation of several new equipment inputs in addition to the revision of current equipment inputs for ultrasound services and included pricing information for new and existing equipment items.
In its review, CMS does not believe that all of the equipment items listed in the ultrasound room packages are used for all ultrasound services. However, the costs of all these items make up the resource inputs for every service for which the ultrasound room is a direct PE input. This increases the resource cost for every service that uses the room. In the 2014 proposed rule, CMS sought comment from stakeholders on the items included in the ultrasound rooms, especially as compared to the items included in other equipment “rooms.”
At this time, CMS is unsure how to best reconcile the information and is seeking more comment on the appropriate price to use as the typical cost for portable ultrasound units in the future.
CMS finalized a proposal to change the interest rates used in the calculation of equipment costs per minute. The interest rates are based on the Small Business Administration maximum interest rates for different categories of loan size equipment cost and maturity (useful life).