Radiology averts cuts in proposed 2016 MPFS

Radiology has dodged a bullet in the proposed rule for the 2016 Medicare Physician Fee Schedule (MPFS) released on July 8 by the U.S. Centers for Medicare and Medicaid Services (CMS), receiving no payment increases or decreases.

Other subspecialties will see payments increase -- for example, interventional radiology will enjoy a boost of 1% -- but some won't be so lucky: As of January 1, radiation oncology and radiation therapy payments will be slashed by 3% and 9%, respectively.

"Radiology is not being singled out in this proposed rule for specific cuts," Cynthia Moran, executive vice president for government relations at the American College of Radiology (ACR), told AuntMinnie.com.

The proposed rule is the first since Congress passed the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) in April, which repealed the sustainable growth rate (SGR) formula. This document is the beginning of the implementation of the new payment system for physicians and other practitioners, called the Merit-Based Incentive Payment System, which is required by the legislation, CMS said.

Not so fast

In this proposed rule, radiology will have no payment increases or decreases, while interventional radiology will get a reimbursement boost of 1%. But reimbursement for radiation oncology services would be cut by 3%, and payments to radiation therapy centers would be cut by 9%.

The payment cuts to radiation therapy would likely be caused in part by a proposed change to the use rate assumption for linear accelerators -- from 50% to 70%, according to ACR. This change would be put into effect over two years, so CMS is proposing a 60% utilization rate assumption for 2016 and a 70% rate for 2017.

Estimated effect of MPFS on total charges
  Allowed charges Impact of work relative value unit (RVU) changes Impact of practice expense RVU changes Impact of malpractice RVU changes Combined impact
Interventional radiology $296 0% 1% 0% 1%
Nuclear medicine $46 0% 0% 0% 0%
Radiation oncology $1,769 0% -3% 0% -3%
Radiation therapy centers $52 0% -9% 0% -9%
Radiology $4,472 0% 0% 0% 0%

Advancing AUC

The Protecting Access to Medicare Act of 2014 (PAMA) directed CMS to develop an appropriate use criteria (AUC) program for advanced diagnostic imaging services -- that is, diagnostic MR, CT, and nuclear medicine (including PET). The program must establish a list of AUC from among those developed or endorsed by national medical professional specialty societies and provider-led entities by November 15 of this year.

The AUC program must also approve clinical decision-support tools that healthcare professionals can use by April 1, 2016, as well as begin collecting additional information on the Medicare claim form regarding AUC by January 1, 2017. Thereafter, the AUC program will perform annual reviews to identify outlier ordering physicians, for which a prior authorization requirement would begin January 1, 2020.

This rule only addresses the first component, establishing applicable AUC.

"Evidence-based AUC for imaging can assist clinicians in selecting the imaging study that is most likely to improve health outcomes for patients based on their individual context," CMS wrote. "We believe the goal of this statutory AUC program is to promote the evidence-based use of advanced diagnostic imaging to improve quality of care and reduce inappropriate imaging."

This proposed rule demonstrates that CMS has been listening when it comes to the AUC program, Moran said.

"Regarding the implementation of the AUC/decision-support policy, CMS staff members heard us in the numerous meetings we've held with them," she said. "It's clear that the agency understands the intent of the legislation and has a good grasp of how to implement this policy into a workable, beneficial program that will better ensure the appropriate utilization of advanced diagnostic studies."

PACS pricing

In the 2015 final rule, CMS changed practice expense values associated with the transition from film-based radiology to PACS, using expense values for desktop computer workstations as a stand-in for these values. In this proposed rule, the agency has positively updated practice expense values, Moran said.

"We are very pleased that CMS updated the practice expense value for the PACS workstation from this year's $2,501 to $5,557 for 2016," she said. "Our physicians and staff made a tremendous effort to obtain the necessary invoices that would show the need for this update."

Lung cancer screening coverage

In February, CMS announced that it would begin covering annual lung cancer screening with low-dose CT for beneficiaries at high risk of the disease. This rule proposes a work relative value unit (RVU) of 1.02 for annual lung cancer screening.

"CMS is proposing pegging the reimbursement for lung cancer screening to the level of noncontrast chest CT," Moran said. "The ACR will continue to argue that, due to registry involvement and other elements, the reimbursement should be higher."

Misvalued codes

Since the MPFS was established, CMS has worked to revalue services regularly to ensure that payment rates reflect changing trends in the practice of medicine and current prices for data inputs used in the practice expense calculations.

About 30 of 118 CPT codes identified by CMS as potentially misvalued relate to radiology or radiation oncology, including CT, MR, plain film x-ray, and radiation therapy planning, ACR said. The organization will continue to track this issue.

CT equipment standards

PAMA mandated that the technical component of applicable CT services paid under the physician fee schedule and the Hospital Outpatient Prospective Payment System (HOPPS) be cut by 5% in 2016 and by 15% in 2017 and subsequent years if the exams are performed using equipment that does not meet the National Electrical Manufacturers Association (NEMA) Standard XR-29-2013. In this proposed rule, CMS said it plans to create a code modifier that will identify CT services that do not meet the NEMA criteria.

As usual, CMS is taking comment on the proposed rule for 60 days, until September 8. The final rule will be published November 1 and will go into effect on January 1, 2016.

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