CMS final rule for MPFS could cost radiology $5B

By Rebekah Moan, AuntMinnie.com contributing writer

November 5, 2019 -- Radiologists could lose approximately $5 billion over the next 10 years if the final rule issued November 1 by the U.S. Centers for Medicare and Medicaid Services (CMS) regarding the Medicare Physician Fee Schedule (MPFS) for 2020 stands, an American College of Radiology (ACR) spokesperson said.

The proposal, first issued in July, remains largely unchanged, according to Cynthia Moran, ACR's executive vice president of government relations, economics, and health policy. However, because CMS didn't take into account changes that the group requested, the final rule could severely affect radiology when the rule is implemented on January 1, 2021.

"CMS says there will be an 8% reduction of reimbursement for radiologists, but our private estimate is 9% or more," Moran said. "There are a variety of winners and losers here. Endocrinologists will gain 16% in reimbursement, but radiologists will lose 8% to 9%."

Pain point

Cynthia Moran
Cynthia Moran, ACR's executive vice president of government relations, economics, and health policy.

ACR's biggest point of contention is the new coding structure for the office or outpatient evaluation and management (E/M) codes as recommended by the American Medical Association (AMA), as well as times and values recommended by the RVS Update Committee. Separate payments will exist for each of the five levels of office or outpatient E/M instead of the blended payments for levels 2 through 4, along with a new add-on code for prolonged visits and a code for complex patients, according to the final rule.

CMS, however, is not making any changes to the E/M office visits captured in the 10- and 90-day global codes. Because radiologists and other specialties such as pathologists and surgeons rarely bill for office visits, they will be the most penalized, Moran said. Congress looks at policy implementations in 10-year chunks, so radiologists could potentially lose $5 billion over that period during which the new E/M codes will be in effect.

Next steps

Even though CMS is still taking comments on the final rule, it's unlikely the comments will sway CMS, Moran said. Instead, Congress will have to step in to change the policy.

"Asking Congress to do anything is a big lift, but that's where we're going to have to turn our focus because CMS is not going to pay much attention to our concerns," she said. However, that strategy will also prove challenging.

"We had more than 8,000 emails and phone calls to Congress asking them to tell CMS not to implement this policy," she said. "It was water off a duck's back -- it didn't make an impression on the administrator or agency. We're going to have to drum up similar kinds of campaigns to get Congress members to jump into debate, but the likelihood is remote at best."

Also considering 2020 is an election year, it will be hard to attract the attention of most members of Congress. However, the ACR will use all opportunities to convince government agencies that certain physician groups, radiologists included, shouldn't be penalized.

New codes

The MPFS final rule includes values for over 100 new/revised codes impacting radiology. Following comments from radiology stakeholders, CMS did update its proposed values to accept values recommended by the RVS Update Committee for intravascular ultrasound, CT of the orbit, sella, or fossa, and myocardial imaging with PET. CMS also increased its proposed value for one of the codes related to pericardial drainage procedures. Additional information on these code-specific changes will be provided in the coming weeks.

Bundling payments

CMS received many comments on opportunities to expand the concept of bundling to recognize efficiencies among physicians' services paid under the MPFS and better align Medicare payment policies. The agency said it will consider the comments for future rulemaking on this topic.

Quality payment program

In the final rule, CMS confirmed it is moving forward with the Merit-Based Incentive Payment System (MIPS) Value Pathway framework for 2021 and will continue to solicit feedback from stakeholders, especially as it relates to burden reduction across the four MIPS categories.

CMS defines MIPS Value Pathways as "a subset of measures and activities established through rulemaking." The purpose of the MIPS Value Pathways framework will be to transform MIPS into a more streamlined and cohesive program, with the hope of offering measures and activities that are meaningful to all clinicians, CMS said.

More on MIPS

For the 2020 MIPS performance year, CMS will increase the performance threshold to 45 points, with the intention of increasing it to 60 points for the 2021 MIPS performance year.

Additionally, CMS will increase the exceptional performance bonus threshold to 85 points for the 2020 and 2021 MIPS performance years. CMS will also move forward with increasing the minimum MIPS penalties and maximum MIPS base incentives from -7% and +7% in 2019 to +9% and -9% for 2020.

CMS finalized its proposal stating the required percentage of hospital-based MIPS eligible clinicians billing under groups or virtual groups will be reduced from 100% to 75% to qualify for that special status as a group or virtual group. The change would begin with the 2022 MIPS payment year.

CMS also confirmed it will reestablish automatic reweighting of the Promoting Interoperability category for nonpatient-facing MIPS-eligible clinician groups or virtual groups. CMS unintentionally altered the application of auto-reweighting to such groups in last year's final rule, and this revision corrects the regulatory language, the ACR said in a document reviewing the final rule on its website. Additionally, CMS modified and clarified several of the Promoting Interoperability measure scores and exclusions.

Finally, the final rule also includes references to the following:

  • Updated pricing for 70 equipment and supply items for ultrasound and vascular ultrasound rooms
  • The exclusion of fine-needle aspiration codes on the list of potentially misvalued codes for 2020
  • The inclusion of current procedural terminology (CPT) code 76377 (3D rendering with interpretation and reporting of CT, MRI, ultrasound, or other tomographic modality with image postprocessing under concurrent supervision; requiring image postprocessing on an independent workstation) as misvalued
  • Revised physician supervision requirements for physician assistants


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