The Final 2018 MPFS: What Radiology Providers Need to Know

By Adrienne Dresevic, Esq. and Clinton Mikel, Esq. of The Health Law Partners, P.C. 

On November 2, 2017, the Centers for Medicare and Medicaid Services (CMS) released the 2018 Final Medicare Physician Fee Schedule (the Final Rule). The Final Rule addresses changes to the Medicare physician fee schedule and other Medicare Part B policies. This article will highlight some of the important provisions for radiology providers.

Estimated Impact to Radiology           

As a starting point, CMS estimates a conversion factor of $35.9996, an overall slight increase from the current conversion factor.

CMS estimates that the Final Rule will have an impact on radiology as follows:

1. Radiology, interventional radiology, and nuclear medicine is expected to be neutral (0% change);
2. Radiation oncology and radiation therapy may see an overall impact of a 1% increase; and
3. Independent Diagnostic Testing Facilities are expected to have a 4% decrease.

New “FY” Modifier mandated for the TC of Computed Radiography Technology

Beginning January 1, 2018, a new billing modifier “FY” must be used on claims for the technical component (TC) of X-ray services taken using computed radiology technology. This new modifier was established to implement the mandate of the Consolidated Appropriations Act of 2016 which requires a 7% payment reduction for such services during 2018 through 2022, and a 10% decrease for 2023 and beyond. This new modifier is mandated on claims for the TC portion of the X-ray service, regardless of whether the service is billed globally or billed separately using the -TC modifier and will result in the applicable payment reduction. Failure to use the modifier if utilizing older “computed radiography technology” would arguably be construed as billing false claims.

Mammography with CAD

Addendum B of the Final Rule includes new category I CPT codes for mammography with CAD, replacing the G-codes descriptors used in the 2017 MPFS. Further, the payment rates for mammography remain almost the same from the CY2017 MPFS.

Stark Law Annual Updates to List of CPT/HCPCS Codes

As brief background, Section 1877 of the Social Security Act (Stark) prohibits a physician from referring a Medicare beneficiary for certain designated health services (DHS) to an entity with which that physician (or his/her immediate family member) has a financial relationship, unless an exception applies. DHS is defined to include radiology services and radiation therapy services and supplies. With respect to radiology services and radiation therapy services and supplies, Stark defines these categories in a list of CPT/HCPS codes (the Code List) which is updated annually in the MPFS. Table 44 of the Final Rule includes several CPT code additions to the definition of radiology services. Table 45 of the Final Rule includes several code deletions from the definition of radiology services and radiation therapy services and supplies. The Code list which was updated in the MPFS is also available at the CMS Stark page website at https://www.cms.gov/Medicare/Fraud-and-Abuse/PhysicianSelfReferral/ListofCodes.html.

Off-Campus Provider-Based Hospital Departments Paid Under the MPFS

Section 603 of the Bipartisan Budget Act of 2015 required that, effective January 2017, certain items/services furnished by non-exempt off-campus hospital outpatient provider-based departments would no longer be paid under the Hospital Outpatient Prospective Payment System (OPPS). The Final Rule provides a 10% reduction from the current MPFS payment rates for these items and services from 50% of the OPPS payment rate to 40% of the OPPS rate.

Appropriate Use Criteria for Advanced Imaging

CMS further delayed the effective date of the Appropriate Use Criteria (AUC) program to January 1, 2020, even though the 2018 MPFS Proposed Rule specified it would have an implementation date of January 1, 2019. It is on and after this January 1, 2020 date that ordering professionals must consult specified applicable AUC using a qualified clinical decision support mechanism (CDSM) when ordering applicable imaging services, and furnishing professionals must report consultation information on the Medicare claim. The cited reasons for this extension were related to comments and concerns from industry stakeholders about timing for implementation and the complexity of the AUC program.

Due to the complexity of the AUC program, in the Final Rule CMS rolls out an educational and operations testing period of one year that will begin on January 1, 2020. During this educational period, ordering professionals will be required to consult AUC, and the furnishing providers must report the consultation, but CMS will continue to pay claims whether the correct information is included or not. This educational testing period will be helpful for providers, allowing participation while avoiding claims denials during the period.

Additionally, CMS plans to move forward with the voluntary reporting period, which was pushed back for one year from the original date as outlined in the Proposed Rule. The voluntary reporting period will extend from July 2018 through December 31, 2019. The voluntary reporting period, however, is dependent on the ability of the Medicare claims system to accept and process such AUC claims that include consultation information.

Conclusion

The Final Rule will be officially published in the November 15, 2017 Federal Register, but radiology providers can review the unofficial version here.

Adrienne Dresevic, Esq. is a Founding Shareholder of The Health Law Partners, P.C., a nationally recognized healthcare law firm with offices in Michigan and New York. Practicing in all areas of healthcare law, she devotes a substantial portion of her practice to providing clients with counsel and analysis regarding compliance, Stark Law, Anti-Kickback Statute, and compliance related issues. Ms. Dresevic serves on the American Bar Association Health Law Section’s Council, which serves as the voice of the national health law bar within the ABA. Ms. Dresevic also serves as the ABA Health Law Section’s Co-Chair of the Physicians Legal Issues Conference Committee, Vice Chair of the Programs Committee (Executive Leadership), and Vice Chair of the Sponsorship Committee. She is licensed to practice law in Michigan and New York, and can be contacted at adresevic@thehlp.com. 

Clinton Mikel, Esq. graduated from the University of Michigan Law School. Practicing healthcare law, he concentrates in Stark, fraud/abuse, telehealth/telemedicine, compliance, and the corporate and financial aspects of healthcare practice.

The authors are members of The Health Law Partners, P.C. and may be reached at (248) 996-8510 or (212) 734-0128, or at www.thehlp.com.