Proposed Medicare rule will not improve radiology reimbursement

The U.S. Centers for Medicare and Medicaid Services (CMS) announced its proposed Medicare Physician Fee Schedule (MPFS) rules for 2024, including provisions for the Quality Payment Program (QPP).

Sandy Coffta.

While not a done deal until the final rule is issued toward the end of the year, the Proposed Rule gives an indication of where the CMS is headed with regard to payment policy. In recent history, even the Final Rule isn't final because Congress has had to intervene to stave off significant reimbursement reductions.

Here are the highlights of the 2024 Proposed Rule:

MPFS payment provisions

In fairness, the CMS is bound by statutory constraints when setting the fee schedule conversion factor (CF). Applying the formula as required produces a CF of $32.7476, which is 3.36% lower than the $33.8872 CF used for the 2023 fee schedule. This rate includes the 1.25% upward adjustment provided by the Consolidated Appropriations Act, 2023 (CAA 23) that was passed late in 2022 to help mitigate the effects of the formulaic calculation for 2023 and 2024.

Without the CAA 23, the proposed 2024 reimbursement rate would have been even lower. Our recent article describes a legislative effort (H.R. 2474) that would permanently improve the methodology used in the calculation of the CF for Medicare reimbursement.

The CMS estimates the following specific effects for radiology from the proposed MPFS:

The CMS-estimated 4% overall decrease in interventional radiology (IR) reimbursement is the highest of any specialty listed in the CMS Proposed Rule. The CMS estimates could be understated because the 2023 rate used in their calculation did not include the 1.25% CAA increase, and so it does not match the final payment rate for the year.

Other factors

The changes in reimbursement for any specialty are the result of several factors other than the CF. The relative value units (RVUs) are adjusted upward or downward annually to account for changes in practice expenses due to supply or technology costs. Specialties that have a higher level of evaluation and management (E/M) services might see a significant increase due to the availability of a new add-on code for complex cases in 2024.

A more in-depth analysis of the RVU table in an upcoming article will reveal which procedures were increased and which were decreased by more or less than the overall estimates.

Another factor affecting the final payment amount is the Geographic Practice Cost Index (GPCI). The CMS provides a table of geographic adjustment factors showing the overall change that will be applied through the GPCI's. Of the 109 payment localities, 72 will be decreased (35 by 1% or more), including by more than 2% in areas of Arkansas, Louisiana, Mississippi, Alabama, and Queens (NYC).

Thirty-two payment localities will have an increase to their geographic index, including areas of California that will be increased by around 2%. The Consolidated Appropriations Act, 2021, established a GPCI floor of 1% for the work component through December 31, 2023, and many of the decreases are due to the fact that the floor is not being applied in the 2024 proposed rule. This is something that could change either in the MPFS final rule or by last-minute congressional intervention.

Appropriate use

The 2024 Proposed Rule would finally put to rest the appropriate use criteria/clinical decision-support (AUC/CDS) program that would deny payment to radiologists when the ordering physician fails to consult a CDS to obtain AUC. This program was enacted by the Protecting Access to Medicare Act (PAMA) in 2014 and has been delayed consistently over the intervening years. The 2024 rule "proposes to pause implementation of the AUC program for reevaluation and rescind the current AUC program regulations." There is no time frame for resuming implementation.

Direct physician supervision of Level 2 diagnostic exams, such as those requiring contrast administration, will continue to be allowed via real-time audio and video telecommunications through December 31, 2024. Audio-only telecommunication will not be allowed.

Quality

Revisions to the Quality Payment Program (QPP) will make it more difficult for radiology practices to avoid a payment penalty, let alone earn a positive payment adjustment. The performance threshold is proposed to increase from 75 points to 82 points for the 2024 performance year. This is the minimum score that must be earned to avoid a payment penalty in the 2026 payment year.

Achieving the threshold will be hindered by the proposed removal of several quality measures that have been useful to radiologists, including:

• Measure #147, Nuclear Medicine: Correlation with existing imaging studies for all patients undergoing Bone Scintigraphy
• Measure #324, Cardiac Stress Imaging not meeting appropriate use criteria: Testing in asymptomatic, low-risk patients
• Measure #436, Radiation Consideration for Adult CT: Utilization of dose lowering techniques.

One new measure is proposed to be added to the diagnostic radiology set:

• Excessive Radiation Dose or Inadequate Image Quality for Diagnostic Computed Tomography in Adults.

The category weighting will remain the same as it is for 2023, however the data completeness threshold is proposed to be increased to 75% from 70%. The range of payment adjustment will continue to be ± 9%.

Complete information on the proposed changes to the QPP is available for download from the CMS.

Conclusion

The proposals put forth by the CMS could change in the Final Rule that is typically issued in early December. The Radiology Business Management Association (RBMA)'s Radiology Patient Action Network (RPAN) urges Congress to pass H.R. 2474, which will go a long way toward alleviating the annual swing in proposed and final payment rates.

We will continue to analyze the valuation changes proposed by the CMS using the published RVU tables and keep our readers apprised of the latest information.

Sandy Coffta is the vice president of client services at Healthcare Administrative Partners.

The comments and observations expressed are those of the author and do not necessarily reflect the opinions of AuntMinnie.com.