Even though the deadline has passed for submitting comments to the U.S. Centers for Medicare and Medicaid Services (CMS) on the proposed rules for the 2017 Medicare Physician Fee Schedule (MPFS), it's never too late to review the changes that may occur. In two months or so, CMS will issue the final MPFS rules, and we'll know for sure what goes and what stays.
In the meantime, the two radiology-specific changes listed below were included in the 2017 proposed rules:
- The second phase of the appropriate use criteria for advanced diagnostic imaging services, including proposals for priority clinical areas and clinical decision-support mechanism requirements
- New current procedural terminology (CPT) coding and payment changes for mammography services
Mammography services
The American Medical Association's (AMA) CPT Editorial Panel recommended that CPT codes 77051, 77052, 77055, 77056, and 77057 be deleted for 2017. It proposed three new CPT codes (final codes listed below) to bundle computer-aided detection (CAD) with screening and diagnostic mammography:
- 77065: Diagnostic mammography, including CAD when performed; unilateral
- 77066: Diagnostic mammography, including CAD when performed; bilateral
- 77067: Screening mammography, bilateral (2-view study of each breast), including CAD when performed
(For the use of CAD, providers now report CPT codes 77051 and 77052, and 77055, 77056, and 77057 for film mammography.) The panel also recommended that CMS delete Healthcare Common Procedure Coding System (HCPCS) level II codes G0202, G0204, and G0206, which currently are assigned when digital mammography is used.
For 2017, the AMA's Specialty Society Relative Value Scale Update Committee recommended the following work relative value units (RVUs):
- 0.81 for CPT code 770X1
- 1.00 for CPT code 770X2
- 0.76 for CPT code 770X3
CMS evaluated the above coding changes and the recommended changes to the RVUs and stated that the "overall Medicare payment for mammography services would be drastically reduced," especially for the technical component of the services. The reduction, CMS said, could be up to 50% relative to the practice expense (PE) RVUs currently used for payment for these services.
To avoid making changes in coding and payment that could disrupt beneficiary access to services and providers, CMS proposes to adopt the new coding, including the elimination of separate billing for CAD, for 2017 without proposing immediate implementation of the recommended resource inputs. It plans to consider the recommended inputs, including the pricing of the required equipment, as carefully as possible prior to proposing revised PE values through subsequent rule-making.
To understand the potential effects of any future proposed revisions to PFS payment rates, CMS requested information and comments on the rates for these services in the commercial market and the list of items recommended as equipment inputs for mammography services. Invoices that would help with future pricing of these items also would be helpful, according to the agency.
Appropriate use criteria
As required by the Protecting Access to Medicare Act (PAMA) of 2014, CMS established (in the 2016 MPFS rule) the first of the four components of a new program for fee-for-service Medicare to promote the use of appropriate use criteria (AUC) for advanced diagnostic imaging services. The program focuses on requiring an evidence-based and transparent process for developing AUC.
Under this program, only qualified provider-led entities may develop AUC; two such entities are the Society for Nuclear Medicine and Molecular Imaging and the American College of Radiology. (The initial list of qualified entities is posted here.)
In the 2017 proposed rule, CMS focuses on the next component of the program, which includes the following:
- Priority clinical areas
- Requirements for a clinical decision-support mechanism (CDSM)
- The CDSM application process
- Exceptions for ordering professionals for whom consultation with AUC would pose a significant hardship
CMS defines CDSM as an interactive electronic tool through which a clinician consults AUC to determine the level of clinical appropriateness for an advanced diagnostic imaging service for a particular patient's clinical scenario. It could be a module within or available through certified electronic health record (EHR) technology or private-sector mechanisms independent from certified EHR technology.
The program's third component (when ordering professionals must begin consulting CDSMs and furnishing professionals must append AUC-related information to the Medicare claim) will not begin earlier than January 1, 2018.
For the proposed rule (CMS-1654-P), click here.
Catherine Huyghe, a senior healthcare consultant with Panacea Healthcare Solutions, has more than 30 years of experience in the interventional radiology and cardiology auditing, revenue cycle, and management industry. She performs cardiology, interventional radiology, image-guided invasive procedure, electrophysiology, and radiology procedure-based CPT and ICD-10 diagnosis coding audits; charge master assessments; reviews for regulatory agency compliance; and evaluations of administrative policies and procedures. She also assists in the development of compliance programs and conducts radiology, electrophysiology, interventional radiology, and cardiology educational training seminars.
