The U.S. Centers for Medicare and Medicaid Services (CMS) has released proposed rules for the 2021 Medicare Physician Fee Schedule (MPFS) and the 2021 Hospital Outpatient Prospective Payment System (HOPPS) -- and they don't bring good news for radiology.
In fact, if the MPFS proposed rule goes into effect, radiology will take an overall reimbursement hit of 11%. And the proposed HOPPS rule could translate to insufficient reimbursement for CT exams, according to the American College of Radiology (ACR).
"These changes will result in significant payment reductions to all services including radiology services in 2021 unless Congress acts to suspend the budget neutrality requirement," the ACR said in a statement regarding the MPFS. "The ACR will use every avenue available to work with Congress to modify the impact of these changes."
Quick critique
The ACR quickly released criticism of the two proposed rules after they were issued on August 4. Among its concerns about the MPFS, the ACR listed changes to the structure of office/outpatient evaluation and management (E/M) codes, as well as payment policies for the Quality Payment Program and its participation methods (which include the Merit-Based Incentives Payment System [MIPS] and Advanced Alternative Payment Models [APMs]).
CMS is proposing to follow through on its plan to adopt a new, higher-valued coding structure for E/M codes as well as values recommended by the Relative Value Update Committee. To ensure these increases are budget neutral, the agency would decrease the conversion factor by 10.6%, from the current $36.09 to $32.26.
This change could result in an overall 11% decrease in payment levels for radiology, as well as decreases by specialty, according to the ACR.
| Impact of CMS proposed 2021 MPFS on radiology payments | |
| Specialty | Payment decrease |
| Overall | 11% |
| Interventional radiology | 9% |
| Nuclear medicine | 8% |
| Radiation oncology | 6% |
| Radiation therapy | 6% |
CMS is also suggesting the following:
- 40 new or revised codes that would affect radiology, including a new code for low-dose CT for lung cancer screening and reduced values for diagnostic chest CT codes
- Permanent permission for nurse practitioners, clinical nurse specialists, physician assistants, and nurse midwives to supervise diagnostic tests, in addition to physicians
- Continued permission for the direct supervision requirement to be fulfilled with real-time audio and video technology through December 31, 2021
- New codes for telehealth services
As for quality reporting measures, the rule proposes to delay implementation of MIPS Value Pathways (MVPs) until 2022, although these MVPs would be added to the Quality Payment Program (QPP) as available -- a change due in part to complications of the COVID-19 crisis, according to the ACR. MIPS category weighting for 2021 would be the following: quality, 40%; promoting interoperability, 25%; cost, 20%; and improvement activities, 15%.
"ACR staff will review the entire MPFS proposed rule in the coming weeks and provide a comprehensive summary of the rule," it said.
Hitting hospitals
CMS's proposed HOPPS rule for 2021 could also negatively affect imaging, particularly CT and MRI, according to the ACR. The rule would increase the HOPPS conversion factor by 2.6% to $80.79, but it would also use hospitals' CT and MR cost data "regardless of the cost allocation method," the college said in a second statement.
"The ACR has raised concerns repeatedly in the past regarding the use of claims from hospitals that continue to report under the 'square foot' cost allocation method, noting that it would underestimate the true costs of CT and MR studies," it wrote. "CMS has given hospitals six years to adjust their cost allocation methods from 'square foot' to either 'direct' or the 'dollar' method. These changes are the result of a study that was done by the Research Triangle Institute (RTI) back in 2007. Although ACR has argued that the RTI study, and data which back it up are outdated, CMS is adamant to continue with fully implementing its recommendations."
The 2021 HOPPS also proposes payment level changes to two CT codes, one for low-dose CT (LDCT) for lung cancer screening and another for "visit to determine lung LDCT eligibility," both of which the ACR believes will prove insufficient.
"The ACR has raised concerns about the inadequate payments for CT lung screening based on flawed hospital data in the past rules," it said.
CMS is taking comment on the proposed HOPPS rule through October 5.
