In the year ahead, radiologists must continue to adapt to changes and rise to the evolving challenges delivered by health care reform, including better utilization of available data that are necessary to inform practice decisions and make long-term, significant changes to sustain their businesses, according to Mark Isenberg, Partner of Client Services with Zotec Partners. Isenberg discusses five topics with imagingBiz that should be on the radar for all radiologists in the coming year.
Digital breast tomosynthesis
New revenue opportunities will result from the CMS decision to reimburse for Digital Breast Tomosynthesis (DBT) beginning in 2015. This additional reimbursement will be paid when the CPT Code 77063 or HCPCS code G0279 is added to the current digital screening and diagnostic mammography codes. The new add-on codes will be paid at $30.79 for the Professional Component and $25.78 for the Technical Component (National fee schedule) in addition to the payment for the screening or diagnostic mammogram.
“We view this as a positive outcome that 3D Tomosynthesis has been recognized as a reimbursable code. There are many hospitals that currently offer this service, but radiologists had been struggling to get reimbursement for the provision of the professional service,” said Isenberg.
Despite the good news on the decision, it should be pointed out that there is no way to report DBT when it is performed separately from a digital mammogram. In addition, the CMS decision to reimburse for the add-on code may cause some confusion, as commercial payers will have the option to utilize and reimburse newly-created CPT codes 77061 and 77062 for Breast Tomosynthesis Diagnostic, unilateral and bilateral, respectively. Practices may have to use different billing methods for commercial payers than they do for Medicare if they opt to recognize the CPT codes established for these services.
“It’s important to point out that this may be a short-term opportunity to benefit from this decision,” added Isenberg. “Under the misvalued code initiative, CMS proposed a 2015 revaluation of all the mammography codes. In the Final Rule, CMS elected not to make any changes for 2015 in that respect. The revaluation will occur during 2015 and assumedly take effect in 2016. The suspicion is there will likely be some type of bundled codes along with potential elimination of the G-codes, which would essentially drive down the value of those codes, but for now, the total reimbursement is up.”
Lung cancer screening
Lung cancer is the largest cause of cancer mortality in the U.S., killing more than 160,000 people per year. The CMS decision to reimburse lung cancer screening as a preventive services benefit under Medicare is considered another positive outcome. However, there are some strings attached to the victory. Patients will be allowed to enter a screening program only after undergoing a mandatory lung cancer screening, counseling and a shared decision-making visit with his or her physician. On the provider side, radiologists who conduct the CT screenings are required to collect and submit data to a CMS-approved national registry for each low-dose CT lung cancer screening exam they perform.
Screening is already included for eligible individuals in private health plans under terms of the U.S. Affordable Care Act (ACA), but up to now, CMS has not approved reimbursement for the screening of Medicare patients.
“From an operational standpoint, we’ve yet to see how the screening and reporting program will be carried out, but it’s definitely a step in the right direction to compensate it as a payable procedure for that particular situation,” said Isenberg. “My personal opinion,” he added, “is that we may be a long way from getting away from fee for service, and the CMS decision to pay for this service may still support the fee for service framework, but the fact that they are also collecting the result data implies that they are gathering information to support a more outcome-based payment model in the future.”
“In this day and age,” said Isenberg, “the person with the most information wins. But it’s important that radiologists are collecting the right pieces of data with the ability to recognize what the patterns or trends in that data can tell them about their business. From there, it’s important to have systems that are providing them with the information they need in order to make business decisions going forward.”
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Claudette Lew is associate editor, imagingBiz.com.