Chipping Away

Modest victories over Medicare’s irrational payment policies could pay off in the future.chipping away

As public policy makers have looked for ways to pay for the ever-increasing costs associated with the Medicare system over the past decade, there have been a number of policy decisions both in Congress and CMS that have specifically targeted and negatively impacted radiology.

While there were always explanations from Congress and CMS justifying payment cuts, most of the reasons cited by policy makers to support the payment reductions have been, in my opinion, specious and irrational. Yet, despite our many efforts to educate these individuals, the overarching agenda of decreasing costs and redistributing the remaining resources to primary care services has made significant mitigation of these policies difficult. However, we did have a few notable wins last year that I'd like to share with you.

While we continue to believe that even at 25 percent a professional component (PC) Multiple Procedure Payment Reduction (MPPR) remains unjustified by CMS, it was the result of ACR's efforts that CMS reduced the impact of the policy, which was originally 50 percent. This change in policy came about primarily because we were able to use an empirical analysis of payment policy data to support our position.1 CMS has almost always used 50 percent as the benchmark for other MPPR policies and I believe without our evidence-based approach demonstrating the modest nature of efficiencies when a radiologist interprets two examinations on the same patient during the same session, CMS would not have changed its position and radiology would have faced an even greater negative impact. So, while we continue in our comments to CMS to oppose the Final Rule for the 2012 Medicare Physician Fee Schedule and search for additional ways to mitigate the 25 percent MPPR, I am pleased we were able to effect this change in policy. In a previous column, I discussed the new ACR Committee on Imaging Health Policy and Economic Research (CIPER).2 One of the charges for this committee is to make our educational efforts with policy makers more evidence-based, and the initial outcome of providing this type of data, while modest, was favorable. Hopefully this will become a trend in the future.

Another success we had in our dealings with CMS over the MPPR policy was that, at the urging of the ACR, CMS rescinded their plan to apply the MPPR to procedures on the same patient interpreted by different physicians in the same group practice. In other settings where CMS has a MPPR policy, CMS applies the payment reduction to all physicians in the same group practice. However, after considering our arguments that (1) there are no efficiencies when the interpretations are rendered by different physicians, and (2) that there would be administrative difficulties for radiology practices and CMS contractors in determining what constitutes different sessions, CMS has for now reconsidered their proposal indicating in their letter to us that they are primarily concerned with "operational considerations" for their contractors. In our comment letter on the final rule, we continue to emphasize that it is difficult to imagine what efficiencies could possibly be achieved with more than one radiologist involved in furnishing the professional components of multiple advanced imaging services. The ACR, of course, remains quite troubled by the fact that radiologists in small practices or rural hospitals and imaging facilities are likely to be more affected by the MPPR policy than physicians in larger practices. In fact, a number of members have voiced this concern, suggesting that large sub-specialized practices should suffer the same consequences as smaller ones. The ACR position is that poor payment policy must be discouraged wherever possible. The fact that CMS rescinded the broader application of the MPPR policy to group practices provides a new opportunity for CMS to define what constitutes same and different sessions when services are provided by the same physician. As compared to larger practices, solo practitioners and small group practices will be required to use the distinct procedural service modifier (-59 modifier) to describe encounters where interpretations are performed in separate sessions as might occur when patients are examined for different clinical reasons, using different modalities or at different times of the day. This modifier is used when procedures are performed for a different anatomical site and for a distinct patient encounter. In our comments to CMS, we informed the agency to expect an appropriate increase in the use of the -59 modifier, and we have posted guidelines on the ACR website describing instances where reporting separate interpretation sessions for the same patient on the same day by the same physician would be appropriate. We will work with both CMS and, when necessary, other payers to ensure that policy is not applied more broadly that was intended in the CMS regulations.

Lastly, I'd like to share the ACR's role in mitigating the dramatic reductions suffered by hospitals for payments from the bundling of CT abdomen and pelvis in 2011. For 2011, CMS established Hospital Outpatient Prospective Payment System (HOPPS) payment rates for the new CT codes that were at the same level as the unbundled services. This created an immediate 50 percent reduction in the reimbursement to hospitals for 2011 for the identical services they provided in 2010. The ACR worked extensively with CMS through the Medicare Ambulatory Payment Classification (APC) Advisory Panel to correct this error and, as a result, CMS established a separate APC group for the bundled services, restoring the hospital payment to essentially 2010 levels. The ACR (HOPPS) Committee analyzed CMS and hospital data to support arguments. Once again, evidence-based arguments were able to sway CMS, emphasizing the need to have data supporting our positions whenever possible. While this change in payment policy at CMS was a win for radiology, some ACR members have questioned whether we should be using College resources to assist hospitals. The ACR expends the vast bulk of its resources to promote and maintain fee-for-service payments for radiologists in both the professional component (PC) and technical component (TC) payments. However, physician payments are calculated very differently than hospital payments by CMS. CMS if very proud of the HOPPS methodology and because the hospital rates are now significantly higher for imaging studies than those paid to physicians and imaging centers, we would like for hospital payments to be maintained at appropriate levels to serve as a benchmark increased payments for value-added services provided by radiologists. We have begun to use CMS's own data to challenge deficiencies in the physician payment system, and if the PC and HOPPS payments are ever bundled, there is opportunity for radiologists to get a share of the hospital payment by providing value-added services to the hospitals. In novel payment models, there may be bundled payments to hospitals, which include both professional and technical payments. Therefore, the ACR cannot afford to ignore any opportunity to promote proper payment policy.


bibb allen jrBy Bibb Allen Jr., M.D., FACR

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