2016 Medicare Physician Fee Schedule Final Rule Radiology Summary

On Friday, October 30th, the Centers for Medicare and Medicaid Services (CMS) released the 2016 Medicare Physician Fee Schedule Final Rule.  Below is a summary of the most important changes impacting radiology in 2016:

2016 Medicare Radiology Pricing

Most radiology practices will see a decrease of 0.5% to 1.0% in their overall Medicare reimbursement.  This decrease is similar for professional radiology practices and global imaging centers.  For the first time in several years, there is not a significant difference in the rate reduction for professional vs. global radiology billing.

This aggregate fee decrease is a combination of 3 factors as follows:

  1. The conversion factor decreased from $35.9335 to $35.8279
  2. RVU’s were changed for several misvalued CPT codes
  3. The Geographic Practice Cost Index (GPCI) was modified for several regions

CPT Coding Changes

There are several CPT coding changes for 2016 that impact the CPT codes assigned to studies.  Fortunately, the monetary impact of these coding changes should be relatively minor for most practices (thankfully, there is not another CT abdomen/pelvis type change this year).

The most common changes by radiology category are listed below:

  • X-ray: the codes for scoliosis studies and femur X-ray’s have been revised and the hip X-ray codes were replaced with codes that include the hip and pelvis
  • Nuclear medicine: two new codes were added for gastric emptying studies
  • MRI: two new codes were added for fetal MRI
  • Non-vascular interventional radiology: new codes were developed covering biliary and urinary procedures and several miscellaneous codes were added to cover previously unlisted procedures
  • Vascular interventional radiology: new codes have been introduced to cover intravascular ultrasound and intracranial intervention

CT Lung Screening

CMS has added two CPT codes to cover CT lung screening or low dose CT.  There is a code assigned to cover a CT lung screening (low dose CT).  There is also a code assigned to cover patient counseling for the appropriateness of CT lung screening.  The reimbursement for these studies is similar to a CT of the chest and patient visit, respectively.  The general guidelines regarding patient age and smoking history will remain in effect.  However, we are awaiting more specific information regarding medical necessity criteria from the Medicare carriers.

CT Equipment Update (NEMA Standard XR-29)

Providers who furnish CT studies who do not meet the updated dose standards as set by the National Electrical Manufacturers Association (NEMA) must utilize a ‘CT’ modifier when submitting CT studies to Medicare as of January 1st of 2016.  If the equipment fails to meet the new dose standards, the Medicare reimbursement will be reduced by 5% in 2016 and 15% in 2017.


Appropriate Use Criteria for Advanced Diagnostic Imaging Studies

The final rule provides the framework for referring physicians, who order advanced diagnostic imaging studies, to begin using appropriate use criteria by a clinical decision support mechanism.  Advanced diagnostic imaging studies are defined as MRI, CT, PET, and other imaging studies as may be determined.  X-ray’s, ultrasounds, and fluoroscopy are excluded from this category.  Again, the framework is provided, but we are still awaiting more specific information.  Therefore, it is likely that referring physicians will not be required to comply with this requirement by the original deadline of January 1st of 2017.

Changes to the Physician Quality Reporting System (PQRS)

As in 2015, physicians will be required to report at least 9 PQRS measures to avoid Medicare penalties.  A number of PQRS measures have been added to fill in gaps in the existing PQRS measure dataset.  For radiology, three diagnostic radiology PQRS measures and six interventional radiology PQRS measures have been added to assist radiologists in meeting the 9 measure requirement.

The three new diagnostic radiology PQRS measures are:

  1. Measure #405: Abdominal imaging follow up
  2. Measure #406: Thyroid nodule follow up
  3. Measure #436: Radiation dosing for CT’s (all CT’s)

The six new interventional radiology PQRS measures are:

  1. Measure #437: Surgical conversion post lower extremity endovascular revascularization
  2. Measure #418: Osteoporosis management in women who had a fracture (for vertebroplasties)
  3. Measure #409: Clinical outcome post endovascular stroke treatment – registry only
  4. Measure #413: Door to puncture time endovascular stroke treatment – registry only
  5. Measure #420: Varicose vein treatment with outcome survey – registry only
  6. Measure #421: IVC filter assessment – registry only

Additional information regarding the PQRS measures will be provided in the upcoming weeks.

Again, the above is a summary of the main provisions in the 2016 Medicare Fee Schedule that impact radiology.  As more information becomes available, ADVOCATE will continue to keep you up to date.

Best regards,
Wendy Driscoll, MBA
Senior Client Manager