From concept to CPT code to compensation: how the payment system works

All radiologists and radiation oncologists provide medical services to patients every day with the full anticipation that these services will be appropriately reimbursed. Yet most take this process for granted. Few have even a rudimentary idea how the system works by which a coding mechanism and reimbursement schedule are developed and maintained for the vast array of services they provide. Clearly, this is not good business. You need not stay in the dark any longer! This article describes (1) the fundamental structure of reimbursement for radiology and radiation oncology services; (2) the multiple steps required as a new procedure advances from a research concept to the assignment of a code in the American Medical Association’s Current Procedural Terminology; (3) the process by which the new procedure and code are assigned a reimbursement value in the Medicare Fee Schedule, which acts as the base for over 75% of current medical reimbursement; and (4) the maintenance of this system for existing procedures.     

Musculoskeletal biopsy: utilization and provider distribution in the United States Medicare population

RATIONALE AND OBJECTIVES: Physicians from many specialties perform musculoskeletal biopsy. Using the Medicare database, we sought to determine which specialties represent the physicians who are performing the majority. MATERIALS AND METHODS: Using the CMS physician supplier procedure summary master file for 1996-2003, we extracted all claims for biopsy procedure codes (including marrow aspiration, muscle biopsy, percutaneous bone biopsy, and open surgical biopsy) categorized by provider specialty, and we analyzed procedure volumes. RESULTS: Since 1996, the rate of utilization of percutaneous bone biopsy has remained stable. In 2003, marrow aspiration was most commonly performed by hematology/oncology (80,038, 57%), followed by medical oncology (23,428, 17%); radiologists performed 755 (0.5%). Muscle biopsies were predominantly performed by radiologists (4,761, 40%), followed by neurosurgery (591, 5%). Percutaneous bone biopsy was mostly performed by radiologists (14,830, 53%), but orthopedic surgeons, neurosurgeons, and hematology/oncology specialists performed a large minority (6,879, 2,296, and 1,048 respectively; in aggregate, 37%). From 1996 to 2003, radiologists performed 71% more muscle biopsies (2,788 to 4,761) and 60% more percutaneous bone biopsies (9,259 to 14,830). Although most specialties are performing fewer percutaneous bone biopsies (e.g., oncologists: 7,217 to 1,048, -85%), orthopedic surgeons are performing 247% more (1,983 to 6,879) and neurosurgeons are performing 2,343% more (94 to 2,296). CONCLUSION: Excluding marrow aspiration, radiologists perform the majority of percutaneous bone biopsies, and the volume is increasing in the U.S. Medicare population. The overall volume has remained relatively stable from 1996 to 2003; although medical specialties are performing fewer, the volume performed by surgeons is increasing rapidly.     

Effect of Health Care Financing Administration regulation on radiology fellowship training

RATIONALE AND OBJECTIVES: The purpose of this study was to assess the effect of Health Care Financing Administration (HCFA) regulations on radiology fellowship training. MATERIALS AND METHODS: Surveys were sent to 157 fellowship program directors in body imaging and vascular/ interventional radiology. Questions addressed program accreditation status, faculty supervision of fellows, and any change in faculty supervision of fellows in response to HCFA's revised plan for Medicare Part B reimbursement. RESULTS: Eighty of 157 (51%) surveys were returned. Thirty (37%) respondents indicated supervision of fellows had changed after institution of the new HCFA rules in July 1996. Vascular/interventional program directors (n = 25, 49%) were more likely to have changed their practice than body imaging program directors (n = 5, 17%). Nearly all respondents (29 of 30, 97%) indicating a change stated supervision had increased. Twenty-seven (33%) respondents also indicated faculty supervision was beyond that necessary for patient care and house staff education; most of these respondents (21 of 27, 78%) stated the new HCFA regulations were responsible. Many program directors also expressed concern the HCFA regulations might prevent fellows from obtaining sufficient experience to effectively learn independent clinical decision-making. CONCLUSION: HCFA regulations intended to address attending physician billing practices at teaching institutions may have had the unintended effect of substantively altering the training of radiology fellows.     

Secondary Interpretation of CT Examinations: Frequency and Payment in the Medicare Fee-for-Service Population

PurposeSecondary interpretation of diagnostic imaging examinations (providing a second formal interpretation for imaging performed at another institution) may reduce repeat imaging after transfer of care. Recently, CMS requested information to guide payment policy. We aimed to study historic trends in submitted claims and payments for secondary interpretation services in the Medicare fee-for-service population.MethodsApplying current procedural terminology codes by body part to Medicare Part B aggregate claims files, we identified all CT interpretation services rendered between 1999 and 2012. Secondary interpretation services were identified using combined code modifiers 26 and 77, in accordance with CMS billing guidelines. The frequencies of billed and denied services were extracted for primary and secondary CT interpretation services. Primary versus secondary interpretation denial rates were calculated and compared.ResultsOf all 227 million Medicare Part B claims for CT services, 299,468 (0.13%) were for secondary interpretation services. From 1999 to 2012, growth in secondary interpretation claims outpaced that in primary interpretation claims (+811% versus +56%; compound annual growth rate 17% versus 3.2%). As a percentage of all services, secondary interpretations increased from 0.05% in 1999 to 0.30% in 2012. Denial rates for second interpretations decreased from 1999 to 2012 (12.7% to 7.0%), and now approach those for primary interpretations (5.4% in 2012).ConclusionsMedicare claims for secondary interpretation of CT examinations are growing but account for less than 1% of all billed CT interpretation services. Denial rates are similar to those of primary interpretation services.     

Reimbursement risks with radiologist extenders: there is no free lunch!

There is great allure in the concept of using qualified health care providers to assist radiologists and radiation oncologists, increasing efficiency and possibly even improving patient care delivery. However, physician services are most commonly reimbursed under a system that is resource based, and the physician work and practice expense components of reimbursement for existing procedure codes are periodically reexamined to ensure their appropriate rank in this “relative value system.” Also, as new codes are developed, demonstrable physician work and practice expenses will determine the relative values for the new procedures. In both cases, the type of individual who actually performs different portions of a procedure will determine the reimbursement level. In addition, the total reimbursement must be appropriately apportioned between the physician involved and the facility where the service is delivered. This article examines some of the potential impacts on procedure coding and radiologist and radiation oncologist reimbursement schedules if physician extenders perform work previously performed by physicians. It also examines possible shifts in reimbursement from physician to facility if an extender is employed by a facility.     

Unique Medicare Beneficiaries Served: A Radiologist-Focused Specialty-Level Analysis

PurposeThe aims of this study were to compare the number of unique Medicare fee-for-service beneficiaries served by radiologists and other physicians and to identify characteristics of radiologists serving the most number of unique patients.MethodsMedicare Physician and Other Supplier Public Use Files were used to identify all physicians who provided services to Medicare fee-for-service beneficiaries for the entirety of 2013. The average number of unique beneficiaries served was computed per specialty. The number of unique beneficiaries served was further stratified among radiologists in terms of physician and practice characteristics.ResultsAmong 56 unique physician specialties, diagnostic radiologists on average served the most unique beneficiaries (3,150 ± 2,344). Among radiologists, the number of unique beneficiaries varied in association with numerous characteristics and was larger for male (3,214) versus female (2,521) radiologists, rural (3,551) versus urban (3,092) radiologists, nonacademic (3,427) versus academic (1,932) radiologists, generalist (3,866) versus subspecialist (1,981) radiologists, and radiologists in the South (3,716) versus other geographic regions (range, 2,432-3,217). The number of unique beneficiaries served increased significantly with smaller group practice size (2,218 for ≥100 group members versus 3,669 for ≤9 members). Among subspecialists, the number of unique beneficiaries was largest for breast imagers (2,594).ConclusionsThe large number of unique beneficiaries served by radiologists highlights their important role in orchestrating patient care and their immense opportunities to expand the face of the specialty. An understanding of which radiologists serve the largest numbers of unique patients may help radiology practices target patient engagement and other Imaging 3.0™ efforts.     

Increasing Volume of Bone Marrow Biopsies by Radiology Providers: Evaluation of Trends by Physician Specialty and Practice Setting

PurposeThe aim of this study was to evaluate trends in bone marrow biopsies performed in the United States by physician specialty and practice setting.MethodsThe CMS Medicare Physician Supplier Procedure Summary database was queried from 2005 to 2016 for bone marrow biopsies and aspirations (BMBs). Data were categorized according to the largest subspecialty groups (medicine, surgery, radiology, pathology, and other) and encounter setting (office, inpatient hospital, and outpatient hospital). Trends in procedure volume by specialty and practice setting were evaluated.ResultsBetween 2005 and 2016, an annual average of 11,417 BMBs were performed (range, 10,380-14,204), with no significant year-over-year change in volume. Medicine was the largest provider of BMBs by specialty, although their market share over this time period declined from 60.2% to 36.6%. Radiology saw the greatest growth in BMB market share from 4.1% to 16.2%. The compound annual growth rate (CAGR) of BMBs performed by medicine subspecialists demonstrated a decrease in year-over-year procedural volume at −5.16% (P < .001). Both surgery and radiology demonstrated positive trends in the number of BMBs performed, with CAGRs of 6.20% (P < .001) and 12.43% (P < .001), respectively. Independent of physician specialty, there was a decrease in the number of biopsies performed in the office setting, decreasing by a CAGR of −5.59% (P < .001).ConclusionsFrom 2005 to 2016, medicine has remained the primary provider of BMBs, although their market share has declined. Radiology has experienced the greatest rate of growth in this time period and now represents the third largest individual specialty providing this service.     

How Do Publicly Reported Medicare Quality Metrics for Radiologists Compare With Those of Other Specialty Groups?

PurposeTo characterize and compare the performance of radiologists in Medicare’s new Physician Compare Initiative with that of other provider groups.MethodsCMS Physician Compare data were obtained for all 900,334 health care providers (including 30,614 radiologists) enrolled in Medicare in early 2015. All publicly reported metrics were compared among eight provider categories (radiologists, pathologists, primary care, other medical subspecialists, surgeons, all other physicians, nurse practitioners and physician assistants, and all other nonphysicians).ResultsOverall radiologist satisfaction of all six Physician Compare Initiative metrics differed significantly from that of nonradiologists (all P ≤ .005): acceptance of Medicare-approved amount as payment in full, 75.8% versus 85.0%; Electronic Prescribing, 11.2% versus 25.1%; Physician Quality Reporting System (PQRS), 60.5% versus 39.4%; electronic health record participation, 15.8% versus 25.4%; receipt of the PQRS Maintenance of Certification Program Incentive, 4.7% versus 0.3%; and Million Hearts initiative participation, 0.007% versus 0.041%. Among provider categories, radiologists and pathologists demonstrated the highest and second-highest performance levels, respectively, for the two metrics (PQRS and MOC) with specialty-specific designs, but they ranked between fifth and eighth in all remaining non–specialty-specific metrics.ConclusionsThe performance of radiologists and pathologists in Medicare’s Physician Compare Initiative may relate to the extent to which metrics are tailored to the distinct aspects of their practices as diagnostic information specialists. If more physician participation in these programs is desired, more meaningful specialty-specific (rather than generic) metrics are encouraged.     

Diagnostic Radiology Resident and Fellow Workloads: A 12-Year Longitudinal Trend Analysis Using National Medicare Aggregate Claims Data

PurposeThe aim of this study was to evaluate changes in diagnostic radiology resident and fellow workloads in recent years.MethodsBerenson-Eggers Type of Service categorization was applied to Medicare Part B Physician/Supplier Procedure Summary Master Files to identify total and resident-specific claims for radiologist imaging services between 1998 and 2010. Data were extracted and subgroup analytics performed by modality. Volumes were annually normalized for active diagnostic radiology trainees.ResultsFrom 1998 to 2010, Medicare claims for imaging services rendered by radiologists increased from 78,901,255 to 105,252,599 (+33.4%). Service volumes increased across all modalities: for radiography from 55,661,683 to 59,654,659 (+7.2%), for mammography from 5,780,624 to 6,570,673 (+13.7%), for ultrasound from 5,851,864 to 9,853,459 (+68.4%), for CT from 9,351,780 to 22,527,488 (+140.9%), and for MR from 2,255,304 to 6,646,320 (+194.7%). Total trainee services nationally increased 3 times as rapidly. On an average per trainee basis, however, the average number of diagnostic services rendered annually to Medicare Part B beneficiaries increased from 499 to 629 (+26.1%). By modality, this represents an average change from 333 to 306 examinations (−8.1%) for radiography, from 20 to 18 (−7.4%) for mammography, from 37 to 56 (+49.7%) for ultrasound, from 88 to 202 (+129.1%) for CT, and from 20 to 47 (+132.0%) for MRI.ConclusionsBetween 1998 and 2010, the number of imaging examinations interpreted by diagnostic radiology residents and fellows on Medicare beneficiaries increased on average by 26% per trainee, with growth largely accounted for by disproportionate increases in more complex services (CT and MRI).     

Volume and Coverage of Secondary Imaging Interpretation Under Medicare, 2003 to 2016

PurposeThe aim of this study was to assess changing Medicare volumes of, and coverage for, secondary interpretations of diagnostic imaging examinations stratified by modality and body region service families.MethodsMedicare Physician/Supplier Procedure Summary Master Files for 2003 to 2016 were obtained. Aggregate Part B fee-for-service claims frequency and payment data were isolated for noninvasive diagnostic imaging and stratified by service family. Using published Medicare payment rules, secondary interpretations were identified as studies billed using both modifiers 26 and 77. Billed and denied services volumes were calculated and compared across modality and body region service families.ResultsSeven service families showed a compound annual growth rate from 2003 to 2016 of >20% (an additional 12 service families, >10% growth). For select high-volume service families (chest radiography and fluoroscopy [R&F], brain MRI, and abdominal and pelvic CT), relative growth in billed secondary interpretation services exceeded that for primary interpretations. In 2016, body region and modality service families with the most billed secondary interpretations were chest R&F (674,124), abdominal and pelvic R&F (65,566), brain CT (45,642), extremity R&F (34,560), abdominal and pelvic CT (14,269), and chest CT (10,914). All service families had secondary interpretation denial rates <25% in 2016 (15 service families, <10%).ConclusionsAmong Medicare beneficiaries, the frequency of billed secondary interpretation services for diagnostic imaging services increased from 2003 to 2016 across a broad range of modalities and body regions, often dramatically. Payment denial rates were consistently low across service families. As CMS continues to seek input on appropriate coverage for these services, these findings suggest increasing clinical demand for and payer acceptance of these value-added radiologist services.     

Trends in Diagnostic Imaging Medicare Reimbursements: 2007 to 2019

PurposeThe aim of this study was to evaluate recent trends in Medicare reimbursement rates for various imaging studies.MethodsCommon diagnostic radiologic studies were selected across multiple imaging modalities: bone densitometry, CT, CT angiography, mammography, MR angiography, MRI, nuclear medicine, radiography, and ultrasound. The Physician Fee Schedule Look-Up Tool from CMS was queried for Current Procedural Terminology codes to extract reimbursement data. All monetary data were adjusted for inflation to 2019 US dollars. The compound annual growth rate, average annual change, and total percentage change in reimbursement were calculated on the basis of these adjusted trends.ResultsInflation-adjusted Medicare reimbursement for all imaging modalities decreased between 2007 and 2019. The greatest mean decrease in reimbursement rates was observed for MRI (−$52.08), and the largest decrease in total percentage change was seen for bone densitometry (−70.5%). Nuclear medicine demonstrated the smallest mean decreases in both annual change (−$0.32) and total percentage change (−4.28%).ConclusionsThis study examined Medicare reimbursements for radiologic studies from 2007 to 2019. After accounting for inflation, reimbursement rates were shown to decline for all studies across all imaging modalities except for individual studies in nuclear medicine, radiography, and ultrasound. Further investigation is encouraged to properly model future trends in reimbursement rates.     

Geographic Variation in Gender Disparities in the US Radiologist Workforce

PurposeTo assess geographic variation in gender disparities in the US radiologist workforce.MethodsGender, location, and practice affiliation of all radiologists and gender of all nonradiologists were identified for all providers listed in the Medicare Physician Compare database. Variation in female representation among radiologists was summarized at state, county, and individual practice levels, and associations with a variety of county-level population characteristics were explored.ResultsNationally, 23.1% (7,501 of 32,429) of all radiologists were women versus 46.6% (481,831 of 1,034,909) of Medicare-participating nonradiologists. At the state level, female representation among radiologists was overall highest in the Northeast and Mid-Atlantic regions (Washington DC, 39.3%; Massachusetts, 34.3%; Maryland, 31.5%) and lowest in the West and Midwest (Wyoming, 9.0%; Montana, 10.7%; Idaho, 11.7%). At the county level, female representation varied from 0.0% to 100.0%, with weak positive correlations with county-level population (r = +0.39), median household income (r = +0.25), college education (r = +0.23), English nonproficiency (r = +0.21), mammography screening rates (r = +0.12), Democratic voting in the 2016 presidential election (r = +0.28), and weak negative correlation with county-level rural population percentage (r = −0.32). Among practices with ≥10 members, female representation varied greatly (0.0% to 100.0%). Female representation was higher among academic (32.3%) than nonacademic (20.6%) radiologists, and in states with higher female-to-male relative earnings (r = +0.556).ConclusionCompared with nonradiologists, women are underrepresented in the national radiologist workforce. This underrepresentation is highly variable at state, county, and practice levels and is partially explained by a variety of demographic, socioeconomic, and political factors. These insights could help inform and drive initiatives to reduce gender disparities and more actively engage women in the specialty.     

Merit-Based Incentive Payment System Participation: Radiologists Can Run but Cannot Hide

PurposeTo optimize the flexibility and relevancy of its Merit-Based Incentive Payment System (MIPS), CMS exempts selected physicians and groups from participation and grants others relaxed reporting requirements. We assess the practical implications of such special status determinations.MethodsFor a random sample of 1,000 Medicare-participating radiologists, the CMS MIPS Participation Lookup Tool was manually searched. Individual radiologists’ and associated groups’ participation requirements and special statuses were assessed.ResultsAlthough only 55% of radiologists were required to participate in MIPS as individuals when considering only one associated taxpayer identification number (TIN), 83% were required to participate as individuals when considering all associated TINs. When using the group reporting option, 97% of radiology groups were required to participate. High participation requirements persisted across generalist and subspecialist radiologists, small and rural, and both academic and nonacademic practices. Non-patient-facing and hospital-based statuses were assigned to high fractions of individual radiologists (91% and 71%, respectively), but much lower fractions of group practices (72% and 25%). Rural and health professional shortage area statuses were assigned to higher percentages of groups (27% and 39%) than individuals (13% and 23%). Small practice status was assigned to 22% of individuals versus 16% of groups.ConclusionAlthough not apparent if only considering individual radiologist-TIN combinations, the overwhelming majority of radiologists will be required to participate in MIPS, at the individual or group level. Radiology groups are strongly encouraged to review their physicians’ MIPS participation requirements and special statuses to ensure optimal performance scores and payment bonuses.