Reimbursement, Billing in Radiology: Updates and Issues

Radiology, as a business, has become increasingly complex as regulatory demands grow and revenues, both on the hospital and physician side decrease. Doing more with less has become a common theme and both the commoditization of billing as well as the implementation of ICD-10 codes have played an important role over the past year, according to industry experts at RSNA 2016.

The implementation of ICD-10 occurred approximately one year ago, and despite heightened anxiety prior to the shift, one year later the disruption has been minimal, said Melody Mulaik, MSHS, president of Coding Strategies.

“ICD-10 is the foundation for just about everything, including payment and communication to CMS and the patient,” she explained, emphasizing the importance of this new coding mechanism compared to its predecessor. “ICD-10 diagnosis codes are able to translate relevant clinical information into data used for research, social history, co-morbiditities, and underlying risk factors,” she said. “It’s not just a software update.”

Premonitions versus Reality with ICD-10
One year later, Mulaik shared that while each organization experienced ICD-10’s implementation differently, overall observations for radiology demonstrated no major drain on productivity, and payment denials did not increase. Because the nature of the new coding system requires more detailed information than the last version, hospitals desired additional staff to support the transition, while physicians found their greatest pain was a backlog that, at times, affected productivity. ”Radiology practices have been in much better shape than most specialties because they have a system in place around coding already,” she said.

The few hiccups shared on a national scale have centered around the use of unspecified codes, particularly coming from referrers. The grace period allowing for the use of this code expired in October 2016. There is also a known issue with NaF-18 PET scan codes, Mulaik said. She suggested cancerpetregistry.org as a tool to decide on the best solutions for your group. “It takes time and effort to get that payment,”  and CMS does not currently intend to change the options, she said.[[{"type":"media","view_mode":"media_crop","fid":"56728","attributes":{"alt":"Radiology reimbursement","class":"media-image media-image-right","id":"media_crop_2127698339398","media_crop_h":"0","media_crop_image_style":"-1","media_crop_instance":"7134","media_crop_rotate":"0","media_crop_scale_h":"0","media_crop_scale_w":"0","media_crop_w":"0","media_crop_x":"0","media_crop_y":"0","style":"height: 133px; width: 199px; border-width: 0px; border-style: solid; margin: 1px; float: right;","title":"©Constantine Pankin/Shutterstock.com","typeof":"foaf:Image"}}]]

ICD-10's Strong Impact on Quality
Ensuring the proper ICD-10 usage allows for both hospitals and physicians to get paid and steers quality improvement.

“When you think about PQRS today, you’ve got the CPT and diagnosis codes. As you look at other pieces of how quality programs are structured, there are a lot of things that go into play, including patient safety issues, severity of illness, and hospital acquired conditions,” Mulaik said.

Radiologists need to communicate their own interactions with patients. “If I look at diagnosis codes, I get the story of that patient translated from what the radiologist put into the radiology report,” she said.  Reports should be robust and contain the story of why the patient was there, what was done to them, and what was diagnosed.

The Quality Payment Program (QPP) formerly known as MACRA went into effect January 1, 2017, and further ties radiologists’ reimbursement to quality metrics that can be relayed through diagnosis code. Codes also offer data rich opportunities to look for variances within practices and departments as well as improvement opportunities to tell a patient’s story more accurately.

Get What You Pay for in Radiology Billing
While technology and coding efforts have allowed physicians to create robust reporting while managing a heavier workload, technical automation and the use of third party offshore vendors for billing to reduce cost has also become a growing trend.

“Billing is a manufacturing process, so you are always seeking efficiencies  to maintain quality and drive cost down,” said Patricia Kroken, principal at Healthcare Resource Providers. “There also is no real inherent value to the billing process.” Because billing is a stable process, she says often there is an assumption that it is easy to do and that quality will not be impacted, regardless of cost.

“I don’t think I’ve ever seen the volume of instability in the number of unhappy radiologists that I am seeing right now in terms of what they are getting for what they are paying for,” Kroken said. She noted that many groups are dissatisfied with financial performance and quality. “You can only drive cost down so far and then it becomes painful,” she said.

Lowest Cost Options Rarely Produce High Quality Outcomes
Instead of looking only at cost, practices need to look at cost value and may need to pay more to get more. The use of automated systems for billing is a trend that has reduced the need for in house staff by outsourcing bills to collection agencies sooner and calling patients directly through Automation.

“Just because you can automate doesn’t mean that you should,” Kroken said. “Even the best automation cannot overcome bad processes. It just does bad stuff faster.”  Automation can suffer from hiccups when transcription goes down or hospital technology has an upgrade or downtime. It might also not offer the patient the ability to correct the bill. The result is revenue that is no longer billable.

Outsourcing to third-party offshore vendors is another low-cost option for billing. Language barriers, lack of follow up on worker’s comp and patient calls, and errors regarding refunds and credits, are pitfalls to look out for. Internal audits and mini audits throughout the year should be implemented to manage those situations much more closely.

“A price only emphasis has gotten us where we are now,” Kroken said. She suggested a balance of intelligent automation backed by a skilled workforce is the ideal mix. “You can trust most of the time but verify often.” Paying more to get more may be the best option.