Still Work to Do in Fee-for-service

Apprehension for the end of fee-for-service payments presumably stems from the loss of a system mastered, but as discussed at ACR 2016, radiology still has a lot to learn in fee-for-service, and probably ample time to learn it.

Fee-for-service (FFS) is still a key foundation for new payment models that focus on increasing quality and reducing cost, Richard Duszak, Jr, MD, said at ACR.

“MIPS, which will be how most radiologists end up getting paid under the increasing MACRA roll out moving forward, will be based on some measure of fee for service,” he said. “And we all have lots of opportunities to shore up how we get our current [payments].”

Duszak referred to a 2012 JACR article that looked at over 330,000 abdominal ultrasound reports from over 1,000 radiologists. They conducted natural language processing and used a multi-institutional coding and billing database to analyze the reports. The goal was to identify reports that would have qualified as complete, and therefore generated the full appropriate reimbursement. The study found that 10%-20% of radiologists did not include key elements that were necessary for documentation of those services to be considered complete examinations.

“They basically got paid about 40% less than they should have because they didn’t use structured reporting, they didn’t use macros, they didn’t use tools to capture the revenue legitimately,” Duszak said.

Structured reporting would easily accomplish quality metrics for radiology, Duszak said.

“We don’t have good metrics, some of the metrics that are out there are easy to measure but not necessarily meaningful or robust,” he said.

Duszak, a self-described believer of templates, thinks structured reporting can do more than show value, it can also drive consistency.

“CPT code changes happen every year and the requirements for documentation continue to roll out, and this is tricky stuffy,” he said. “Not every practicing radiologist can keep up with these things but if you have a champion, one of your informaticists, physicians, or coders, and you roll out structured report [templates] every year, it makes it really easy for everyone to check all the boxes and get paid for the services they are doing as the rules change.”

The structured report can make sure that the same metric is reported on 100% of the time, Duszak added.

The measure of actual value doesn’t necessarily evolve from the structured report. Duszak cited the example of fluoroscopy PQRS #147, which is the documentation of radiation dose or exposure time.

“I can dictate a barium enema examination and say fluoroscopy time was six hours and the patient got radiation burns,” he said. “That would satisfy PQRS #147.”

The goal, he said, is to get radiologists thinking about these things and at some point to identify legitimate measures of value (and dose, as technology improves).

Without tools, Duszak said, radiologists will fail under the new payment systems. In the meantime, though, use tools to improve upon the current system.