By Mark Isenberg

Mark Isenberg, Partner of Client Services, Zotec Partners

Mark Isenberg, Partner of Client Services, Zotec Partners

As radiologists welcome a new year, they must also continue to meet the challenges delivered by healthcare reform and adapt to changes. This includes enhanced utilization of available data that is necessary for practices to make informed decisions and long-term, significant changes for business sustainability. That being said, there are five issues that all radiologists should consider in the coming year that could potentially impact their reimbursement, including:

  • Big Data
  • ICD-10
  • Collections
  • Digital Breast Tomosynthesis
  • Lung Cancer Screening

Big Data for Informed Decisions

In today’s fast-paced world, it’s important that radiologists are collecting the right pieces of data with the ability to recognize what any patterns or trends in the data can reveal about their business. It is also important to have systems that are providing radiologists with information they need in order to make business decisions going forward. One example of this is illustrated by the Centers for Medicare and Medicaid Services (CMS), when asking radiologists to input lung cancer screening data into registries, in order to support its future decision-making on the issue.

The industry is beyond the need for standard or generic reporting, and radiologists are increasingly seeking ways to work more efficiently—without additional resources. For instance, practices can use analytics technology to mine the data they are collecting and turn it into actionable information. Practices might ask: “Is there anything here I can use to increase my rates with my carriers?” Or “What can I do to increase my staffing efficiencies?” At this stage in the game, the types of information that can be gleaned from advanced analytics services are far from basic.

Emergency departments (EDs) also provide an example of how a radiology practice’s data can be effectively mined to create solutions. For instance, the hospital may have poor information collection at the ED point of care, and the radiology group may not have enough patient information for billing or reimbursement. If data is analyzed effectively, the radiology group can do several things, including but not limited to:

  • Tracking the amount of uncompensated services it renders to the ED;
  • Finding ways to improve the collection of information and bringing it to the attention of the facility; and
  • Providing additional benefits for itself and the hospital, while simultaneously improving its standing with the hospital.

ICD-10: Beyond Implementation and Coding Concerns

The postponed implementation of ICD-10 coding has been a source of great frustration for the healthcare industry. However, radiologists need not be concerned solely with the implementation and, specifically, the coding side of the equation. Instead, if and when ICD-10 does move forward, providers should actually focus more on the payment side. There will be a predicted slowdown in timely reimbursement, as payors may adopt it at different times. This may be challenging for providers who are submitting claims.

From a physician standpoint, there will need to be changes in dictation patterns, but the economic side of the equation should be carefully considered, as it could cause real problems if physicians are not prepared for the changes in their reimbursement patterns.

Collections: Traditional Versus Data-Driven

money_handingNow more than ever, healthcare providers need to step up their traditional collection efforts to include data collection, mainly due to the fact that the financial burden of healthcare has shifted to patients.

Self-pay after insurance due to high deductibles is leading to bad debt more often. If a group is more aggressive in trying to get those payments from patients, it can put stress on the group’s hospital relationship, which in turn can increase the number of complaints received. Payors state they are allowing 100%, but also state that it must come from the patient. Physicians should be cautious, since those same payors that readily paid at 100% in the past are paying at 60% to 70%. This means practices are spending more on collection efforts including sending out more statements, texts, and phone call reminders.

In terms of traditional collections, current data indicates that physician groups’ rates of bad debt are steadily increasing, the results of which are a staggering shift of the healthcare financial burden to patients via high deductible health plans. Physicians obviously feel this impact too, since they need to collect payment from these patients. Physicians must strike a delicate balance if they wish to improve their collection efforts.

New Revenue from Digital Breast Tomosynthesis

New revenue opportunities will result from the CMS decision to reimburse for digital breast tomosynthesis (DBT) beginning in 2015. This additional reimbursement will be paid when the CPT Code 77063 is added to the current G-codes for digital screening and diagnostic mammography services. The new add-on codes will be paid at $30.79 for the professional component and $25.78 for the technical component in addition to the regular payment for the screening or diagnostic mammogram.

It is a positive outcome that breast tomosynthesis has been recognized as a reimbursable code, as there are many physicians and hospitals that want to offer this service, but most radiologists had been struggling to get reimbursement for it.

Despite this positive decision, it should be pointed out there is no way to report DBT when it is performed separately from a digital mammogram. In addition, the CMS decision to reimburse for the add-on code may cause some confusion, as commercial payors will have the option to utilize and reimburse newly created CPT codes 77061 and 77062 for breast tomosynthesis diagnostic, unilateral and bilateral, respectively. Practices may have to use different billing methods for commercial payors than they do for Medicare.

Also noteworthy is the short-term opportunity to benefit from this decision. Under the misvalued code initiative, CMS proposed a 2015 reevaluation of all the mammography codes. In the Final Rule, CMS elected not to make the change for 2015. The reevaluation will occur during 2015 and take effect in 2016. The suspicion is that there will likely be some type of bundled codes and potential elimination of the G-codes, which would essentially drive down the value of those codes. As it stands now, however, the reimbursement is up.

Lung Cancer Screening: Medicare Compensation Confirmed

Lung cancer is the largest cause of cancer mortality in the United States, killing more than 160,000 people per year. The CMS decision to reimburse low-dose CT for lung cancer screening as a preventive services benefit under Medicare is considered another positive outcome. However, there are some strings attached to the victory. Patients will be allowed to enter a program only after undergoing a mandatory lung cancer screening, counseling, and a shared decision-making visit with their physician. On the provider side, radiologists who conduct the CT screenings are required to collect and submit data to a CMS-approved national registry for each low-dose CT lung cancer screening exam they perform.

Screening is already included for eligible individuals in private health plans under terms of the U.S. Affordable Care Act (ACA), and just recently, CMS approved reimbursement for the screening of Medicare patients.

From a billing and operational standpoint, it’s unclear how the screening and reporting program will be carried out, but it’s definitely a step in the right direction to compensate it as a payable procedure for that particular situation. The industry may be a long way from getting away from fee for service, and the CMS decision to pay for this service may still support the fee for service framework. It can, however, be implied that CMS is forward thinking on the subject, given they are also collecting the result data. They can hopefully gain information to support a more outcome-based payment model in the future, in other words.

In sum, it is important that radiologists prepare for and pay attention to these five impactful issues on the horizon, so they can be better equipped for financial success in 2015 and beyond.


Mark Isenberg is a partner of client services with Zotec Partners.