AHLA UU. Diagnostic Imaging Services Thomas W. Greeson Reed Smith LLP Falls Church, VA Institute on Medicare and Medicaid Payment Issues March 26-28, 2014
Diagnostic Imaging Services AHLA Medicare-Medicaid Payment Institute Baltimore, MD March 28, 2014 116740774v1 Agenda Current Environment Medicare Coverage and Payment Rules for Imaging New Focus on Supervision Rule Place of Service/Date of Service Billing Rules Breast Biopsy Challenges for IDTFs Accreditation Standards for Advanced Imaging New CMS 1500 Claim Form 1
Latest Medical Imaging Payment Cuts 2013 Multiple Procedure Payment Reduction (MPPR) CMS applied the 25% cut to the professional component (PC) and 50% cut to the technical component (TC) to multiple physicians within the same practice for a second imaging procedure in the PFS* * when performed on the same patient, in the same session, on the same day 2014 Utilization Rate (UR) in the American Taxpayer Relief Act (ATRA) CBO Score: $800 million over 10 years CMS raises the UR to 90% (up from 75%) Included in Obama 2015 Budget proposals Exclude advanced imaging from the Stark in-office ancillary services exception to the prohibition against physician self-referrals, except in cases where a practice meets certain accountability standards Expand the authority CMS to mandate prior authorization of advance imaging services 2
Supervision of Diagnostic Tests Medicare Supervision Rules Physician Offices IDTFs Provider-Based Entities HOPPS Supervision of Diagnostic Tests Levels of Supervision General Supervision Direct Supervision Personal Supervision 3
Supervision of Diagnostic Tests Level 1: General Supervision The supervising physician need not be present for the test, but he/she has overall responsibility for the control and direction of the service. Supervision of Diagnostic Tests Level 2: Direct Supervision The supervising physician need not be in the room when the procedure is performed, but must be present in the same office suite and immediately available to assist if required. 4
Supervision of Diagnostic Tests Level 3: Personal Supervision The supervising physician must be in the same room where the test is performed throughout the procedure. Non-Physicians Nurse Practitioners, Clinical Nurse Specialists and Physician Assistants may not function as supervising physicians under Medicare s Diagnostic Test Benefit They may perform diagnostic tests pursuant to State Scope of Practice laws 5
Radiologist Assistants and Radiology Practitioner Assistants Cannot supervise test for Medicare patient Cannot perform an invasive or surgical procedure for Medicare patients who are then billed under the NPI of a radiologist Note: Incident to services may be billed only in a physician s office - not in the hospital - and only for non-test services that are performed for patients being treated by the practice HR 1148 113th Congress Medicare Access to Radiology Care Act of 2013 Creates independent right to bill for RA/RPA services Payment to radiology group Does not permit RA/RPA to supervise a test Even PAs may not supervise tests 6
HOPPS Direct Physician Supervision Physician Supervision of Medicare Hospital Outpatient Diagnostic Tests Standard varies based on location: In the hospital or an on-campus provider-based department Off-campus provider-based department Under arrangement services HOPPS Direct Physician Supervision 2011 Rule In the hospital or an on-campus provider-based department "Direct supervision" means immediately available to furnish assistance and direction throughout the performance of the procedure (i.e., services) Does not require physical proximity "Immediately available" no specific spatial or temporal standard 7
HOPPS Direct Physician Supervision 2011 Rule Off-campus provider-based department "Direct supervision" means immediately available to furnish assistance and direction throughout the performance of the procedure (i.e., services) Does not require physician proximity HOPPS Direct Physician Supervision Non-hospital location, i.e. mobile or fixed-site diagnostic testing facility furnishing services "under arrangements" "Direct supervision" means physician present in the office suite immediately available to furnish assistance and direction throughout the performance of the procedure (i.e., services) Does not require presence in the room 8
HOPPS Direct Physician Supervision Qualifications: Does the supervising physician for imaging services have to be a radiologist? Physician must be qualified to furnish assistance and direction HOPPS Rule: knowledgeable about the test Transmittal 128, May 28, 2010 Transmittal 137, December 30, 2010 Place of Service Billing Rules Multiple Attempts to Address Issue (Transmittal 1823, CR 6375, October 2, 2009) Chapter 26, 10.6.1 et seq. Initially to be effective in 2010 Guidelines were issued, reissued and delayed multiple times! Transmittal 2613 issued December 14, 2012 provides the most recent guidance Effective April 1, 2013 9
Place of Service Billing Rules Terminology POS Code: denotes whether the service was provided in a facility or non-facility setting Payment Locality: denotes the relative resource cost in a particular geographic area Global Billing: Use of single CPT code for PC & TC (e.g., no use of -26 modifier or TC) Place of Service Billing Rules Place of Service Billing 11 Office 12 Home 21 Inpatient Hospital 22 Outpatient Hospital 99 Other 10
Place of Service Billing Rules POS for Diagnostic Tests For diagnostic tests the POS code for the interpretation is the setting where the patient received the TC service If the interpretation was performed in the physician s office and the patient received the TC service in the outpatient hospital setting, the physician assigns POS 22 on the claim for the PC Place of Service Billing Rules The physical location of the radiologist interpreting the study (entered in Block 32 of the CMS-1500 form) 11
Place of Service Billing Rules Global Billing If the same physician or entity does not furnish both the TC and PC, or if the professional interpretation was furnished in a different payment locality, the professional interpretation must be separately billed with modifier -26 and the address and ZIP code of the interpreting physician s location Employees of the entity that performs and bills the TC are considered part of the same entity Global billing is permitted when physician-employee of radiology group interprets tests pursuant to a professional service agreement between the radiology group and the TC supplier. (Joinder Agreements) Place of Service Billing Rules Payment Jurisdiction Rule Claims must be billed to the Medicare Administrative Contractor (MAC) responsible for the jurisdiction where the service was furnished (unless the interpretation was performed in an unusual and infrequent location) The payment-jurisdiction rule is particularly relevant when the professional component is routinely performed in a different state (or MAC jurisdiction) from where the technical component is performed (e.g., teleradiology and in urban areas that cross or border state lines) 12
Place of Service Billing Rules CMS Transmittal 503 Dated January 24, 2014 Inter-Jurisdictional Reassignments Entity taking reassignment must still enroll with MAC where interpretation services provided but CMS has relaxed enrollment restrictions MAC must allow entity to enroll in the state where the interpretation was performed and can use interpreting physician s home or office address Date of Service For services in MACs run by WPS and CGS No global billing for advanced imaging if DOS for TC and PC differ 13
Accreditation Its Nexus with Supervision MIPPA The Medicare Improvements for Patients and Providers Act of 2008. Accreditation Required for Advanced Diagnostic Imaging Services: o MR o CT o Nuclear Medicine (including PET) January 1, 2012 14
Mandates Qualifications of Non-Physician Personnel Qualifications of Medical Directors and Supervising Physicians CMS has until now relied on standards of accrediting organizations CMS has requested comments on quality standards for suppliers of advanced diagnostic imaging services Breast Biopsy Procedures - Problem for IDTFs The following codes are DELETED for 2014 Code Definition 77031 Stereotactic localization guidance for breast biopsy or needle placement (eg, wire placement or for injection), each lesion RS&I 77032 Mammographic guidance for needle placement, breast (eg, for wire localization or for injection), each lesion RS&I New Breast Biopsy Codes for 2014 Code Definition 19081 Biopsy, breast, with placement of breast localization device(s) (eg, clip, metallic pellet), when performed, and imaging of the biopsy specimen, when performed, percutaneous; first lesion, including stereotactic guidance +19082 each additional lesion, including stereotactic guidance 19083 Biopsy, breast, with placement of breast localization device(s) (eg, clip, metallic pellet), when performed, and imaging of the biopsy specimen, when performed, percutaneous; first lesion, including ultrasound guidance +19084 each additional lesion, including ultrasound guidance 19085 Biopsy, breast, with placement of breast localization device(s) (eg, clip, metallic pellet), when performed, and imaging of the biopsy specimen, when performed, percutaneous; first lesion, including magnetic resonance guidance +19086 each additional lesion, including magnetic resonance guidance 15
New CMS 1500 Claim Form Effective April 1, 2014 Role of Provider: Qualifier Provider Role DN Referring provider DK Ordering provider DQ Supervising provider Enter the qualifier to the left of the dotted vertical line on Item 17. 16