Implications of Coding and Payment Reform for Radiology Medical Billing

by | Published on Apr 7, 2017 | Specialty Billing

Coding Payment
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Changes to health care regulations and policies have impacted the business of radiology quite significantly. Though efficient radiology medical billing and coding services are available, providers still have to grapple with growing regulatory demands and adapt their workflow and systems to deal with them. According to a recent Diagnostic Imaging report, experts at RSNA say that two developments have affected reimbursement and radiology medical billing in recent times – the commoditization of billing and the implementation of ICD-10 coding.

ICD-10 codes provide the radiologist with detailed information about what’s going on with the patient. Detailed physician documentation is a must for proper claim submission and efficient medical billing and coding. Radiologists need to get the following information from the referring physician:

  • The specific reason why the particular study is being ordered
  • Thorough clinical history and specific diagnostic questions that the study need to answer
  • Exactly what answers or results the study is expected to provide
  • The most appropriate study, in discussion with the radiologist if necessary

The need to report diagnoses with a higher level of specificity also requires radiologists to include more information in their reports, such as laterality and exact anatomical location. Not doing so would lead to claim rejection and drop in reimbursement.

The patient’s medical record also must include dictated reports and meet medical necessity guidelines from payers. The coding of the dictation will differ based on whether the procedure is an outpatient or inpatient one. ICD-10 procedure codes are used only for facility reporting of inpatient procedures and exams and do not affect the use of CPT codes.

Another program that has had a significant impact on radiology is the Physician Quality Reporting System (PQRS). Under the program, eligible professionals can report quality measures intended to improve care and demonstrate opportunities for improvement. PQRS informs Value-Based Modifier calculations and participation is required to avoid payment reductions. Reporting as many measures as possible in a consistent manner improves performance scores, which in turn, impacts Medicare payments.

In 2016, radiologists needed to report 9 measures across 3 domains. In addition to 8 new radiology-specific measures, individual providers or group practices with face-to-face encounters had to satisfactorily report at least one cross-cutting measure.

The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) went into effect January 1, 2017. MACRA also links radiologists reimbursement to quality metrics which can be conveyed through diagnosis codes. So here too, proper coding and documentation is the key to providing a clear picture of the patient’s story.

All of these changes present opportunities to improve the quality of care and thereby, reimbursements. It’s all about the patient experience. Radiologists need to keep a patient population as healthy as possible, and curtail the need for expensive imaging tests and procedures, emergency room visits, and hospitalization.

Outsourcing medical billing and coding is a practical option for radiologists to manage their revenue cycle. This has helped many radiology practices avoid payment denials and ensure quality improvement. Experienced service providers are well-equipped to ensure the efficiencies required to maintain quality and provide cost-effective medical billing solutions.

Meghann Drella

Meghann Drella possesses a profound understanding of ICD-10-CM and CPT requirements and procedures, actively participating in continuing education to stay abreast of any industry changes.

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