Radiology Reimbursement on the Rocks: Decade’s Research Shows Undeniable Decline

With the Medicare Physician Fee Schedule Final Rule (PFS) now released, payment cuts are officially coming for radiology. Radiology will experience a two percent decrease, while interventional radiology will brace for an aggregate decrease of three percent. Nuclear medicine can expect to see a two percent decrease, with radiation oncology and radiation therapy centers preparing for a one percent decrease. These policies are just one wave in a sea of reimbursement erosion. A study this year revealed a stark warning when it comes to reimbursement trends in radiology. The study, called “Declining Medicare Reimbursement for Diagnostic Radiology: A 10-Year Analysis Across 50 Imaging Studies,” published in Current Problems in Diagnostic Radiology, conducted over the course of a decade, examined the most widely performed imaging studies at two different levels, at the individual study level and also stratified by imaging modality. Even more radiology services paid the price, with the study suggesting these services took in the reimbursement cut costs to the tune of 44 percent. The conclusions of the study showcase a strong need for policy advocacy to reverse the troubling trends as well as highlights the significance of maintaining proper coding accuracy and compliance through continued education and strategies.

Result Revelations

The study took aim at the situation by analyzing the 50 most universal and common imaging studies for diagnostic radiology. The reimbursement rates were taken from the global reimbursement data provided by the Centers for Medicare & Medicaid Services. The data per study was extracted from the years 2011 to 2021. These reimbursement rates were then “adjusted for inflation and assessed as a function of time for each individual study and by imaging modality. There was a combined mean reduction of inflation-adjusted payments of 44.4 percent across all included imaging studies from 2011 to 2021.”

According to the authors of the study, only three out of 50 studies experienced an increase in adjusted reimbursement over the course of that decade. But for everything else, linear regression analysis showed that the total mean adjusted reimbursement had “significantly declined over time.”

When examining the pool adjusted yearly percent change, the only years that experienced any type of reimbursement raise was 2016 to 2017 and only of 0.2 percent. 2013 to 2014 experienced the sharpest decline of (-16 percent). The general yearly percent change amounted to -5.5 percent.

One of the most important aspects was examining reimbursement by the actual imaging modality. The results were striking.

• MRI saw a -60.6 percent drop over the course of the decade
  
• CT experienced a similar drop of -44.4 percent
  
• Ultrasound saw a drop of -31.3 percent
  
• Lastly radiographs skated by with a -6.2 percent decrease.

All imaging modalities “experienced a mean decline in reimbursement, though at significantly different severities (P <0.0001). An evaluation of wRVUs during the study period revealed a decline from a mean value of 0.79 to 0.78 wRVUs (-1.3 percent).”

The hits to cross-section modalities may preview an unsustainable future ahead for radiology, especially on the heels of a punishing pandemic that has gripped healthcare for the past two years slashing service volumes left and right and creating turnover in healthcare. Ultimately, “This data further characterizes reimbursement trends for the field and suggests the need for sustainable future reimbursement schedules.”

Expert Insight

Nationally renowned radiology subject matter experts Cathy Huyghe, CPC, Director, Radiology and Cardiology Services at Panacea Inc. and Jolynn Van Ert, RT(R)(CT), CPC, CIRCC, RCC, Senior Healthcare Consultant at Panacea Inc. took time to answer some pressing questions about the implications related to the study. Huyghe leads the discussion with a series of questions and answers.

1. What different revelations does this study show for each area of radiology?
   • “There has been less reimbursement for radiology due to creating combination codes from the AMA via CMS requests eg. CT abdomen/pelvis, nuclear medicine (MUGA used to be three codes, now it is one), and hip/pelvis. For interventional radiology some impacting factors include many combined codes reversing the component coding from 1992—Imaging is included in the surgical code, TIPS, lower extremity revascularization, AV fistula codes, and creating territories for many procedures which include all aspects of the procedure. Every time there is a combination code created, whether surgical or diag-nostic, huge reimbursement losses occur.
   • NCCI edits and MUEs with MAIs have created either not reporting certain codes together or removal of codes. This has also caused an increase in denials.”
2. Based on this study, what do you expect for the future of reimbursement and radiology?
   • “The AMA symposium brought up an issue that CMS has not evaluated their application of reimbursement according to the cost of supplies in over 20 years. This was a project they were going to take on.
   • The equipment for radiology keeps going up, but the reimbursement does not. More involvement from the radiologists to the societies is needed.
   • Many of the bread-and-butter studies have already been heavily affected by these decreases.
   • There needs to be additional studies done to prove some of these decreases are inappropriate.
   • There is a shortage of radiologists currently.
   • There is also a shortage of radiology technologists.”
3. Based on this study, what actions should radiology-associated stakeholders such as compliance professionals, coders, and radiology providers take?
   • “The coders and compliance professionals must be well educated to assure no money is being left off the table. Education on CPT, ICD-10-CM, modifiers, documentation requirements and coding guidelines should be ongoing to ensure accuracy.
   • Radiologists and administrators need to get involved with the societies to fight against some of these trends.”
4. How can radiology providers best guard themselves against a reimbursement decline trend?
   • “Get involved with the societies and understand the trends.
   • Radiologists need to provide accurate and compliant documentation.”

Furthermore, Huyghe states, “Even though reimbursement has declined significantly, the coding guidelines and documentation guidelines have increased tremendously. This requires more documentation from the radiologists. The coding staff need a higher understanding of their RIS system and coding to be compliant and get reimbursed appropriately. Simply applying codes is not enough in today’s world.”

Van Ert notes several factors and future trends that contribute to and complicate the picture including:

• Radiologist shortages will continue
• Radiology staff (technologists and support staff to include IT) shortages will continue
• Supplies, contrast, radiopharm shortages and limitations continue due to supply chain interruptions as well as reduced access to base production materials.
• Increased staff burnout
• There is an increased radiology services utilization (demand)—naturally occurring due to the aging population as well as the recent COVID-19 emergency
• A continued trend of healthcare systems (hospitals) purchasing radiology groups
• Increased use and application of artificial intelligence software/applications

Continued administrative burden to remain compliant with various quality measures affecting payment. Example: Federal No Surprise Act

• Continued increase of patient shopping around and requesting price estimates for high deductible health insurance plans and out-of-pocket.

She notes that “Continued adjustments to PFS and budget neutrality measures are further impacting radiology.” Another compounding factor is “Moving forward with Appropriate Use Criteria (AUC) for advanced medical imaging and penalty phase (payment) for non-compliance, which is postponed to Jan 1, 2023, due to the COVID-19 Public Health Emergency and currently being reviewed by Congress and faces ongoing society pushback.” Even more, “NCCI narrative directives, edits, MUE values, etc. continue to affect the allowable submission of services directly affecting reimbursement.”

Mirroring Huyghe’s insight, Van Ert commented, “I would further stress the importance of advocacy to raise the voices of stakeholders. Radiologists need to be actively involved in their societies and drive change—move from a reactive stance to a more proactive position. Healthcare policy is being directed with very little ‘meaningful’ input from implicated stakeholders. If radiology does not stand up, they are essentially abdicating decisions to others.”

Editors note: This article was originally published in our July 2022 Radiology Compliance Manager newsletter. Explore more regulatory, policy, and coding knowledge to master compliance and coding with our monthly Radiology Compliance Manager.

Information Sources:

https://pubmed.ncbi.nlm.nih.gov/35153101/

https://www.acr.org/-/media/ACR/Files/Advocacy/MPFS/ACR-Preliminary-Summary-2023-MPFS-FR-FINAL_11_1_22.pdf

https://www.sciencedirect.com/journal/current-problems-in-diagnostic-radiology

https://www.sciencedirect.com/science/article/pii/S0363018822000081