U.S.A healthcare providers are to adopt digital radiology (DR), the Medicare system will begin reducing payments for exams performed on analog x-ray systems starting in 2017. The year after that, sites using computed radiography (CR) equipment will also see payment reductions.
The New Norms
Medicare payments will be reduced by 20% for providers submitting claims for analog x-ray studies starting in 2017 under a provision in the Consolidated Appropriations Act of 2016, which was enacted into law in December 2015. Starting in 2018, payments for imaging studies performed on CR equipment would be reduced by 7% for the next five years, and 10% after that.
While the law’s provisions on analog x-ray are expected to have a minor impact due to the small number of traditional systems still in operation in the U.S., the reductions in CR payments could have a much broader effect: More than 8,000 CR units are still in service in the U.S. All of these systems must be replaced or imaging facilities will experience payment reductions.
New Radiology Facilities
Radiology procedures are defined as global services and fall in the 7xxxx series of the CPT book. For example, the radiology code 71020 (two-view chest, frontal and lateral) is considered a global CPT code, as it consists of the professional component and the technical component combined. The relative value units have been calculated to include the expense for the whole package. When charging for only a portion of a service, a modifier must be appended to the code on the CMS-1500 form to indicate a reduction in reimbursement is owed to the service provider.
The common modifiers in radiology billing are 26; TC, 76, 77, 50; LT, RT, and 59 below are the brief explanation regarding each modifier:
26 -professional component
When a radiologist is only interpreting films or imaging/tracing and is not providing the machinery, this modifier should be added to the code on the claim form. Typically, this occurs when a radiologist is reviewing for a hospital, an ambulatory surgery center (ASC), or a doctor’s office that owns the equipment and provides the staff but requires the radiologist to interpret the images and write reports.
TC – technical component
This modifier covers the expense of the staff, machinery, equipment, and nonprofessional interpretation elements required to provide a radiological film or image/tracing. Oftentimes, a hospital, ASC, or office will use this modifier when submitting a claim for a radiological service performed.
Modifiers 76 and 77 are similar in that they relate to the same radiological service performed on the same date of service; however, the provider of service determines which modifier is selected for the additional service performed.
76 – repeat procedure same physician
When a procedure or service must be performed again on the same date of service by the same physician, it requires this modifier should be included with the CPT code on the CMS-1500 form.
77- repeat procedure different physician
This modifier should be included with the CPT code for the same scenario involving modifier 76 but when a different physician performs the repeat procedure. (Note: Medicare considers all physicians in the same group practice with the same specialty to be the same physician.)
50 – the bilateral procedure
This modifier relates to circumstances in which both sides of the body are imaged or a procedure is performed on both sides of the body. Do not use this modifier if the code is written as a bilateral procedure or service, as it is expected to be performed on both sides. Also, “both sides” do not mean front and back (AP/PA and lateral); it refers to the right and left sides.
LT/RT – left side/right side
Depending on the side of the body that is imaged, one of these modifiers is to be appended to the code to reflect only one side was imaged.
It is important to note that radiologists should not decrease the fees they submit to payers, as payers will do those themselves when a modifier is submitted. However, fees should be increased when modifiers are submitted, with two units added when reporting on one line item because the payer will not automatically increase its reimbursement if the rates aren’t already increased.
It is imperative that general radiology does not get left behind as the rest of the world moves with advanced technology. It can be easy to overlook the impact and importance of general radiology on patient volumes and consequently, the bottom line, as reimbursements are much lower for these types of exams and especially due to the high cost associated with upgrading technology.
However, the clinical benefits and soft dollar considerations can help offset some of the financial burdens. Even though the high price of going digital presents a challenge in today’s healthcare economy, it will not be long until we are looking at analog technology as a thing of the past.