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Medicare reimbursement for radiologists could drop over 10% in 2021

por John R. Fischer, Senior Reporter | August 19, 2020
Business Affairs CT MRI Ultrasound Women's Health X-Ray
A proposed rule by CMS would cut reimbursements for radiology services across-the-board by 10.6%.
The Medicare Physician Fee Schedule (MPFS) Proposed Rule by the Centers for Medicare and Medicaid Services (CMS) in 2021 calls for the adoption of a new coding structure for E/M services that cuts reimbursement across-the-board by 10.61% from the current relative value unit of $36.0896 to the proposed rate of $32.2605, according to Healthcare Administrative Partners.

Factoring in proposed valuation adjustments, these cuts are expected to affect different areas of radiology in the following ways:

  • Diagnostic radiology – 11% decrease
  • Interventional radiology – 9% decrease
  • Nuclear medicine – 8% decrease
  • Radiation oncology and therapy centers – 6% decrease
“Under the revised E/M coding structure, physicians may elect to document a visit based either on the time spent with the patient or on the medical decision-making involved in the visit,” wrote Healthcare Administrative Partners. “There will continue to be separate payments for each of the five levels of office or outpatient E/M visits along with a new add-on code for prolonged visits and for complex patients.”
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The new rule is a change from the original plan to use a single, blended rate for a range of E/M codes. The impact on radiology services varies according to Healthcare Administrative Partners, which calculates a decrease of at least 10% and up to as much as 18% for CT thorax and 1%–3% for diagnostic X-rays. MR imaging is expected to see an 8% decrease in the imaging center, while ultrasound will see a 5%–7% drop. Most procedures are expected to experience cuts in the 11%–12% range.

The negative effect on radiology and medical services is due to increases in reimbursement made for level 2–5 E/M visits for established patients, which represent the highest volume within the Medicare payment system.

The proposed rule does not change the timeline of the Appropriate Use Criteria/Clinical Decision Support (AUC/CDS) Medicare payment rule. CMS announced that full implementation will be delayed until January 1, 2022, at which point payments to radiologists will be denied for certain advanced imaging services that do not meet the ordering criteria, in which the ordering physician must consult a qualified clinical decision support system. He or she must then review the AUC and report the required information to the radiologist for submission along with the Medicare claim.

The proposed rule will, however, allow non-physician practitioners (NPP) to supervise performance of diagnostic tests, within the scope of practice permitted by their state licenses. NPPs include nurse practitioners; physician assistants; clinical nurse specialists; and certified nurse midwives. A proposal for direct supervision of tests to be completed using real-time interactive audio and video technology through the end of 2021 is also on the table, with the expectation being that this is made a permanent change to the rules. Both of these proposals are already in effect temporarily for 2020 due to the COVID-19 public health emergency.

The proposed rule contains more than 40 new or revised codes that affect radiology.

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