2022 Radiology Billing: Positive and Negative

Is 2022 Radiology Billing Impact: Positive and Negative? Really? As almost everyone knows, the Final Rule from CMS for the 2022 Medicare Physician Fee Schedule shows radiologists facing a 9.75% reimbursement cut unless Congress intervenes: see “Physician Billing in 2022: 10% Medicare cut!“.

But there are also several positive factors in the Final Rule and other recent rulings

The clinical labor wage update is now phased in, reducing its impact by at least 50%
Penalties for Appropriate Use Criteria (AUC) have been postponed until at least 2023
Updated AUC criteria have been published
The FDA is finally moving ahead with rules for Clinical Decision Support systems (CDS)
Reimbursement for Low Dose CT for Lung Cancer screening has been increased. Coupled with expansion of the screening criteria, experts project an increase up to 60%
Restrictions on the use of PET scans will be removed in 2022

Clinical Labor Wage Update

“Despite objections from [the American College of Radiology] and others, CMS chose to move forward with implementation of clinical labor pricing updates,” the professional association said. “However, due to the actions of ACR and others, the updates will be phased in over a four-year period, and the payment impact to radiology and radiation oncology providers largely reduced by half.”

According to the ACR, these changes will decrease the initial estimated impact to diagnostic radiology and nuclear medicine from -2% to -1%, interventional radiology from -9% to -5% and radiation oncology from -5 to -1%. Of course, the impact on a specific practice will be determined by its mix of procedures.

Appropriate Use Criteria Penalties Postponed

CMS is postponing the penalty phase for the Appropriate Use Criteria (AUC) program to the later of January 1, 2023, or the January 1 that follows the declared end of the COVID public health emergency. This proposal (delayed for many years) requires physicians to consult a decision-support system (see below) before ordering advanced imaging. The rule would apply penalties to physicians who order advanced imaging services without clinical decision support based on AUC.

Updated Appropriate Use Criteria from ACR

The American College of Radiology recently published new imaging appropriateness criteria. The update includes five new topics and eight revisions to earlier ones. ACR initially published its influential criteria in 1993, with evidence-based guidelines to aid in selecting proper imaging exams and guided procedures. It now offers 216 topics spanning 2,400 clinical scenarios.

“ACR appropriateness criteria serve a vital role in helping to ensure that patients receive the necessary, quality care that they expect from their healthcare providers,” Mark Lockhart, MD, chair of the Committee on Appropriateness Criteria, said Oct. 11. “These criteria are recognized as the national standard in radiologic care.”

New topics include imaging of a child with suspected Crohn’s disease, facial trauma following a primary survey, axillary masses, newly diagnosed scrotal abnormalities, and pediatric musculoskeletal infections. The guidelines have color-coded categories of appropriateness, along with relative radiation levels for each exam.

The eight updates cover the range from staging of colorectal cancer to imaging after shoulder arthroplasty. Providers can consult the guidelines to meet their legal requirement (specified in the 2016 Protecting Access to Medicare Act) to consult appropriate-use criteria before ordering imaging. CMS has designated ACR as a qualified provider-led entity.

Clinical Decision Support (CDS)

One of the reasons for the delay in AUC enforcement (see above), has been the lack of approved CDS systems. Much of the industry has been waiting for the FDA to issue CDS guidelines. A first draft was published in 2017 and a revised draft in 2019. Both drafts received extensive comments from the industry, including from the American Medical Informatics Association, warning that guidance may leave “lingering confusion” about the regulatory status of software.

The FDA recently added clinical decision support as an “A-list priority” and now seems close to finalizing the guidance, including clarifying when CDS meets the definition of a medical device and a risk-based framework for the software functions.

Most observers are pleased that clinical decision support is finally an A-list priority, but disappointed that the guidelines have taken more than five years to get to this point.

CT for Lung Cancer Screening

The combination of higher reimbursement and expanded guidelines for low dose CT screening for lung cancer has drawn cheers from the radiology community.

In the 2022 Medicare Hospital Outpatient Prospective Payment System (HOPPS), CMS increased the reimbursement rate for hospital outpatient CT lung cancer screening. This is a positive for radiologists and for the ACR. For years, the ACR has pointed out the inadequate payments for low-dose CT for lung cancer screening for the disease for years. The new reimbursement rate will be $111.19, up 37.4% from the current rate of $80.90 (CPT code 71271).

“New U.S. Preventive Services Task Force guidelines have nearly doubled the number of people eligible for such screening,” the ACR said. “However, less than 15% of Americans who met previous USPSTF lung cancer screening criteria are tested. Improved payment may bolster lung cancer screening availability.”

In a recent JAMA Network Open, experts said that new lung cancer guidelines could generate up to a 54% increase in eligibility for low-dose CT screening, with significant gains in minority populations. Another recent study indicated that healthcare systems should plan to increase capacity by 50%-60% to help accommodate this new cohort of patients. This could include increasing the number of trained radiologists, CT scanners, and thoracic surgeons, the authors advised.

The influential U.S. Preventive Services Task Force (USPTSF) recently lowered the recommended starting age from 55 down to 50, among other changes. Along with dropping the smoking history from 30 to 20 pack-years, Kaiser Permanente researchers believe these modifications could produce a 30% uptick in lung cancer diagnoses when compared with previous recommendations.

On November 17, CMS released a proposed updated to its screening guidelines to accommodate the USPTSF recommendations. The ACR immediately applauded the CMS proposal, with ACR Lung-RADS Committee chair Dr. Ella Kazerooni saying, “As lung cancer kills more people each year than breast, colon, and prostate cancers combined, this cost-effective exam is poised to save more lives than any cancer screening test in history. It is critical that physicians know of new guidelines so they can engage with patients to make informed screening decisions.” The ACR plan to comment on the proposed changes during the comment period which ends December 17. A final rule is expected by February 15 of next year.

PET scans

The Society of Nuclear Medicine and Molecular Imaging (SNMMI) has applauded a recent federal decision to lift longstanding restrictions on payment for PET scans.

This noncoverage determination dates to 2000, when CMS implemented broad, national restrictions on positron emission tomography (PET) scans outside of cancer care. SNMMI and others have lobbied against the change for more than ten years and were rewarded with the release of the 2022 physician fee schedule.

SNMMI President Richard Wahl, MD, said the decision opens a pathway for PET use in assessing cardiac, neurological, infectious, inflammatory and other conditions. “Removal of the exclusion will enable physicians to base their care decisions on using the right procedure for the right patient at the right time,” Wahl said in a Nov. 11 statement.

The change will take effect on January 1, 2022 and will allow Medicare Administrative Contractors to make decisions about payment for non-oncologic PET use “quickly and effectively.” SNMMI said it is now working with MACs to ensure the coverage rule is implemented properly. It also continues to advocate for the removal of similar noncoverage determinations related to amyloid and NaF PET.