“The recent changes to evaluation and management (E/M) services send the message that the value in a value-based system is in face-to-face visits,” says Gregory N. Nicola, MD, FACR, vice chair of the ACR Commission on Economics and chair of the Economics Committee on MACRA. “Radiologists will need to seek more opportunities to provide that type of value. It is a shot across our bow that these types of payment redistributions are coming — but it is not yet clear whether these changes will provide any new opportunities to see patients.”

On Nov. 1, 2019, CMS issued its 2020 final rule with updates to payment policies, payment rates, and misvalued codes for services provided under the Medicare Physician Fee Schedule (MPFS). The new policy will have a significant impact on payments for all physician services, including radiology, beginning in 2021.

The new rule creates a coding structure that will reallocate payments for E/M services. According to CMS, the E/M changes are intended to reduce administrative burden, improve payment rates, and better reflect current clinical practice. CMS chose to adopt new relative value units (RVU) for the E/M codes recommended by the AMA Relative Value Scale Update Committee (RUC) and the
Current Procedural Technology (CPT®) Editorial Panel. Because the MPFS is based on budget neutrality — increasing reimbursement for one type of service while others are diminished — radiologists who do not typically bill for E/M services will see their payments reduced in 2021. The ACR is working to minimize the impact of these new policies.¹

Moving Monies

“CMS has essentially increased payments for office visits,” says Lauren P. Golding, MD, vice chair of the Economics Committee on MACRA. “So physicians who bill a higher proportion of office visits will do well. If you don’t bill for any office visits, you’ll do the worst.” Diagnostic radiologists who don’t see patients will feel the impact the most, Golding says, with an estimated 8–9% reduction in
payments (see sidebar on page 12). Radiation oncologists and IRs who see patients for clinic and office visits will blunt the impact a little, she says. “But payments for those patient-facing visits won’t be enough to offset the relative decrease in procedural payments.”

Primary care providers (PCPs) will be among the main beneficiaries of the rebalanced payment system, as MPFS payments move away from specialty, procedural, and surgery services to those providers who serve patients in an office or outpatient setting. While the College does not oppose a re-weighting of services that increases payments to PCPs, it objects to other specialties being penalized for these increases to E/M code values.

“We support primary care receiving an update,” Golding stresses. “It is well-deserved and fits with ACR’s goals around population health.” Yet, the goal of offering more patients equitable, quality care may be compromised by some specialties having to absorb the deep payment cuts, she says. “Our main concern is that payments will be reduced for radiologic care, as well as many other necessary services in underserved and rural areas.”

Picking Losers

The E/M code set represents the highest volume/highest expenditure CPT code set in the MPFS. If you use the 9% estimated reduction of payments, that equates to a roughly $452 million annual hit for radiology. “It’s a sizable hit, and we have real concerns about access to care,” Nicola says. “CMS should not be picking winners and losers. It should support the primary care community in every aspect possible, without creating losers.”

Rural areas and those with small hospitals and health centers may lose the most, he says. They would not stop serving Medicare patients, but the dollar amounts would go down enough that it could hurt the profitability of an imaging center, which may have to close. “There are areas that have a large percentage of Medicare patients and are only marginally profitable,” Nicola says. “Rural centers that don’t have their scanners packed all day long could go under.”

We support primary care receiving an update. It is well-deserved and fits with ACR’s goals around population health. Our main concern is that payments will be reduced for radiologic care, as well as many other necessary services in underserved and rural areas.

Finding Patients

Each CPT code is assigned an RVU value, which determines the reimbursement for healthcare services. These RVU values can be adjusted for individual codes through RUC recommendations and CMS policy. However, because of budget neutrality, large changes in reimbursement can result not from direct adjustments to a specialty’s codes, but from adjustments to other codes in the fee schedule. In the case of the E/M increases, the impact of changes to other codes is significantly larger than changes to specific radiology codes.

“Imaging utilization continues to increase, and it will increase even more with a growing aging population that will be sicker,” says Melissa M. Chen, MD, chair of the Commission on Patient- and Family-Centered Care Economics Committee. “Our value is not in doing more procedures, but in ensuring we are providing appropriate care for patients that is not excessive,” Chen says. Ultimately, radiologists must become more patient-facing and be seen as part of a healthcare team, she says.

For IRs who have been advocating that radiologists should have a more active role in patient management, updates in the E/M coding structure and reimbursement can facilitate this more patient-centered approach to care. For practices that have not adopted this approach, the updates to E/M services may make the transition to a more clinic-based IR practice more feasible.

Showing patient-facing value is not a challenge unique to radiology. ACR should align with other specialties within the house of medicine to offset payment reductions under the new rule, Nicola says.
CMS has proposed using a new add-on code (GPC1X), for example, that allows for additional payments under E/M services to physicians who serve patients with ongoing care for serious or chronic and complex conditions.

Not implementing the code — which CMS could still consider — could soften the 9% payment reduction by several percentage points, Nicola says.

CMS has not provided much guidance on when this add-on code can be used, Chen says. It is unclear for which patients this code should be used — a concern of the AMA. “This highlights the need for us to stay involved in the AMA process, and to make sure radiology’s voice is heard by working together with other physicians,” says Chen.

Rethinking Value

“The changes in the final rule of course get us thinking about valuation and how our codes are impacted,” Golding says. “We really should be thinking out of the box on our involvement in patient care. We’re going to have to be more innovative in approaching what we do.”

The Commission on Economics has formed a workgroup to look at ways in which radiology practices might mitigate or weather these cuts, Golding says. “We’re working on the advocacy front as well to innovate our practices and best be prepared.”

With the finalization of the 2020 MPFS changes, Congress would now have to intervene to prevent payment reductions to radiologists and others who do not typically bill for E/M services. One solution would be to increase the total budget for the MPFS so that E/M visits could increase without drastic decreases in the conversion factor that determines dollar values.²

According to ACR BOC Chair Geraldine B. McGinty, MD, MBA, FACR, ACR is taking the fight to Congress, while acknowledging the unlikelihood that lawmakers will agree to waive the budget neutrality requirement or add funding to offset payment reductions. “ACR members will need to come together as never before to articulate the value of what we do as radiologists,” says McGinty. “Mitigating these cuts will be a challenge, but there is no organization better equipped to engage with policymakers and payers.”

Radiologists’ job, now more than ever, Chen says, is to ensure appropriate imaging, create clear reports, educate clinicians, and be accessible to patients. “This is a wake-up call,” Chen says. “Healthcare is changing, and unfortunately right now that may mean decreased reimbursement for radiologists. More change will happen, and we need to stay ahead of it.”