On Tuesday, July 13th, the Centers for Medicare and Medicaid Services (CMS) released the proposed rule for the 2022 MPFS. Contained within that proposed rule are a number of provisions that, if enacted, will have a significant impact on radiology. Below are a number of areas we expect will be most relevant to radiology.
Appropriate Use Criteria (AUC)
One of the proposals forwarded by CMS is the recommendation to move forward with the AUC program for advanced diagnostic imaging services. This program is mandated by the Patient Access to Medicare Act (PAMA) of 2014 and has a penalty phase that is scheduled to begin on January 1st of 2023 (or the first day of the year after Covid-19 is officially declared over). In theory, once fully implemented, the AUC program will help ensure that patients receive the right imaging at the right time. The proposed rule also attempts to engage multiple potential solutions to dealing with claims processing issues that have slowed the implementation of the program thus far. Advocates, such as the American College of Radiology (ACR), view this proposal as an important step in the right direction, but will continue to review the details of this proposed rule to offer the most useful feedback during the comment period.
Conversion Factor and Estimated Payments
The proposed rule estimates a conversion factor of $33.58, which is down from $34.89 in 2021. CMS estimates the overall impact to radiology will drop by 2%. There will also be a 9% drop in interventional radiology, a 2% decrease in nuclear medicine, and a 5% decrease in both radiation oncology and radiation therapy centers if the proposed rule is finalized as is. There are a number of factors influencing these decreases, including changes in Relative Value Units (RVUs), proposed changes in clinical labor pricing, and implementation of earlier changes to supply and equipment pricing.
In 2021, there was a 3.75% adjustment to the conversion factor implemented by the Consolidated Appropriations Act. This lessened the payment cuts to radiologists from 10% to 4%. However, without more action from Congress, payment cuts could be even greater in 2022 for Interventional Radiology and Radiation Oncology.
Valuation of Services
There have been recommendations for 5 new or revised codes that impact radiology which CMS proposes to accept. These changes include increased values for needle biopsy of lymph nodes, as well as improvements in value for the new trabecular bone score code family. There were no radiology codes beyond these that were identified as being misvalued.
Some National Coverage Determinations (NCDs) Removed
The CMS proposes to remove the NCD for position emission tomography (PET) scans, which hasn’t been updated since 2013. This would defer to local Medicare Administrative Contractors to make decisions related to coverage and would require that every non-oncologic indication for PET scans have a separate NCD. CMS hopes that this change will allow greater access to PET scans for non-oncologic indications to Medicare beneficiaries.
The Quality Payment Program (QPP)
The CMS has continued to work on transitioning MIPS Value Pathways (MVPs) into the Merit-based Incentive Program System (MIPS). With that said, the proposed rule suggests putting off implementation until the 2023 performance year, upon which time 7 MVPs would become available. The CMS also seeks comments regarding the proposal to entirely remove the traditional MIPS at the end of the 2027 performance and data submission periods.
In the next couple of years, CMS encourages voluntary subgroup reporting through MVPs or the APM Performance Pathway (APP). Mandatory subgroup reporting would begin in 2025, and MVP scoring policies similar to those used in traditional MIPS would be employed to support reporting in the future. The category weights for this scoring scheme would be as follows:
Quality – 30%, Cost – 30%, PI – 25%, and IAs – 15%
These weights operate according to the 2020 MPFS Final Rule which proposed lowering the Quality category to 30% for 2022 and beyond, which resulted in Cost being increased to 30%.
The CMS has also proposed raising the performance threshold to 75 points beginning in 2022 and setting the exceptional performance threshold at 89 points. A number of other changes to the scoring system have been suggested, including:
• Changing the scoring range for benchmarked measures to 1-10 points (and eliminating the 3-point floor)
• Scoring non-benchmarked measures at 0 points, even if data completeness is met
• Raising the scoring floor to 5 points for new measures without a benchmark for the first 2 years in the MIPS program
Finally, CMS also proposes eliminating bonus points for high-priority measures submitted beyond the required 6. Most notable to radiology are the removal of:
• #195: Radiology: Stenosis Measurement in Carotid Imaging Reports, and
• #225: Radiology: Reminder System for Screening Mammogram
New CPT Code for Artificial Intelligence (AI)
In addition to the above potential changes, the American Medical Association (AMA) has recently approved a new Current Procedural Terminology (CPT®) code for the use of artificial intelligence in radiology. It was officially added on July 1, 2021 and will take effect January 1, 2022. This new category III code (0691T) applies to AI being used for analysis of CT studies for vertebral fractures. This includes assessing bone density, data preparation, interpretation, and reporting.
Ideally, the implementation and increased use of AI will enhance radiology’s role in population health and ultimately decrease morbidity, mortality, and financial costs in more debilitating chronic conditions.
Because it is a category III code, it is a temporary code that is often denied by the majority of insurances for reimbursement, as these codes are generally perceived as experimental or investigational. Some payers may reimburse this code in the next few years, but consistent reimbursement will remain unlikely until a permanent category I CPT code is assigned. That said, most view this as an important step in the right direction, and the fact that radiological specialty societies were so integrally involved in the development of the code proposal likely means radiologists will continue to be included in the payment models for AI usage.
Ultimately, none of the above proposals are finalized yet, but there are clearly an array of changes in the pipeline that will affect radiologists and their reimbursement in the coming years.