ACR Bulletin

Covering topics relevant to the practice of radiology

A November Tradition

The Medicare fee schedules may be an annual event, but in reality, it’s a year-round endeavor.
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While the bar gets higher to achieve a positive payment adjustment in MIPS, the road gets harder for radiologists due to a paucity of available quality measures.

—Gregory N. Nicola, MD, FACR
November 30, 2021

Everyone has annual traditions. For the ACR Commission on Economics, one of those November traditions is the end of CMS’ rulemaking cycle — culminating in the release of the Medicare fee schedules. Much like the commonly celebrated holiday it closely follows, this tradition typically brings both tricks and treats. The 2022 Medicare Physician Fee Schedule (MPFS), the Quality Payment Program (QPP), and the Hospital Outpatient Prospective Payment System (HOPPS) rules continued the annual tradition with plenty of both.

The MPFS Final Rule estimates a -1% impact to diagnostic radiology reimbursement due to changes in relative value units and adjustments to clinical labor pricing across the budget-neutral fee schedule. The good news is — thanks to advocacy efforts of a multispecialty coalition, including the ACR — the impact is less than the 2% reduction in the Proposed Rule and will be phased in over four years. The bad news is that IR still faces a formidable reduction of 5% (reduced from 9%). The worse-than-bad news is that additional cuts threaten radiology via reductions in the conversion factor (CF). Last year, Congress allocated an additional $3 billion to the MPFS to mitigate draconian cuts to physicians caused by revaluation of Evaluation and Management (E/M) codes. This one-time cash infusion buffered the CF by 3.75% in 2021. Unless Congress legislates another payment to the fee schedule, the CF will come back to haunt us with a 3.75% decrease in 2022. Additional reductions of 4% and 2% may result from Pay-As-You-Go (frequently referred to as “PAYGO”) and Medicare sequestration, respectively — in the absence of legislative intervention before the end of the year.

Past rules have placed radiology in the crosshairs of payment reduction via nomination of specific CPT® codes as potentially misvalued. Fortunately, no radiology codes were nominated by CMS or public stakeholders in the 2022 MPFS rule. However, we continue to face further reductions to the CF as the remaining families of E/M codes are revalued in a budget neutral system.

The 2022 QPP rule details updates to the Merit-Based Incentive Payment System (MIPS) and plans to transition away from MIPS toward MIPS Value Pathways (MVPs). CMS finalizes the seven initial MVPs that will be available, beginning with the 2023 performance year, and maintains that additional MVPs will be added as they are developed. It remains unclear how radiology and other specialties whose care is not episode-based will participate in MVPs. As for MIPS, the difficulty of the program escalates, and radiologists encounter a particular disadvantage. The performance threshold (below which clinicians receive a financial penalty) increases to 75 points, and the exceptional performer bonus (above which clinicians are eligible for a bonus outside of budget neutrality) increases to 89 points. The data completeness threshold, proposed to increase to 80%, will remain at 70%.

While the bar gets higher to achieve a positive payment adjustment in MIPS, the road gets harder for radiologists due to a paucity of available quality measures. Two radiology measures were finalized for removal: Stenosis Measurement in Carotid Imaging Reports and Reminder System for Screening Mammography. Due to scoring caps on topped-out measures, radiologists simply do not have enough quality measures available to score highly in the Quality category without using Qualified Clinical Data Registry (QCDR) measures. Perhaps the most devastating blow in the 2022 QPP rule is the removal of bonus points, previously awarded for submitting additional high-priority measures or submitting measures using end-to-end electronic reporting. In the early years of MIPS, radiologists have been able to make up for the scoring deficit due to capped measures with bonus points. With the removal of bonus points, even radiologists who perform perfectly on six measures submitted in the Quality category will not be able to score well. CMS will continue to award small practices an additional six bonus points to their score in the Quality category.

The 2022 HOPPS rule brought a solid win to radiology, with a long-awaited increase in the technical component payment for low-dose CT for lung cancer screening performed in the facility setting. This code was reassigned to the second-tier ambulatory payment classification, with a reimbursement rate of $111.19. The HOPPS final rule also included finalized changes to the Radiation Oncology Alternative Payment Model, which is slated to begin Jan. 1, 2022. While CMS made small concessions to the proposed framework of the model, the ACR and other stakeholders remain concerned about the fairness and feasibility for our RO colleagues. We continue to pursue a legislative solution — another example of ongoing efforts by the ACR’s economics and government relations teams.

Author Gregory N. Nicola, MD, FACR,  chair of the ACR Commission on Economics